Teen eating disorders; caring for hospital patients: Upstate Medical University's HealthLink on Air for Sunday, April 30, 2023

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," we're looking at the crisis of eating disorders with an expert in adolescent medicine.

Nurse practitioner Davia Moss: ... The pandemic, combined with social media, combined with our diet culture, has sort of been a perfect storm to create this crisis of eating disorders. ...

Host Amber Smith: And we'll explore the advances in hospital medicine and what a hospital stay is like these days, with a hospitalist.

Timothy Creamer, MD: ... We used to send people home from the hospital when they were well. We then sent people home from the hospital when they were better. And now we're really looking at getting people home when they are treated. ...

Host Amber Smith: All that, and some expert advice about nursing careers, followed by a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, hospitalist Dr. Timothy Creamer gives an overview of advances in hospital medicine. But first, nurse practitioner Davia Moss tells how she cares for adolescents with eating disorders, which have increased substantially.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Eating disorders have one of the highest mortality rates in all of psychiatry, with 12 times higher death rates in 15- to 24-year-olds than any other cause. It's a crisis that's part of the nation's mental health crisis. Here to talk about care of patients with eating disorders is Davia Moss, who is a family nurse practitioner specializing in adolescent medicine at Upstate.

Welcome to "HealthLink on Air."

Nurse practitioner Davia Moss: Hi, Amber. Thank you so much.

Host Amber Smith: Let's start by defining what qualifies as an eating disorder. What are the main types of eating disorders?

Nurse practitioner Davia Moss: So, the diagnoses that people have probably heard of are anorexia nervosa, bulimia nervosa and binge eating disorder. There is also a newer diagnosis that the letters we use are ARFID, (avoidant/restrictive food intake disorder). Sometimes we see this in younger patients. We see it with patients who have maybe sensory difficulties with different foods, and they can have a very restrictive eating, without the body image concerns. So those would be the most common diagnoses that you would hear.

Host Amber Smith: You mentioned anorexia, bulimia and binge eating. Do those all have body image tied up in them, or how do they differ from one another?

Nurse practitioner Davia Moss: Anorexia nervosa is probably what everyone pictures when we think of eating disorders, when we see an emaciated body, that's sort of our stereotypical eating disorder, which actually does not apply to majority of people with an eating disorder, that sort of visual that we have.

Anorexia nervosa has restrictive patterns of eating. Also very significant body image concerns. Bulimia nervosa has a binge and then intentional vomiting, which some people call purging after eating. So that would be the difference there.

And then a binge eating disorder is where people actually feel out of control with food and often are not able to control how much intake they have.

Host Amber Smith: How prevalent are these eating disorders?

Nurse practitioner Davia Moss: The numbers are changing rapidly. You can look at a hundred different sources anywhere from 5% to 10% in the general population. However, we know there that there are certain populations that are underdiagnosed significantly, in particular males. Populations of color are often underdiagnosed. And certainly as you spoke to, during this crisis we will see those numbers change rapidly as more data comes out in the next few years.

Host Amber Smith: Is it mostly adolescents? Are you seeing a lot of this in your patients?

Nurse practitioner Davia Moss: We are seeing an enormous increase in our patients, both in our outpatient clinic and in the hospital. The number of patients that we have had to hospitalize has gone up by about four- to fivefold throughout this crisis.

Host Amber Smith: Do we know what this is all about or what is causing it?

Nurse practitioner Davia Moss: Eating disorders thrive on isolation. Often it starts as a matter of control. And as we all know, these teenagers lost a lot of control in their life, and they were home and had more time to pour their energy that typically would've gone into school or socializing, maybe into exercise. Then you add the social media piece to things. It often started as, I will quote, because I hear this from a lot of my patients, they will say they were "just trying to get healthier and then somewhere along the line things, you know, became out of control."

Host Amber Smith: Are student athletes more at risk for eating disorders because they focus on the performance of their bodies?

Nurse practitioner Davia Moss: There are certain sports that we know for sure are at higher risk. There are certain sports that actually require a weigh-in. So wrestling, rowing, those things are certainly a higher risk. And sometimes you'll see more eating disorder behaviors during the season. And then there are other sports that actually focus on body image -- cross-country running, dance, ballet. Those are definitely higher-risk activities that we see in our population.

Host Amber Smith: And the ones that got started trying to eat healthy, were they trying to lose weight or trying to bulk up and be more muscular? Because I hear a lot about protein powders, and "health food" stores are popular with adolescents now.

Nurse practitioner Davia Moss: Yeah, our diet culture is really, really incredible. And to be honest, there's no reason for any adolescent to be on a, quote, diet. Their brains are not capable of balance, so it often can get very quickly out of control. The other tricky part is they often get a lot of positive feedback when their body starts to change. And for an adolescent, they really thrive off that, and that's when things can get very out of control pretty quickly.

Host Amber Smith: Are close friends at risk? If you have someone that you're close to who's dealing with an eating disorder, are you vulnerable to developing this disorder as well?

Nurse practitioner Davia Moss: That's a great question. I don't know any particular data on that. I would say I don't see it anecdotally. There is a huge genetic component. We do know that if a parent had an eating disorder or a grandparent had an eating disorder that that does put you at risk for an eating disorder.

Host Amber Smith: Eating disorders are the third most common chronic health condition for children and adolescents, behind asthma and obesity. It was not always that way. Is the pandemic to blame for this?

Nurse practitioner Davia Moss: The pandemic, combined with social media, combined with our diet culture, has sort of been a perfect storm to create this crisis of eating disorders. Absolutely.

Host Amber Smith: How is it that eating disorders have such a high mortality rate, though? You said a lot of your patients end up hospitalized. How do you go from binging and purging or whatever to needing to be hospitalized?

Nurse practitioner Davia Moss: So the patients that are hospitalized are often the ones that are restricting to very, very significant, under 500 calories a day, over-exercising. They can have long-term cardiac, when I say sequelae, those are sort of symptoms that you could deal with for a very long period of time. So cardiac (and) things having to do with the gut, with the GI (gastrointestinal, or digestive) system. We have patients that abuse laxatives, which can actually impact the ability of your GI tract to even function correctly for the rest of your life.

Patients will have frequent, the term is syncopal episode, where they pass out. Unfortunately sometimes it's seen as normal for a teenage girl to pass out. If that's happening more than once, that should be followed by a medical provider. It can go downhill very quickly, and they're at a time of rapid growth in their life.

Host Amber Smith: How would a person know they have an eating disorder?

Nurse practitioner Davia Moss: I'm going to focus in on the adolescent population for right this second because that's what I work with. And I think we really depend on the caregivers, parents, teachers, guidance counselors to be able to hone in on if something is changing in a child, if we notice that their body is changing dramatically, that's a red flag. If we notice that their attention concentration is changing, their fatigue levels, if they're starting to isolate themselves more, suddenly wanting to exercise more often, all of those are red flags that should be followed up on.

Host Amber Smith: Is it normal though for teens to have concerns about their appearance or weight? I thought that was, sort of, part of growing up?

Nurse practitioner Davia Moss: It's very normal to have concerns of our body. Unfortunately, actually, the concerns about weight are really this diet culture that we currently live in. You know, the other crisis is obesity. And unfortunately sometimes when our medical providers really hone in on obesity being a weight issue, depending on how we discuss those things with our teenagers, that can actually send the wrong message.

So you know, medicine is constantly evolving, and changing how we communicate with our kids about their bodies is very important.

Host Amber Smith: So are eating disorders usually diagnosed by the primary care provider, someone like yourself?

Nurse practitioner Davia Moss: I'm not a primary care provider. We're the specialty, so usually we receive the consult from the primary care providers. But certainly in a well-child check, if an adolescent has lost weight since their last visit, there needs to be a conversation.

Often parents notice these things before the pediatricians because teens don't go to the general provider often. It can be once a year. During COVID, it was even less than that. So it can depend. Sometimes it's a teacher, sometimes it's a guidance counselor, sometimes it's a coach. But certainly, yes, we definitely depend on our primary care providers to make that call.

Host Amber Smith: Is this something that can be handled without medical intervention? Can a family solve this on their own?

Nurse practitioner Davia Moss: Family-based therapy is actually the strongest evidence for healing an eating disorder, but also you need a mental health provider to help guide you through that.

There are certainly books out there, and I'm sure there are families that have made this happen on their own and helped their child turn it around. But support for the family and the patient is really important to help those relationships stay intact through a really difficult time.

Host Amber Smith: How would you recommend someone prepare for a medical appointment if they're coming to talk about eating disorders? What should they bring with them or be prepared to answer?

Nurse practitioner Davia Moss: We hopefully will have records from their primary care provider or whoever referred them, which shows weights, which is not all the information we need, but that is a huge indicator and often the first sort of red flag that will bring them into our office.

We do, it's called a blind weight, so our patients step onto the scale backward, and we do not show them what their weight is in our office. And if, honestly, if there's any question, even if someone was sent to us for a different diagnosis, if there's any question that this might be a difficult topic for the patient, we do a blind weight.

This is followed by orthostatic vital signs, which is a heart rate and a blood pressure in different positions. Often when we have malnutrition, when we go from laying to sitting to standing, our body doesn't do what it's supposed to do, so we can have dizziness, our blood pressure can drop, our heart rate can change significantly, and those are really big indicators that we're not getting enough nutrition.

Host Amber Smith: Is there any other medical testing that has to be done, or imaging or blood work?

Nurse practitioner Davia Moss: There's no imaging. We do have some blood work done on our patients. Our bodies are very, very good at keeping us stable. So often, blood work can look normal, and that's a good thing.

For patients that are hospitalized, when we start refeeding them -- meaning start giving them nutrition again -- there is a syndrome called refeeding syndrome that can be fatal. It's rare, but because it can be fatal, we're very careful to watch what happens to their electrolytes. That's things like magnesium, phosphorus, sodium that's in our bodies, and we keep an eye on those things to make sure they stay within normal limits.

Host Amber Smith: Can eating disorders be successfully treated, or can they be cured?

Nurse practitioner Davia Moss: They can. It's actually only about a third of our patients are truly cured. Some providers say it's similar to addiction, where you say you're continually in recovery. Some patients that I'm still in touch with that are in adulthood say that they truly are cured, and they don't -- what we refer to as the "eating disorder voice." It really can be a pretty cruel voice in their head -- and they find that that voice truly goes away. But it is a small, small amount of people that have true recovery. Some deal with this chronically through the rest of their lives, and some do succumb to their illness.

Host Amber Smith: So what's involved generally in the treatment?

Nurse practitioner Davia Moss: The most important thing is nutrition. We always say food is their medicine. Sometimes it involves SSRIs (selective serotonin reuptake inhibitors) or other antidepressants, anti-anxieties. These medicines actually don't work if you are malnourished. You need a chemical called serotonin, and when we're malnourished, we actually don't produce enough serotonin.

So that can be really, really discouraging, especially for parents, that it's just terrible to watch their child getting sicker and sicker. And unfortunately, food is their main medicine, and the food is the most difficult part for their child.

Host Amber Smith: So is nutrition education ... are there classes or guides that the patient learns?

Nurse practitioner Davia Moss: We have a couple of dietitians that we work with that have experience with eating disorders. You really want to make sure that your dietitian has experience with eating disorders because unfortunately, there are dietitians out there that do focus on weight loss and are more focused on the diet culture. So you want to make sure that your dietitian has that knowledge, so they're able to help with nutrition counseling as you're going through that process.

Host Amber Smith: What about psychotherapy? Is that always a component of this?

Nurse practitioner Davia Moss: Always, both for the patient and the family. The more that the family can be involved and help understand what the underlying symptoms that have led to this eating disorder, the better the patient can do.

Host Amber Smith: Are there therapists that specialize in eating disorders?

Nurse practitioner Davia Moss: Yes. We work with a number of therapists in our region that are specialized in eating disorders. And it's so crucial that as a team we collaborate. We often are emailing after every appointment, so we are all on the same page. Eating disorders are very, very, very powerful, and they can almost convince the patient that one part of the team, one provider in the team, is bad versus another member of the team. So it's really important the team is on the same page to make sure we can provide the best care for the patient.

Host Amber Smith: Upstate's "HealthLink on Air" will take a short break, but please stay tuned for more about eating disorders with nurse practitioner Davia Moss.

Welcome back to Upstate's "HealthLink on Air," with your host, Amber Smith. My guest is Davia Moss. She's a family nurse practitioner who specializes in adolescent medicine at Upstate, and we've been talking about the crisis of eating disorders.

What happens to someone who has an eating disorder that goes untreated?

Nurse practitioner Davia Moss: The longer a patient stays in an active eating disorder, the likelihood that they will recover from their eating disorder actually quickly declines. So the faster that we can find the eating disorder and treat the eating disorder, the better they do. The younger that we can address it, the better that they do.

We do have some patients that if they are not doing well with outpatient, which is what I do, they may need something called either partial hospitalization, which is like a full-time day program or residential treatment, which was when they lived there for anywhere from six to 12 weeks while they're recovering.

Host Amber Smith: When you have someone that you're treating, do you ask them to limit their social media usage or television, or are there things in the home environment that you try to shape for them?

Nurse practitioner Davia Moss: We try to find the balance of quality of life for teenagers. Social media is a huge piece of quality of life for them. So I think that piece is for the therapist to discuss what might be, we use the word "triggering," for a patient, and what is helpful. I think it's the same as, are these friendships toxic to your life, or are these friendships helpful? So those conversations are definitely important.

Exercise can be the same thing. Finding the balance of pulling a patient from their activities that they love so much, but recognizing what's actually helpful to their body at that time.

Host Amber Smith: Well, I want to ask you also about some of the medical side effects that come along, often, with eating disorders. Electrolyte imbalances, is that something that can be managed in the outpatient setting?

Nurse practitioner Davia Moss: Yes. So depending on how sick a patient is guides us on how often we might be doing blood work, or if we have patients waiting for a bed in residential treatment, especially through this crisis right now, we will do blood work more often. Sometimes we have them replacing electrolytes with things like Gatorade, eating foods with more salt, such as pretzels, what we know they can tolerate. That's sort of more like crisis management while we're waiting to get them to a higher level of care. EKGs, meaning we actually put stickers on the chest, so we can get a picture of the electrical activity in the heart, is also something very important that we keep an eye on, in the outpatient setting.

Host Amber Smith: How common are digestive problems like constipation or diarrhea?

Nurse practitioner Davia Moss: Very, very common. Constipation is much more common. Obviously the less you eat, the slower your gut is working. And then our patients that have abused laxatives or maybe diet pills can impact our gut for long-term use.

Host Amber Smith: For the female patients, do they typically have menstrual problems as well?

Nurse practitioner Davia Moss: They can. They can lose their menses for numerous months, which can impact their bone density. After losing their menses for about six months, we will do a bone density scan. Although truly bone density scans, we can't read them very well for adolescents because their bones are different. We only gain our bone density until about 22 years old. So if we don't treat that eating disorder and get them back on track and get their hormones such as estrogen back to the healthy levels, they can impact their bone density for the rest of their life.

Host Amber Smith: What about tooth erosion, cavities? Does this impact dental care as well?

Nurse practitioner Davia Moss: Absolutely. That's something we look at in our physical exam. That typically happens in our patients that are self-induced vomiting. And there are also patients that, if they're trying to decrease the amount of laxatives they're using, they actually can have unintentional vomiting. So dental care is very important.

Host Amber Smith: Well, knowing that this is such a risk for adolescents, is there anything that parents can do to try to prevent an eating disorder from developing in the first place?

Nurse practitioner Davia Moss: I think, 1, the culture we create in our house, how we talk about food, how we talk about good foods, bad foods, how we talk about dieting. If our parents are dieting frequently, throughout their lives, that's a huge risk factor for these kids. And then it makes you wonder, does the parent themselves just have an eating disorder that was never addressed? So absolutely creating the culture, being careful of how we talk about bodies in general.

I have a number of patients that were told as they, when they were young, that they were so skinny, and the minute they hit adolescence, which is very normal, all of a sudden they stopped hearing that, and that was the trigger. That was all they needed to go down the path of an eating disorder.

Host Amber Smith: Are there triggers like that -- for someone who's treated as an adolescent and 10 years later, 20 years later -- are there triggers that may make the eating disorder return?

Nurse practitioner Davia Moss: Yes. Especially in the female population, think pregnancy, body changes, even just stressors, going off to college, being in another environment that's full of diet culture, being surrounded by other people that may have an eating disorder that was never addressed. Absolutely those are things that we try to prepare them for as they move into the recovery phase of their eating disorder. We then try to move into having conversations about the triggers that will happen throughout their life.

Host Amber Smith: So someone who's in recovery from an eating disorder, does that set them up for other medical problems later in life? Not the ones that you would treat actively, but later on. If you have a history of eating disorders, would your primary care doctor need to be thinking about other things that might come up?

Nurse practitioner Davia Moss: It would be very important for a primary care provider to know if an adult did have an eating disorder as an adolescent.

We can certainly see from a mental health perspective, you can see OCD (obsessive compulsive disorder) symptoms, significant anxiety. We can see fertility difficulties, again, bone density difficulties. And of course those need to be addressed, maybe in a 30-year-old, where typically an internal medicine provider would not think to address that until much older.

Host Amber Smith: Do you see support groups for people with eating disorders?

Nurse practitioner Davia Moss: There are support groups. There's not enough. as we know in this mental health crisis in general, there's just not enough.

I think the biggest thing to look out for, for support groups, especially if you're a parent looking for a support group for your kid, is to know what stage of recovery the other members of the group are in. Because, of course, this could be very triggering if one patient is not in a state of recovery and maybe not healthy, doesn't have that support at home. That's definitely something to be aware of.

Host Amber Smith: It's got to be tricky to learn, if you've dealt with an eating disorder, to then learn how to eat healthy because you're focusing on food again to do that, right?

Nurse practitioner Davia Moss: Yes. So I think there's a balance. People use the term "intuitive eating," and that is sort of, I would say, the end of the road in recovery, to truly learn how to intuitively eat.

I know there's a lot in the diet culture world about what's not healthy on our shelves, what is healthy on our shelves, and so knowing that there's a balance. And if your body is craving something, typically that means that it wants it. And often if we withhold it, eventually you end up eating more than maybe you would have if you had just given your body what it was asking for.

Host Amber Smith: Davia Moss, thank you so much for making time for this interview.

Nurse practitioner Davia Moss: Thank you, Amber.

Host Amber Smith: My guest has been family nurse practitioner Davia Moss. She specializes in adolescent medicine at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," what a hospital stay is like today.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Most people who are hospitalized are quick to ask, "When can I go home?"

The answer to that question is quite a bit different today than 20 years ago or even 10 years ago.

For help understanding what is changing about hospitalizations. I'm speaking with Dr. Timothy Creamer. He's an assistant professor of medicine at Upstate, and he started the hospitalist program at the Community campus (Upstate Community Hospital) in 2001.

Welcome to "HealthLink on Air," Dr. Creamer.

Timothy Creamer, MD: Thanks for having me.

Host Amber Smith: Hospital stays are different today than a couple decades ago, so I'm looking forward to you walking us through some of the changes and the reasons for those changes.

One thing people may notice is, if they have a primary care doctor and they're hospitalized, their primary care doctor is not the one who takes care of them. It's a hospitalist like yourself, right?

Timothy Creamer, MD: That's correct. Medicine has expanded greatly over the past 30 years, and especially with regard to the availability of different types of medications and care, and what's happened is that because of that, being a primary care physician focuses your time. I was a primary care physician in Fabius for 25 years, and so I understand that dynamic of taking care of people and then driving in and seeing people in the evening.

The other problem was that as a primary care physician, your focus was in the office, and you weren't always available to the patient for questions and needs and out-of-town family and things of that sort. Out of that, the hospitalist developed, and the term was coined in 1994 and then really got started in the late '90s. And in 2001, we started the program over at the Community campus. It's expanded since, and what's happened is that now, in the hospital, you have a specialist taking care of you who specializes in the care of hospitalized patients.

Your primary care physician is still involved because we use their data and their medications and their interface to get background on the patient, and also the primary care physician helps to say, "Oh yes, the hospitalist will take care of you in the hospital," and kind of helps that interface.

One of the more difficult things that a hospitalist has to do is to establish a relationship with a patient and family at the time when the patient is in some level of crisis, either low level or more high level, so what happens is the primary care physician helps us with that interface to make sure the relationship is smooth.

Host Amber Smith: Do most of the doctors who specialize in hospital medicine have a background like you do, in primary care?

Timothy Creamer, MD: In the early days, yes, they all were primary care physicians. I was the only hospitalist for 14 months at Community General (now called Upstate Community Hospital) until we expanded the program. Program now has eight physicians and eight APPs, advanced practice providers, either PAs (physician assistants) or nurse practitioners assisting them.

So, having that background helped. I also worked with family practitioners at the LaFayette Health Center, and so I had familiarity with family practice and how they were trained and was able to interface well with them.

Host Amber Smith: Do hospitalists specialize? Are they subspecializing in particular types of illnesses?

Timothy Creamer, MD: Not necessarily. Now, there is a board certification for hospital medicine, and so it is considered a specialty. We focus on the care of patients in the hospital, whereas a gastroenterologist takes care of things associated with the digestive system, and cardiologists take care of the heart, the hospitalist takes care of the hospitalized patient. And with the availability of all the different techniques, it continues to expand as a specialty and really needs separation from the primary care, separation as well as integration with the primary care. Because as an outpatient, you have different responsibilities now, so it's a specialty that continues to expand.

Host Amber Smith: Do we know yet whether hospitalists have measurably improved overall care in the hospital?

Timothy Creamer, MD: Definitely. There's definite data, especially out of Johns Hopkins (University), that shows that the hospitalist availability in and of itself as far as the interface with patient and families, we can address the needs of a patient within minutes, whereas if I was in Fabius, it might take hours for me to get into the hospital. And really a lot of that was handled previously by nursing. Now it can be handled by physician.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Upstate's Dr. Timothy Creamer about the hospitalist program and what a hospital stay is like these days from the patient's point of view. Technology is improving health care in many ways. Can you tell us some of the things a hospitalized patient might notice today?

Timothy Creamer, MD: There's a number of things that are really changing.

One of them is the length of stay. We used to send people home from the hospital when they were well. We then sent people home from the hospital when they were better. And now we're really looking at getting people home when they are treated.

As you led in with, people always want to get home as soon as possible. First question a lot of people ask is, "When can I go home?"

And so what happens is the services in the community are expanding and continue to expand to the point where we really feel safer going home and being at home and comfortable at home, yet still providing the services necessary for them to get well.

The other thing people may notice is a lot more bedside technology. Used to be, we had a stethoscope and our ears to do diagnostics at the bedside. Now, with technology, point-of-care ultrasound is now being used actively, and actually there's a program that's being recognized nationally at Upstate to allow physicians at the bedside to have a sonography at the bedside. In other words, a sound wave test, the tests that used to have to schedule and go down to a special unit. These tests are now being done at the bedside and much more rapid diagnostics.

Well, the last thing I'll say is that the involvement of the previously mentioned APPs, the advanced practice providers, which includes physician assistants and nurse practitioners, are much more involved.

When I started at Community, we had three to four doctors and one PA. We now have eight physicians and eight APPs, and these are professionals that have been involved with health care since they started their training. And so, you'll see more of them at the bedside, assisting the physicians in their care.

And actually, they're as specialized in bedside care as many of the physicians are.

Host Amber Smith: You mentioned length of stay. How short are lengths of stay now compared to the time that you began practicing as a hospitalist?

Timothy Creamer, MD: When I started my first day in hospital medicine, our length of stay was 7.1 days. That number is now down to 4.5 days on average.

And even at an institution, a Level 1 trauma center like Upstate downtown, it's still in the four- to five-day range, so it's decreased significantly from where it was before, but again, the services available as outpatient, especially in our local region, have expanded to where that's safe.

We want to be sure that patients have a safe discharge, and they are evolved to a safe environment at home.

Host Amber Smith: Is the goal to save money, or has it been proven that patients can heal better at home?

Timothy Creamer, MD: There are studies that show that people do better at home, especially mentally. The hospital, especially, has demonstrated, with the COVID pandemic, they really can be treated at home and do better at home.

During the pandemic, we sent people home who we previously would've admitted to the hospital, and actually the outcomes were as good, if not better, because I think mentally they felt they could get better at home.

And again, with the support services available, especially the use of telemedicine, there was still an interface with their provider that they could access if they were getting uncomfortable.

Host Amber Smith: And so this whole program, the Hospital at Home program, can you describe how that works, and is that something that Medicare is supportive of?

Timothy Creamer, MD: Medicare, yes. The Hospital at Home program actually was begun prior to the pandemic, in 2017, and it was recently approved for another two years. It was continued through the pandemic and then approved for another two years. Hospital at home is a great tool to get people back to a setting they're comfortable with, when they're stable medically.

The two types of patients we really look at are people who need long-term antibiotics but are stable medically, but need, say 10, 14 or 21 days of antibiotics in order to complete their treatment course. Those people, basically, in the hospital, just are waiting for, daily or twice daily, for their intravenous, when now they can be at home getting their antibiotics in a comfortable setting with family support around them, and also, in addition, the support of our home care group, the Nascentia (home care agency) group, which has nurses go in at least twice a day, and are available 24/7, as they would be in the hospital to care for them.

The other type of patient that it helps out is, hospice services in Central New York are a little bit overwhelmed with the population. And what happens is sometimes the delay to get into hospice is upwards of three to five to seven days. And what we can do is, especially in a circumstance where a patient wants to be home, if they have a terminal illness, we're able to get them home, keep them comfortable, still have nursing intervention, and yet have a seamless transition to hospice when hospice has the availability to properly care for them.

Host Amber Smith: So how does that work, in terms of nursing intervention? If a patient's at home, does a nurse come to their house? Or how do they check in with the doctor if they have questions or concerns?

Timothy Creamer, MD: There's three ways that health interventions occur.

The nurses go in at least twice a day, and then they do what they call a tuck-in call in the evening. They're also on call through telephone or telemedicine. We have an iPad set up to where you can get a visual of the patient as well as the visual of the provider or the nurse.

The other interface is the previously mentioned APPs at the hospital. There's one assigned each day to interface with the patient so that any orders that need to be updated or any immediate interventions that they have, the availability of contacting a professional provider to adjust their medications and their therapies.

And then the third thing is that I, specifically, have been doing house calls on admission and discharge and at least every three days in between to assist in the interface and to let the patients know that their physician is still involved with them. I can also do a telemedicine interface if necessary.

And so this three-way, this troika, if you will, of communication between three of the providers affords the patient a safe environment to get the therapies they need and also to address their more urgent needs, should they arise.

Host Amber Smith: So, as the doctor overseeing care of these patients in the hospital, if you have a patient who really would like to go home, in addition to the medical issues, do you also have to look at social concerns, such as the safety of the home environment or what type of home environment they have to return to?

Timothy Creamer, MD: Yes, absolutely. What happens is Nascentia Home Care has experience in the homes and recognizes when it's safe and making sure that the environment is set up in a way. I know that we bring in medical equipment into the home, but what happens is when the nurses go in initially, they can basically see where the patient needs to be and adjust, say, where the hospital bed can go, where the IV pole can go, whether there's appropriate bathroom facilities on the floor, and also the availability of family and family support. We are usually able to get a pretty good engagement with the family to describe to them what type of setting we need. And people are so excited, I guess is the word, to get their family member home that they really do adjust the environment so that the patient can be moved safely to the home.

And, we can also intervene in between times to make it even better.

Host Amber Smith: What options does a person have if they live alone?

Timothy Creamer, MD: That's very difficult. It's a difficult circumstance because anytime a person who is chronically ill or terminally ill lives alone, it's very difficult to send them back to that isolated setting.

Chronic illness is difficult to deal with on your own, but to be alone with it is a tricky circumstance. We usually do everything we can to find family members that are available, specifically, even shirttail relatives, to come in and stay with the patient so that we're able to get them home.

But that is a difficult barrier in any setting. Sometimes these people are more supported in a more social situation that a facility might provide. And in general, with people who we are unable to do anything with them living alone, we usually recommend that they go to a facility.

It also all depends on the illness. We have had people who have just needed intravenous antibiotics and have actually handled it on their own. And in that particular circumstance, we do everything we can to get them home and get them the care they need and get them the physical support they need, possibly more phone calls during the day, but that's a situation that is tricky, that we work very hard to get the person home to as safe a setting as possible.

Host Amber Smith: So at some point, the patient will be ready for discharge. And similar to how you would look at someone in the hospital to determine whether they're ready to be discharged to go home, how do you look at a patient who's home to decide whether they're ready to not have that connection with the hospital?

Timothy Creamer, MD: Well, with Hospital at Home, we have the interface of three of us, at least three of us, if not more, being able to kind of see the person physically, see the person daily through tele-interface. And between the three, of us, we are able to determine whether the patient really can be discharged from the, intense service and go back to their life, just like they would if they were in the hospital. We also have the ability to do physical therapy in the home to make sure they're moving, make sure they're up and about. We can also instruct family members, on how to keep them active, and progress them to general good health.

We really haven't, at this stage, knock on wood, had the circumstance of someone deteriorating at home, because I think the attentiveness has been such that we've been able to support them to the point where they got healthy again.

Host Amber Smith: Once someone is discharged, I assume they go back to their primary care provider.

Do they ever see their hospitalist again?

Timothy Creamer, MD: Well, like all hospitalized patients, we hope that they never come back again, and they're able to be managed as an outpatient. They may not see their hospitalist again. We try to communicate our names, and through business cards and things of that sort, who we are and what we do.

But what we try to do is look at the hospitalists as all being equally trained and have a collegial atmosphere, where we all do things in the best interest of the patient. And with our focused training, instead of focusing in on "my hospitalist being Dr. Creamer," or "my hospitalist being Dr. Hegazy," that "I was taken care of by the hospitalist group."

I think that's another thing that's happened in medicine, is that between Tuesday and Wednesday, which is our switchover day, you could have three separate providers taking care of you, the daytime hospitalist on Tuesday, the nocturnist on Tuesday evening and the new hospitalist coming on on Wednesday.

So that's the other thing that we look at in hospital medicine. We make sure that we have this collegial atmosphere to be able to take care of people. And you come into the hospital, you don't get the opinion of a single doctor, you might get the opinion of two or three different professional providers.

Host Amber Smith: Well, Dr. Creamer, thank you so much for making time to tell us about this.

Timothy Creamer, MD: Well, I appreciate you having me and hope that we've helped people understand a very complex health system, especially as we move out of the pandemic, with a lot of these new things happening.

Host Amber Smith: My guest has been hospitalist Dr. Timothy Creamer. He's an assistant professor of medicine at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from Chief Nursing Officer Scott Jessie from Upstate University Hospital. What kind of person would make a good nurse?

Nurse Scott Jessie: The profession attracts a really wide variety of people, and I think that's the beauty of the profession, honestly. There is a lot of pressure in some kinds of nursing, for sure. It can be very, very intense, and in other different types of nursing practice, maybe a little bit less so, and I think that gives a lot of different people options when they get into the career.

I do think you have to definitely be a committed and caring person. I think everybody who gets into nursing at the base level likes to work with people, likes to help people. That's why they do it.

Everybody knows health care is stressful, whether you work in a physician's office where you see an awful lot of patients a day, or you work in the emergency department or an acute care med-surge (medical and surgical) unit taking care of patients, patients' lives are in your hands. It's a high-responsibility position. It's stressful. It is beyond rewarding, and I think that's why people do it,

But yeah, it is stressful, it's challenging, and I do think people who get into it, I don't know if they're all great at dealing with pressure initially; they learn that over time. I think what they do realize, or come to the profession with often, is the ability and acknowledgment that they need to be flexible. Our day's never the same, no matter what we do, and you have to be able to pivot, and that's really important.

We end up getting nurses with all different kinds of backgrounds and degrees. We have a lot of nurses, ultimately, who end up going back to school after they've earned a bachelor's in something else, for example, and end up in the health care profession.

I think naturally you have to be an inquisitive person to be a nurse. You have to like and understand how the body works. That's really important from that perspective.

Do you have to love chemistry? Maybe not so much. I can certainly tell you a lot of nurses would say they didn't love their chemistry classes, but you have to have some basic understandings. The amount of knowledge that you need to be a nurse is tremendous in reality. We take care of all ages of patients under all circumstances and all disease types. And the number of medications, for example, that are available has grown exponentially over the years.

And you have to know how they work and how they interact. And we, thank goodness, have tremendous partners in pharmacists who help us with those things, but at the bedside, you're the person giving the medication, nobody else is, and you have to know the risks and the safety concerns and how they interact, and if it's the right medication, and so, yeah, science is very important. Excellent communication skills are very important. Being a people person is very important. A good, broad background is really important, I think, for people who are interested in getting into the field, though.

Host Amber Smith: You've been listening to Scott Jessie, the chief nursing officer at Upstate University Hospital.

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Rob Jacques lives and writes on a rural island in Washington state's Puget Sound. He takes us through a man's determined struggle to stay clear in his poem "It's Not Dementia."

He begins with some lines from Robert Frost:

-- One can see what will trouble

This sleep of mine, whatever sleep it is.

Were he not gone,

The woodchuck could say whether it's like his

Long sleep, as I described its coming on,

Or just some human sleep.

For the life of me, I can't get used to seeing old friends

gone for years visiting me at odd moments, their being

dead no barrier at all to their attentive listening to me,

then disappearing as if they were never here beside me,

their smiles as warm as ever, their bodies as healthy

as they were long ago when we were young humanity.

The walk may be asphalt to you, but to me, I walk on

a soft woodsy duff as I reach out, not for that steel pole,

but for a black birch that grew old beside my school,

that grows there still in my timeless, faultless mind,

and even now its bold, lenticillated bark feels cool

to my hand though you see metal from where you stand.

My birdfeeders, where are they? Where did I put seed?

Here in my room, I search for small things that stray

and are lost to you, but not to me, and I need their feel

between my fingers: rings, coins, photographs, and such

that trigger scenes that seem to be current still and I'm

in them as I was back then: young, robust with a will.

Strings of long-ago conversations yet come to mind.

I try to carry them on even though I know I'm alone

and who knows who's listening? Things I wished

I'd said I say now hoping those who aren't here

still can hear, those who mattered once can know

I haven't forgotten them though time has shattered.

The past is a better place than here, and I dust off

memories to be back bright again in my world of yore

where I was whole and strong and still am in my

mind's eye where there are no stone strangers,

no corridors that lead nowhere I want to go, and I

live inside a blown reverie of what was until I die.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," a book about Dr. Elizabeth Blackwell, the first female doctor in America. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.