BACKGROUND: Decisions to prescribe opioids to patients depend on many factors, including illness severity, pain assessment, and patient age, race, ethnicity, and gender. Gender and sex disparities have been documented in many healthcare settings, but are understudied in inpatient general medicine hospital settings.
OBJECTIVE: We assessed for differences in opioid administration and prescription patterns by legal sex in adult patient hospitalizations from the general medicine service at a large urban academic center.
UNASSIGNED: This study included all adult patient hospitalizations discharged from the acute care inpatient general medicine services at the University of California, San Francisco (UCSF) Helen Diller Medical Center at Parnassus Heights from 1/1/2013 to 9/30/2021.
METHODS: The primary outcomes were (1) average daily inpatient opioids received and (2) days of opioids prescribed on discharge. For both outcomes, we first performed logistic regression to assess differences in whether or not any opioids were administered or prescribed. Then, we performed negative binomial regression to assess differences in the amount of opioids given. We also performed all analyses on a subgroup of hospitalizations with pain-related diagnoses.
RESULTS: Our study cohort included 48,745 hospitalizations involving 27,777 patients. Of these, 24,398 (50.1%) hospitalizations were female patients and 24,347 (49.9%) were male. Controlling for demographic, clinical, and hospitalization-level variables, female patients were less likely to receive inpatient opioids compared to male patents (adjusted OR 0.87; 95% CI 0.82, 0.92) and received 27.5 fewer morphine milligram equivalents per day on average (95% CI - 39.0, - 16.0). When considering discharge opioids, no significant differences were found between sexes. In the subgroup analysis of pain-related diagnoses, female patients received fewer inpatient opioids.
CONCLUSIONS: Female patients were less likely to receive inpatient opioids and received fewer opioids when prescribed. Future work to promote equity should identify strategies to ensure all patients receive adequate pain management.

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OBJECTIVE: The closure of inpatient pediatric units within general hospitals has contributed to the regionalization of pediatric care. For children in rural areas, the distance traveled for hospitalization impacts the quality of care for children, the impact upon families, and the preparedness for disaster planning within rural communities. We assessed trends in location of hospitalization over time for rural-residing children.
METHODS: Using the Healthcare Cost and Utilization Project\'s State Inpatient Databases, we studied 256,947 hospitalizations for rural-residing children 0-17 years of age within eight states (CO, FL, KY, NC, NJ, NY, OR, WA) from 2002-2017. Level of rurality was defined by Rural-Urban Commuting Area Codes: micropolitan, small rural, and isolated rural. Birth, psychiatric, and surgical hospitalizations were excluded. Trends in number of hospitalizations by hospital location, interfacility transfer (IFT), and whether the hospital location was the same level of rurality as the patient\'s home residence were assessed with the Cochran-Armitage trend test.
RESULTS: From 2002 to 2017, hospitalizations for rural-residing children decreased by 52.7% (56,168 to 26,548) and IFTs increased from 6.7% to 26.5% (p<.001). The proportion of total hospitalizations within metropolitan areas for rural-residing children increased from 32.2% to 72.8% (p<.001). Local-area agreement between the patient\'s residence and hospital utilized decreased from 53.6% to 21.5% (p<.001).
CONCLUSIONS: Although overall hospitalizations for rural-residing children decreased, IFTs increased, and the proportion hospitalized in metropolitan areas increased. The impact of this shift in inpatient health services on efficiency and quality of care for rural-residing children needs further exploration.

Vasopressor medications for circulatory shock have historically been administered through central venous catheters due to concern for extravasation injury when given peripherally. However, recent studies have demonstrated the safety of peripheral administration of vasopressor medications at lower doses and for a limited duration. Peripheral use of vasopressors is appealing to both patients and providers, as obtaining central access is an invasive procedure associated with the risk of pneumothorax, bleeding, and infection. Furthermore, waiting to initiate these medications until central access is obtained can lead to delays in care. Conversely, valid concerns remain regarding the risk of tissue extravasation associated with peripheral vasopressors, which can be life and limb threatening. We discuss the guidelines and data for optimal dose, duration, intravenous line (IV) size, IV location, and nursing IV site monitoring for peripheral vasopressors. We then explore adverse events associated with peripheral vasopressors. Finally, we describe how this practice change may impact hospital medicine providers.

(1) Background: Acute pain in hospitalized children remains under-recognized and under-treated. Our objective is to benchmark pain assessment, documentation, treatment, and patient experience in children admitted to a US children\'s hospital. (2) Methods: A cross-sectional, mixed-method survey of pain for children hospitalized ≥24 h. Charts were reviewed for modalities of pain assessment and treatment for all inpatients. If pain was documented, patients/caregivers were surveyed regarding their experience with pain and its management. (3) Results: Chart review: All 107 patients had ≥1 pain score documented. A total of 47 patients had a pain score ≥0, 35 (74.5%) of whom had ≥1 moderate-severe score. Seventy (65.4%) patients received ≥1 intervention for pain, including medications from ≥1 class (e.g., opioids) (n = 55, 51.4%) and/or integrative/non-pharmacologic intervention(s) (n = 39, 36.4%). There were assessment and documentation gaps. Patient survey: A total of 39 (83.0%) interviews were attempted; 25 (53.2%) were completed. The worst pain was mostly caused by acute illness (n = 13, 52%) and painful procedures (n = 10, 40%). Suggestions for improvement included increasing the use of integrative modalities and optimizing patient-clinician communication. (4) Conclusions: All patients admitted ≥24 h had ≥1 pain score documented; however, gaps in documentation were common. Multimodal treatment and integrative modalities were underutilized. Procedures were a frequent cause of under-treated pain, prompting an institution-wide quality improvement project.

OBJECTIVE: Promoting autonomy is at the core of fellowship education. Pediatric hospital medicine (PHM) fellowship programs are relatively new, and many supervising physicians are not trained on how to promote fellow autonomy. Moreover, no studies have explored fellows\' perception of autonomy throughout training. To fill this gap, we explored PHM fellows\' perceptions of autonomy throughout training.
METHODS: PHM fellows starting fellowship in July 2021 were recruited to participate in a longitudinal qualitative study. Using self-determination theory as a sensitizing framework, the authors conducted semistructured interviews with 14 fellows throughout fellowship. Incoming data were iteratively analyzed, and codes were created from patterns in the data. Coded data were clustered into themes.
RESULTS: Four themes developed: (1) at the beginning of fellowship, fellows valued direct observation and close supervision from their attending. (2) Initially, fellows felt pressured to make the identical clinical decision as their attending, but over the course of training, they realized their autonomous decisions could coexist with different decisions from their attending physicians. (3) At first, fellows desired attending presence to support and guide their decision making. Over time, fellows desired a coach who could provide valuable formative feedback. (4) Because of the hierarchical nature of medicine, conversations between fellows and attending physicians about autonomy were challenging to initiate.
CONCLUSIONS: Fellows\' perceptions of autonomy change throughout fellowship, which should be taken into consideration as provisions of autonomy evolve through training. Our findings can inform PHM fellowship curricula and professional development around the promotion of autonomy in fellowship.

BACKGROUND: Although the roles and responsibilities of hospitalists have grown considerably in recent years, research on the current job status and satisfaction levels of Korean hospitalists is lacking.
OBJECTIVE: We investigate the present state of Korean hospitalists and the factors influencing their job satisfaction 6 years after the pilot program\'s launch.
METHODS: This cross-sectional analysis was based on an online survey conducted from January 30 to February 18, 2023.
METHODS: Korean hospitalists (N = 303) MAIN MEASURES: The survey encompassed participant demographics, hospital information, education, clinical practice, research involvement, and job satisfaction. We employed multiple logistic regression analyses to identify determinants of satisfaction as a hospitalist.
RESULTS: The analysis was based on 79 hospitalists\' responses (response rate 26%). Respondents had a median age of 39 years; approximately half were male internal medicine specialists, possessing over 3 years of hospitalist experience. Most respondents were interested in clinical work (94.4%), with only 21.5% interested in research and evidence-based medicine. Over two-thirds indicated that non-clinical duties occupied less than 20% of their time. Overall, job satisfaction among hospitalists averaged 51.9%. Notably, the availability of a research mentor was significantly associated with job satisfaction (P = .011). While hospitalists with more than 3 years of experience, more hospitalists per facility, and autonomy were associated with increased job satisfaction, these associations were not statistically significant. Furthermore, there was no association between night shift work, work type, or work hours and job satisfaction.
CONCLUSIONS: Although Korean hospitalists primarily focus on clinical practice, our study underscores the positive impact of mentorship from research mentors on job satisfaction, supported by comprehensive univariate and multivariate analyses. These findings signal a progressive transformation in the role of Korean hospitalists, as they increasingly engage in research alongside patient care.

OBJECTIVE: The designation of pediatric hospital medicine (PHM) as a board-certified (BC) subspecialty has led to uncertainty about the importance of PHM board certification in hiring pediatric hospitalists and ambiguity in counseling trainees interested in PHM careers about the decision to pursue fellowship. We sought to determine the importance of PHM board eligibility or certification in hiring practices.
METHODS: We conducted an online, cross-sectional, survey-based study of individuals who self-identified as PHM division leadership utilizing the PHM Division Director Listserv and participant recruitment at a national meeting.
RESULTS: A total of 86 responses were received. A total of 64% (30/47) of university-setting hospitals, 77% (17/28) of community hospitals, and 100% (11/11) of combined settings reported that they will hire applicants who are not board-eligible (BE) or BC (P = .83). Of the hospitals who will be hiring non-BE hospitalists, 50% of university settings, 77% of community settings, and 55% of combined settings plan to give equal consideration to both BE and non-BE applicants (P = .21). A total of 57% (21/37) of programs with a PHM fellowship felt that fellowship training was an important or very important consideration in hiring, compared with 27% (13/49) of programs without a PHM fellowship (P = .04).
CONCLUSIONS: Programs with a PHM fellowship were significantly more likely to believe that fellowship training is an important consideration in hiring hospitalists. PHM board certification and fellowship training are perceived as more important by university-based programs, although all settings will consider hiring applicants who are not BC or BE.

BACKGROUND: Nonverbal communication plays a pivotal role in the provision of effective patient care and has been associated with important patient health outcomes. Clinician posture, a nonverbal form of communication, may influence the patient experience and satisfaction. The relationship between clinician posture (i.e., standing or at the patient\'s eye level) and patient perceptions of clinician communication in the hospital-a setting with heightened power dynamics between patient and clinician-is currently unknown.
METHODS: We conducted searches of Ovid MEDLINE, EBSCO CINAHL Complete, EBSCO PsycInfo, Elsevier Embase/Embase Classic, Elsevier Scopus, and Web of Science Core Collection up to May 2023. English language studies were included if they compared clinician posture (eye-level or standing) during adult inpatient (including emergency department) interactions. Two authors independently abstracted data from included studies and assessed risk of bias or quality of evidence. A third author arbitrated any disagreements. Studies reported adherence to the posture intervention and/or patient perception outcomes. The latter included encounter duration, preferences for posture type, perceptions of interaction quality and clinician communication and compassion, and standardized assessments of patient satisfaction.
RESULTS: Fourteen studies (six randomized controlled trials, four quasi-experimental studies, four observational studies) assessed clinician posture at the bedside. Ten noted at least one favorable outcome for clinicians who communicated at the patient\'s eye level, three revealed no differences in patient perceptions between standing and sitting, and one noted higher patient ratings for standing clinicians. Findings were limited by variation in interventions and outcomes, generally high risk of bias, and relatively low adherence to assigned posture groups.
CONCLUSIONS: Compared to standing, eye-level communication by clinicians appears beneficial. The magnitude and types of benefits clinicians and patients may gain from this behavior remain unclear given heterogeneity and generally high risk of bias in available studies. With its relatively easy implementation and potential for benefit, clinicians should consider communicating with their hospitalized patients at eye level.
BACKGROUND: PROSPERO, CRD42020199817.

BACKGROUND: Pain is ubiquitous, yet understudied. The objective of this study was to analyze inequities in pain assessment and management for hospitalized older adults focusing on demographic and geriatric-related variables.
METHODS: This was a retrospective cohort study from January 2013 through September 2021 of all adults 65 years or older on the general medicine service at UCSF Medical Center. Primary exposures included (1) demographic variables including race/ethnicity and limited English proficiency (LEP) status and (2) geriatric-related variables including age, dementia or mild cognitive impairment diagnosis, hearing or visual impairment, end-of-life care, and geriatrics consult involvement. Primary outcomes included (1) adjusted odds of numeric pain assessment versus other assessments and (2) adjusted opioids administered, measured by morphine milligram equivalents (MME).
RESULTS: A total of 15,809 patients were included across 27,857 hospitalizations with 1,378,215 pain assessments, with a mean age of 77.8 years old. Patients were 47.4% White, 26.3% with LEP, 49.6% male, and 50.4% female. Asian (OR 0.75, 95% CI 0.70-0.80), Latinx (OR 0.90, 95% CI 0.83-0.99), and Native Hawaiian or Pacific Islander (OR 0.77, 95% CI 0.64-0.93) patients had lower odds of a numeric assessment, compared with White patients. Patients with LEP (OR 0.70, 95% CI 0.66-0.74) had lower odds of a numeric assessment, compared with English-speaking patients. Patients with dementia, hearing impairment, patients 75+, and at end-of-life were all less likely to receive a numeric assessment. Compared with White patients (86 MME, 95% CI 77-96), Asian patients (55 MME, 95% CI 46-65) received fewer opioids. Patients with LEP, dementia, hearing impairment and those 75+ years old also received significantly fewer opioids.
CONCLUSIONS: Older, hospitalized, general medicine patients from minoritized groups and with geriatric-related conditions are uniquely vulnerable to inequitable pain assessment and management. These findings raise concerns for pain underassessment and undertreatment.