Tag: Doctors

Nearly All Hospitals Use Locum Tenens Physicians, Demand for Specialists Up: Survey

The use of temporary physicians, known as “locum tenens,” to fill staffing shortages continues to be a very widespread practice, according to a new survey from Staff Care, a leading national physician staffing firm and a company of AMN Healthcare. And a growing percentage of locum tenens physicians are specialists due to acute shortages.

Staff Care’s 2020 Survey of Temporary Physician Staffing Trends indicates that 85% of hospitals, medical groups, and other healthcare facilities used locum tenens doctors in the previous 12 months, primarily to maintain services until permanent physicians are found and to fill gaps caused by turnover.

“Virtually every hospital in the United States now uses locum tenens doctors,” said Jeff Decker, president of Staff Care. “They have emerged as a key part of the medical workforce in an era of physician shortages and evolving delivery models.”

According to Decker, locum tenens physicians are filling openings that last from a few days to over a year while healthcare facilities seek difficult-to-find primary care physicians and specialists. They also can be used to fill-in when healthcare facilities experience turnover on their medical staffs, an increasing problem due in part to the growing employment of physicians by hospitals and other healthcare facilities.

As the employed physician model replaces physician practice ownership, physicians have more latitude to change jobs, according to Decker, creating more temporary openings and hence more demand for locum tenens physicians. Employed physicians commonly enjoy a month of vacation and continuing education time off each year, which also creates demand for locum tenens doctors, Decker said.

Specialists in rising demand as “temps”

Primary-care physicians, including family physicians, general internists, and pediatricians, are the most in-demand type of locum tenens doctors, according to the survey. Thirty percent of healthcare facility managers surveyed indicated they used locum tenens primary care doctors in 2019, higher than any other type of physician. However, this is down from 44% in 2016, the last time Staff Care conducted the survey.

By contrast, the use of locum tenens specialists has accelerated. For example, 21% of healthcare facilities managers reported using locum tenens surgeons in 2019, up from 11% in 2016; 17% reported using locum tenens internal medicine subspecialists, up from 9%; and 22% reported using locum tenens anesthesiologists, up from 11%.

The need for specialists is being driven by an aging population and by an aging physician workforce, with many specialists entering retirement age. In its April 2019 report, the Association of American Colleges projected a shortage of up to 122,000 physicians by 2032, including up to 55,000 primary care doctors but an even larger shortage of up to 67,000 specialists.

“Older patients need specialists to care for ailing organs and body systems,” Decker said, “and we simply don’t have enough specialists to go around.”

52,000 locum tenens doctors

Each year it conducts the survey, Staff Care estimates the number of physicians who work as locum tenens based on the number of doctors the company places annually and its knowledge of the locum tenens staffing industry. Staff Care estimates that approximately 52,000 physicians worked as locum tenens in 2019, or about 6% of the active physician workforce.

“Locum tenens is an increasingly popular practice style among physicians, because it allows them to focus on what they like to do best, which is treat patients, while minimizing the administrative duties they like least,” Decker said.


CPR Still Encouraged During COVID-19 Pandemic

If someone collapses or experiences a heart attack during the coronavirus pandemic, CPR or chest compressions are still strongly encouraged despite potential infection, according to a new report in the journal Circulation.

Bystanders are more likely to save a dying person’s life than to die themselves from COVID-19, according to the report, which was written by a group of doctors who work in emergency departments in Seattle.

Since bystanders are typically family members who see a loved one begin to have heart problems, they especially recommend CPR at home.

“We were worried that people were dying of fear rather than disease,” Michael Sayre, MD, the lead author, told CNN.

To calculate the risk, the doctors looked at heart attacks and COVID-19 cases around Seattle in King County, WA. Between January and April, more than 1,000 cases of cardiac arrest occurred outside of a hospital in King County. Among those patients, fewer than 10% were diagnosed with COVID-19.

Based on a 1% mortality rate for COVID-19, they estimated that 1 in 10,000 bystanders who provide CPR could die from the coronavirus. In contrast, CPR from bystanders saves 300 lives among 10,000 patients who have a heart attack outside of the hospital.

To reduce infection risk, they encouraged bystanders to do hands-only chest compressions or use a defibrillator.

In addition, they wrote, bystanders should only delay CPR to put on personal protective gear when the prevalence of COVID-19 is high in the community.

So far, Sayre and colleagues haven’t found any cases of a bystander contracting COVID-19 from giving CPR, according to CNN. They plan to continue to study the links between CPR and coronavirus transmission, especially if some states continue to see an increase in cases.

“If we have a big second wave and COVID overwhelms the health care system, the risks could be higher,” Sayre said.


COVID-19 patients experience neurological symptoms

People with SARS-CoV-2, which is the virus that causes COVID-19, can experience a variety of symptoms.

According to the Centers for Disease Control and Prevention (CDC), these are usually physical symptoms, such as fever or chills, a cough, fatigue, and shortness of breath.

Among the warning signs that indicate that a person needs emergency medical care, the CDC list confusion and an inability to wake up or stay awake.

Although the neurological symptoms associated with COVID-19 have received much less attention than the physical symptoms, some studies suggest that they are common among people with severe forms of the illness.

A study in the BMJ, for example, found that among COVID-19 patients who died at a hospital in Wuhan, China, 22% had experienced a disorder of consciousness, compared with only 1% of those who recovered.

preprint of another study of hospitalized patients in China found that overall, 25% had central nervous system symptoms or diseases. These included headaches, dizziness, impaired consciousness, uncoordinated muscle movements, seizures, and strokes.

These were more likely in those with severe disease. For example, 6% in the severe group had strokes, compared with 1% in the non-severe group.

In the first published study of its kind, researchers at the University of Cincinnati in Ohio and several Italian universities analyzed the findings of imaging investigations into hospitalized patients in Italy who experienced neurological symptoms with COVID-19.

The researchers have now published their results in the journal Radiology.

Second epicenter

After China, Italy became the second epicenter of the COVID-19 pandemic. Italy has now had more than 33,000 deaths.

The researchers analyzed the records of patients treated at the University of Brescia, the University of Eastern Piedmont in Novara, and the University of Sassari.

Out of 725 patients, 15% experienced neurological symptoms or disease. Of this 15%, 99% underwent a CT scan.

The most common neurological symptoms were “altered mental state,” which 59% of the patients experienced, and ischemic strokes, which 31% of the patients experienced.

Altered mental status” encompasses a wide range of possible signs and symptoms, including confusion, delirium, and coma.

Among the less common neurological symptoms were headache (12%), seizures (9%), and dizziness (4%).

Imaging revealed acute abnormalities in 47% of the patients. Among the most common findings were ischemic strokes, and in 6% of the patients, there were signs of intracranial hemorrhage.

Early interventions

“These newly discovered patterns could help doctors better and sooner recognize associations with COVID-19 and possibly provide earlier interventions,” says lead study author Dr. Abdelkader Mahammedi, an assistant professor of radiology at the University of Cincinnati.

The study was unable to shed light on whether or not SARS-CoV-2 directly damages the central nervous system. It might be that neurological symptoms are a side effect of critical illness. Lack of oxygen in the brain, for example, can cause confusion or loss of consciousness.

In addition, of the 108 patients, 71% had one or more preexisting chronic conditions. These included hypertensiondiabetescoronary artery disease, and cerebrovascular disease.

In their paper, the researchers cite accumulating evidence to suggest that some people with severe COVID-19 experience a “cytokine storm,” in which the body produces an excess of pro-inflammatory molecules called cytokines. This can cause blood clots, which can, in turn, trigger ischemic strokes.

“This topic definitely needs more research,” says Dr. Mahammedi.

“Currently,” he adds, “we have a poor understanding of the neurological symptoms in COVID-19 patients, whether these are arising from critical illness or from direct central nervous system invasion of SARS-CoV-2. We hope further study on this subject will help in uncovering clues and providing better interventions for patients.”


CDC will alert doctors to look out for syndrome in children that could be related to coronavirus

The US Centers for Disease Control and Prevention is preparing to release an alert warning doctors to be on the lookout for a dangerous inflammatory syndrome in children that could be linked to coronavirus infection, a CDC spokesman told CNN Tuesday.The syndrome, marked by persistent fever, inflammation, poor function in one or more organs, and other symptoms similar to shock, was first reported by New York officials.More states began reporting diagnoses of the syndrome this week.

An informal panel of pediatricians organized by Boston Children’s Hospital have dubbed the mysterious illness “Pediatric Multi-System Inflammatory Syndrome Potentially Associated with COVID-19.”The CDC warning will go out on the Health Alert Network (HAN) to thousands of physicians and other clinicians across the country, the agency spokesman said.”We will provide a working case definition of what cases look like,” the spokesman said.Doctors will be asked to report cases to state and local health departments so that the CDC can learn about the syndrome.The CDC is working with the Council of State and Territorial Epidemiologists to get the definition of the syndrome — which could be released Wednesday or Thursday, the spokesman added.

Where cases have been reported

The New York State Department of Health is investigating about 100 possible cases of the illness in children, Gov. Andrew Cuomo said Tuesday.The majority of the cases are in children between the ages of 5 and 9 (29%) and between 10 and 14 (28%) years old, state data shows.

The governor announced last week that three youth had died because of the illness.”We lost three children, (a) 5-year-old boy, 7-year-old boy and 18-year-old girl,” Cuomo told reporters Tuesday.In Kentucky, Health Commissioner Dr. Steven Stack, announced the state is aware of two patients diagnosed with the syndrome.One case is a 10-year-old, who is critically ill in the intensive care unit and the second patient is a 16-year-old, who is doing well and is in a regular medical bed, Stack said.Stack said the 10-year-old patient is showing signs of improvement and has had some of the medications reduced, meaning that their body is showing signs of recovery.”The children who get sick with this can have cardiovascular collapse and require supportive measures to maintain their blood pressure, or respiratory collapse requiring breathing support with a mechanical ventilator,” Stack said.And Boston Children’s Hospital spokeswoman Erin Tornatore told CNN Tuesday two children with the syndrome were hospitalized there, but neither was in intensive care.

What the treatments include

Last week, the informal panel, called the International PICU-COVID-19 Collaboration, released a consensus statement defining the condition. Dr. Jeffrey Burns, chief of critical care medicine at Boston Children’s Hospital, coordinates the panel.

“In some cases, children present with shock and some have features of Kawasaki disease, whereas others may present with signs of cytokine storm. In some geographic areas, there has been an uptick in Kawasaki disease cases in children who don’t have shock,” Boston Children’s Hospital rheumatologist Dr. Mary Beth Son said.Kawasaki disease involves inflammation in the walls of medium-sized arteries and can damage the heart. A cytokine storm is an immune system overreaction that can cause widespread inflammation and organ damage.Treatments may include blood thinners and immune system modulators.”To date, most children affected have done well. Treatments have included anticoagulation, IV immunoglobulin, IL-1 or IL-6 blockade, and corticosteroids. Some children have only needed supportive care,” Boston Children’s Hospital said on its website.


Doctors face ‘nearly an impossible situation’ as they ration remdesivir

As coronavirus cases surged across the United States earlier this year, doctors faced a harrowing prospect. Sometime soon, they worried, physicians might have to decide which patients would receive ventilators amid a projected shortage.

It’s a crisis Italy faced and one the United States largely avoided. But already, doctors in the US are facing another difficult decision: How to ration limited supplies of an experimental drug shown to be effective against the virus.

“We actually did, ultimately, have enough ventilators,” said Dr. Rochelle Walensky, chief of infectious diseases at Massachusetts General Hospital. “But we know the doses of [remdesivir] that we are going to get are not going to be enough to treat every patient that we have in the hospital now and every patient that is going to be coming in for the weeks ahead.”

The US Food and Drug Administration authorized remdesivir for emergency use earlier this month in a move to increase access, but the government’s distribution of the drug has been opaque and confusing.

There is only enough remdesivir in the world for about 100,000 to 200,000 patients, according to the drug’s maker, Gilead Sciences. As the company works to manufacture more, about 40% of its current supply has been reserved for the US, according to the US Department of Health and Human Services.

Last week, the government began distributing vials of remdesivir directly to some hospitals, but it was unclear why some received the drug while others received nothing — even in hard-hit areas of the country.

After doctors expressed outrage, HHS backtracked on its original plan and decided to give remdesivir to state health departments to manage. But as the drug trickles into hospitals — mostly in regions with the largest outbreaks — doctors are grappling with how to ration the few vials they’re getting.

And in most states, doctors still haven’t received any remdesivir at all, leading to difficult conversations about why patients can’t have a drug that White House coronavirus task force member Dr. Anthony Fauci said would set a new “standard of care” for Covid-19.

A committee helps ration the drug

At Mass General, an impartial committee — which includes ethicists — has been putting together guidance on how to allocate the hospital’s limited supply, according to Walensky. The group has already begun working through patients’ charts, and the hospital has enough remdesivir for about 65 patients.

“This was work that was going on before we received the drug,” Walensky said. The committee came together anticipating that “there are going to be patients — they are currently nameless and faceless — who are going to need this drug, and we are going to need to figure out how to prioritize it.”

Two months ago, medical ethicists floated a similar approach for allocating ventilators. In “The Toughest Triage,” published in the New England Journal of Medicine, they suggested insulating doctors on the front lines by leaving decisions to a group “composed of people who have no clinical responsibilities for the care of the patient.

“Unlike ventilators, though, remdesivir is not a lifesaving drug — at least not yet. While it shortened patients’ hospital stays by about four days in a clinical trial, it hasn’t been shown to reduce the risk of death. Still, it’s one of the few tools available with some effect on the virus.

“Perhaps I rest a little easier knowing that we don’t know this drug to be the miracle that people are hoping it is,” said Walensky. She added that “if this were a cure, if this were a vaccine, I would say it would be even harder.

“Even so, “it’s nearly an impossible situation to be in medicine when you think that there’s something you could and should be doing for somebody, and you don’t have it to give.”

For doctors without remdesivir: ‘It’s heartbreaking’

Officials with Health and Human Services have said it’s distributing remdesivir to “areas of the country hardest hit by the pandemic.” But the agency has never released the formula it uses to calculate which states get the drug and how much.

California, for example, has seen more than 67,000 coronavirus infections so far — but hadn’t received any remdesivir from the government as of this weekend, according to HHS.

At Zuckerberg San Francisco General Hospital, doctors can only access the drug through restrictive clinical trials or Gilead’s “compassionate use” program — which is only open to children and pregnant women.

“Before I could honestly say to [Covid-19] patients, I’ve got nothing. But now there is something I could offer but have no ability to do it,” said Dr. Annie Luetkemeyer, a professor of infectious diseases at the University of California, San Francisco, who practices at San Francisco General.

“I came home and told my husband that I was so happy the day the press release announced the remdesivir results, and here I am nine days later still admitting patients and not able to prescribe it,” she said.

San Francisco General is a public hospital, and while other cities are harder hit — New York, for example — San Francisco has sick coronavirus patients too, many of whom come from marginalized communities.

During the H1N1 pandemic, the US Centers for Disease Control and Prevention set up a national system to allocate a different antiviral, peramivir, that had received an emergency use authorization. But no such system exists today, and HHS hasn’t released any information beyond a press release issued this weekend, which lists a handful of states receiving remdesivir.

The agency said it “expects” the drug to be delivered to every state and territory, but offered no timeline.

Luetkemeyer, for her part, says she understands the medicine needs to go to the hardest-hit communities. But the haphazard allocation of the drug, with no clear criteria for the regions getting it, is frustrating.

“My God, it’s the first thing we’ve found that has a signal that it’s working,” she said. “And the safety signal is good too.

“Luetkemeyer described a patient she cared for, knowing she couldn’t give them remdesivir: “It’s heartbreaking.”

Doctors don’t know who will benefit most

As physicians choose who gets remdesivir and who doesn’t, doctors are to some extent flying blind. They want to give it to the patients who benefited most in the drug’s large clinical trial, but the National Institutes of Health still hasn’t published that study.

“We don’t have a lot of data to work on,” Walensky said, and “there’s not a lot of history with this drug.

“Lawmakers are also unhappy.

“A doctor making a life or death decision about how to allocate a limited amount of this drug and which patient gets it and which doesn’t — the clinical trials are very important in that regard. They haven’t made that available,” said Rep. Lloyd Doggett, the Texas Democrat who chairs the House Ways and Means Health Subcommittee.

In a statement, the National Institute of Allergy and Infectious Diseases told CNN that “the study team is currently reviewing the available data for the [clinical] trial and plans to publish a preliminary report of the initial results in the next few weeks.

“Walensky said some doctors in her hospital have also turned down offers of remdesivir for their patients. Those patients appear to be on the mend, she said, and the doctors don’t want to give them a new drug with limited benefits and so little history.

In a Washington Post op-ed last week, Walensky and others from Mass General said remdesivir has left doctors with more questions than answers.

“In the wake of this media bombshell and data tease,” they wrote, “we are left with a treatment that the FDA has permitted us to use, and that patients and families will justifiably expect, but with an extremely limited drug supply and no evidence-driven guidance on how to use it.”

Walensky said using a committee to choose which patients get the drug “is not how we like to practice medicine.” But with so many patients — and so little remdesivir — the hospital decided it was the most equitable approach.

Equitable, though, doesn’t mean easy, especially when it’s unclear who needs the drug most. “It’s a nearly impossible situation when your overarching mission is to do right,” Walensky said.