- Alison Herndon
1. As the Clinical Section Head of Vanderbilt’s PHM Division and Medical Director of Inpatient Acute Care at Monroe Carell Jr Children’s Hospital, can you tell us about your experiences in these roles? What are your favorite parts of the job? What are some challenges?
I started in the newly created Clinical Director/Section Head role in January 2018 and became involved as the Medical Director of Inpatient Acute Care at the same time, officially taking over in July. Looking back, I am grateful I had time to explore these roles and grow more comfortable before the pandemic hit. The Clinical Director role actually bears quite a resemblance to that of a chief resident, minus all the drama. As the Medical Director, I work closely with the hospital and nursing leadership, and have gained a better understanding of the massive amount of work that goes on behind the scenes. These roles complement each other nicely and allow me to be a voice and advocate for our division as well as the residency. Hands down my favorite part centers on my amazing colleagues – it is an honor to be given their trust to represent our section across the enterprise and have close involvement with the planning and decisions that affect all of us. The challenges inherent to these roles look different pre-pandemic to now. Before the pandemic, at times it seemed like pediatric hospitalists were not always given the same respect as other subspecialties, and a good deal of time was spent trying to navigate that. Since the pandemic started, I think pediatric hospitalists have really shined, which is exciting to see. We not only were the first entrusted with the care of COVID-19+ patients at my institution, but we also spearheaded the endeavor to care for young adults in an effort to ease the burden a bit from the adult hospital, and have garnered more recognition and appreciation of what we can bring to the table. I’m really looking forward to seeing where things go from here.
2. You are also the Assistant Program Director of the Vanderbilt Pediatric Residency Program and have interest in fostering resident autonomy. How do you encourage that, and how do you “let go” as the attending and allow the residents to have ownership of their patients?
As hospitalists we are super lucky to work so closely with the residents and get to know them well by the end of their residency careers. I have never felt like I am missing out on continuity or longitudinal relationships with patients, but in recent years it dawned on me that the residents essentially fill that role. I invariably work with them as newborns on July 1st and it is really fun how each day is so different from the day before, and how they look like different people by the end of that first week. I find it incredibly rewarding to not only help shape but bear witness to their growth, and graduated autonomy is a huge part of creating capable, awesome young physicians.
To start with, I think setting expectations while maintaining a safe learning environment is incredibly important. For example, interns know they will be the first to speak when we enter the room on rounds, and it is really satisfying to me when parents look to them to ask a question and not to me or the senior. The senior knows they are in charge of the team, have space to speak up next, and that I am equally happy to just say, “hi,” as I am to drop a knowledge bomb or say something intelligent when necessary. For the more experienced seniors, I try to give them two consecutive days to “pre-tend” without me present. I am nearby, and they know I will be there in a second if needed. But I think there is much to gain from the senior physically doing this exercise rather than just the thought experiment “what would I do if I were the attending?” I have received very positive feedback from the seniors, and it has surprised me how much the interns have enjoyed this as well. I do fall on the less conservative, less detail-oriented side, which probably makes it easier to “let go,” but I’m sure it also helps to have such solid residents we know so well.
3. You presented an interesting workshop at PHM 2017 titled “Trauma Informed Care and NAS”. What is your advice for supporting and collaborating with parents when their infant is being treated for NAS?
When we put this workshop together, I was dismayed to learn how clearly the biases of the medical providers negatively impacted the parents’ experiences. As a teaching hospital, our learners are closely involved with their care, and I have often borrowed an exercise from that workshop to highlight personal/unconscious biases. I ask them to fill out the Adverse Childhood Experiences scale for themselves, and when collected anonymously, most learners have very few ACEs. They are usually surprised to learn that the vast majority of these mothers have very high scores, and I think recognizing those differences in background and upbringing goes a long way in replacing some of that judgement with compassion. I will also remind them that majority of these mothers already feel incredibly guilty, and it is unnecessary to repeatedly remind them on rounds that the patient had intrauterine drug exposures and has developed NAS – we are all well aware of it. We have seen a substantial decrease in length of stay when parents are present and able to perform nonpharmacological interventions, and we encourage them to be as present and involved as possible. We are also lucky to have ancillary support for our NAS population through Team HOPE, which also goes a long way in partnering with parents.
4. How has the COVID-19 pandemic affected family centered rounds and bedside teaching at your hospital? Any tricks you’ve found to engage your learners with smaller rounding groups and/or spending less time in the patients’ rooms?
This has really been really tricky to maneuver as things seem to still be constantly evolving with regard to approved group size, non-resident learner presence (e.g.., med students, pharmacy residents), PPE shortages, etc. We have tried to do our best on rounds and limit the number entering rooms though our census is still lower than normal, and I do worry some about the interns having fewer patient encounters this year and less exposure to bread-and-butter peds (anyone seeing bronchiolitis?!). Some of the hospitalists have incorporated more post-rounds didactic sessions with their teams, and our afternoon teaching sessions became virtual in the spring. It at least feels like this will continue for a finite amount of time now that we have a vaccine.
5. With the COVID-19 pandemic, you have been involved with offloading young(ish) adults from the adult hospital service. What are the challenges, and what have you learned? Any recommendations for others that need to do this at their institutions?
This has been a really interesting, albeit time-intensive, endeavor, and I am repeatedly reminded how lucky I am to be a pediatrician and care for children. The leadership roles I described above put me in a unique position where I can represent and advocate for the hospitalists, residents, and patients, while also building on the relationships I already have with hospital and nursing leadership. I imagine this will be true for many, but it was hard to watch our adult colleagues drown without being able to offer much (other than lots of coffee and snacks), and we were relieved this summer when we opened our doors to a select young adult population. It turns out those in their twenties who require hospitalization are often hot messes, and we have slowly had to increase our age cut-off and expand our accepted diagnoses list. One big challenge has been to identify which ages and conditions pediatric providers and nurses feel comfortable with, while also working with some non-negotiable exclusions (e.g., unstable psychiatric conditions, drug abuse, etc.).
Despite the children’s and adult hospitals falling under the same medical center umbrella, there are more differences in admission processes, primary team designations, and floor vs ICU status than I ever thought possible, and we have had to learn much about each side and establish new lines of communication. In a bit like the hospitalist version of Parent Trap, I was paired with my adult hospitalist counterpart. We have spent a LOT of virtual time together, and luckily for all of us, she is beyond amazing. I think that partnership went a long way in moving this forward – having the representatives from each side that actually live in their respective worlds and know the ins and outs first-hand has made it much easier to create and establish workable guidelines and processes. We are definitely having to flex outside of our comfort zone and normal practice habits, but there is a lot of support and we have been able to do this safely. It has been fun to get to know our adult colleagues, and I am truly impressed with them.
6. You recently published a brief report in the Journal of Hospital Medicine about costs for mental health hospitalizations. What were your results, and is there anything hospitalists can do to decrease costs and improve reimbursements for mental health hospitalizations?
We confirmed what I think most people expected, which is that we do not get reimbursed as well as we do with non-mental health medical admissions. I feel like we’ve unfortunately already lost the battle by the time a patient gets admitted to the hospital (we desperately need outpatient resources), but I definitely think there are things that can be done from the inpatient side to advocate for our patients. One thing that has been a huge success for us was the creation of a behavioral health team a couple of years ago. We were lucky enough to hire a superb psychologist to help lead and shape that team. We now have a second psychologist, an incredible nurse practitioner, and the larger behavioral team includes a dedicated case manager, social worker, and we also partner with the Child & Adolescent Psychiatry team. While it may not directly affect cost or reimbursement, this team has gone a long way to improve patient and provider satisfaction, and we have been able to significantly decrease length of stay, restraint usage, and staff injuries since its inception.
7. Feedback can be difficult to give to anyone but especially to our colleagues. Please tell us about your work with faculty peer observation and feedback.
The idea for peer observations came from an exercise I did as part of the APEX Teaching Program where a mentor observes you on rounds and gives you feedback. I felt like we could learn a lot from each other and potentially grow more cohesive as a division, and I think you can also learn just as much about yourself when you observe someone else. Using available literature about what makes a good hospitalist, the above mentor and I put together a checklist of objective and subjective items to focus on, and I think that took the edge off a bit. This has evolved some, and more recently I’ve paired people with opposing (perceived) strengths and weakness, although the pandemic ran interference, and we had to put this on hold. As I mentioned before, my colleagues are truly amazing people who are humble and constantly working on improvement, and this exercise has felt more natural than difficult.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
My pre-pandemic self really lived by the tagline “fake it til you make it.” In fact, I have artwork with that phrase that was created by a very talented former resident and is displayed in my office. I had been out of residency and in new roles long enough to feel less like an imposter, but would still marvel from time to time that people entrusted me to take on some of those leadership roles. My mid-pandemic self still marvels, but like so many of you I have spent a significant amount of time far from my comfort zone since March, and the phrase has taken on a slightly different meaning. The unknown is uncomfortable for many of us, especially in a year where the world turned upside down and inside out. I have found it easier to deal with it if I “fake it til I make it” – roll with the changes even though it sucks to not be on solid ground, be patient with others even though my to-do list is actively growing, give myself some grace even though I know I could be doing a better job, and answer these questions while respecting the caliber of the people who have done this before me.
I started in the newly created Clinical Director/Section Head role in January 2018 and became involved as the Medical Director of Inpatient Acute Care at the same time, officially taking over in July. Looking back, I am grateful I had time to explore these roles and grow more comfortable before the pandemic hit. The Clinical Director role actually bears quite a resemblance to that of a chief resident, minus all the drama. As the Medical Director, I work closely with the hospital and nursing leadership, and have gained a better understanding of the massive amount of work that goes on behind the scenes. These roles complement each other nicely and allow me to be a voice and advocate for our division as well as the residency. Hands down my favorite part centers on my amazing colleagues – it is an honor to be given their trust to represent our section across the enterprise and have close involvement with the planning and decisions that affect all of us. The challenges inherent to these roles look different pre-pandemic to now. Before the pandemic, at times it seemed like pediatric hospitalists were not always given the same respect as other subspecialties, and a good deal of time was spent trying to navigate that. Since the pandemic started, I think pediatric hospitalists have really shined, which is exciting to see. We not only were the first entrusted with the care of COVID-19+ patients at my institution, but we also spearheaded the endeavor to care for young adults in an effort to ease the burden a bit from the adult hospital, and have garnered more recognition and appreciation of what we can bring to the table. I’m really looking forward to seeing where things go from here.
2. You are also the Assistant Program Director of the Vanderbilt Pediatric Residency Program and have interest in fostering resident autonomy. How do you encourage that, and how do you “let go” as the attending and allow the residents to have ownership of their patients?
As hospitalists we are super lucky to work so closely with the residents and get to know them well by the end of their residency careers. I have never felt like I am missing out on continuity or longitudinal relationships with patients, but in recent years it dawned on me that the residents essentially fill that role. I invariably work with them as newborns on July 1st and it is really fun how each day is so different from the day before, and how they look like different people by the end of that first week. I find it incredibly rewarding to not only help shape but bear witness to their growth, and graduated autonomy is a huge part of creating capable, awesome young physicians.
To start with, I think setting expectations while maintaining a safe learning environment is incredibly important. For example, interns know they will be the first to speak when we enter the room on rounds, and it is really satisfying to me when parents look to them to ask a question and not to me or the senior. The senior knows they are in charge of the team, have space to speak up next, and that I am equally happy to just say, “hi,” as I am to drop a knowledge bomb or say something intelligent when necessary. For the more experienced seniors, I try to give them two consecutive days to “pre-tend” without me present. I am nearby, and they know I will be there in a second if needed. But I think there is much to gain from the senior physically doing this exercise rather than just the thought experiment “what would I do if I were the attending?” I have received very positive feedback from the seniors, and it has surprised me how much the interns have enjoyed this as well. I do fall on the less conservative, less detail-oriented side, which probably makes it easier to “let go,” but I’m sure it also helps to have such solid residents we know so well.
3. You presented an interesting workshop at PHM 2017 titled “Trauma Informed Care and NAS”. What is your advice for supporting and collaborating with parents when their infant is being treated for NAS?
When we put this workshop together, I was dismayed to learn how clearly the biases of the medical providers negatively impacted the parents’ experiences. As a teaching hospital, our learners are closely involved with their care, and I have often borrowed an exercise from that workshop to highlight personal/unconscious biases. I ask them to fill out the Adverse Childhood Experiences scale for themselves, and when collected anonymously, most learners have very few ACEs. They are usually surprised to learn that the vast majority of these mothers have very high scores, and I think recognizing those differences in background and upbringing goes a long way in replacing some of that judgement with compassion. I will also remind them that majority of these mothers already feel incredibly guilty, and it is unnecessary to repeatedly remind them on rounds that the patient had intrauterine drug exposures and has developed NAS – we are all well aware of it. We have seen a substantial decrease in length of stay when parents are present and able to perform nonpharmacological interventions, and we encourage them to be as present and involved as possible. We are also lucky to have ancillary support for our NAS population through Team HOPE, which also goes a long way in partnering with parents.
4. How has the COVID-19 pandemic affected family centered rounds and bedside teaching at your hospital? Any tricks you’ve found to engage your learners with smaller rounding groups and/or spending less time in the patients’ rooms?
This has really been really tricky to maneuver as things seem to still be constantly evolving with regard to approved group size, non-resident learner presence (e.g.., med students, pharmacy residents), PPE shortages, etc. We have tried to do our best on rounds and limit the number entering rooms though our census is still lower than normal, and I do worry some about the interns having fewer patient encounters this year and less exposure to bread-and-butter peds (anyone seeing bronchiolitis?!). Some of the hospitalists have incorporated more post-rounds didactic sessions with their teams, and our afternoon teaching sessions became virtual in the spring. It at least feels like this will continue for a finite amount of time now that we have a vaccine.
5. With the COVID-19 pandemic, you have been involved with offloading young(ish) adults from the adult hospital service. What are the challenges, and what have you learned? Any recommendations for others that need to do this at their institutions?
This has been a really interesting, albeit time-intensive, endeavor, and I am repeatedly reminded how lucky I am to be a pediatrician and care for children. The leadership roles I described above put me in a unique position where I can represent and advocate for the hospitalists, residents, and patients, while also building on the relationships I already have with hospital and nursing leadership. I imagine this will be true for many, but it was hard to watch our adult colleagues drown without being able to offer much (other than lots of coffee and snacks), and we were relieved this summer when we opened our doors to a select young adult population. It turns out those in their twenties who require hospitalization are often hot messes, and we have slowly had to increase our age cut-off and expand our accepted diagnoses list. One big challenge has been to identify which ages and conditions pediatric providers and nurses feel comfortable with, while also working with some non-negotiable exclusions (e.g., unstable psychiatric conditions, drug abuse, etc.).
Despite the children’s and adult hospitals falling under the same medical center umbrella, there are more differences in admission processes, primary team designations, and floor vs ICU status than I ever thought possible, and we have had to learn much about each side and establish new lines of communication. In a bit like the hospitalist version of Parent Trap, I was paired with my adult hospitalist counterpart. We have spent a LOT of virtual time together, and luckily for all of us, she is beyond amazing. I think that partnership went a long way in moving this forward – having the representatives from each side that actually live in their respective worlds and know the ins and outs first-hand has made it much easier to create and establish workable guidelines and processes. We are definitely having to flex outside of our comfort zone and normal practice habits, but there is a lot of support and we have been able to do this safely. It has been fun to get to know our adult colleagues, and I am truly impressed with them.
6. You recently published a brief report in the Journal of Hospital Medicine about costs for mental health hospitalizations. What were your results, and is there anything hospitalists can do to decrease costs and improve reimbursements for mental health hospitalizations?
We confirmed what I think most people expected, which is that we do not get reimbursed as well as we do with non-mental health medical admissions. I feel like we’ve unfortunately already lost the battle by the time a patient gets admitted to the hospital (we desperately need outpatient resources), but I definitely think there are things that can be done from the inpatient side to advocate for our patients. One thing that has been a huge success for us was the creation of a behavioral health team a couple of years ago. We were lucky enough to hire a superb psychologist to help lead and shape that team. We now have a second psychologist, an incredible nurse practitioner, and the larger behavioral team includes a dedicated case manager, social worker, and we also partner with the Child & Adolescent Psychiatry team. While it may not directly affect cost or reimbursement, this team has gone a long way to improve patient and provider satisfaction, and we have been able to significantly decrease length of stay, restraint usage, and staff injuries since its inception.
7. Feedback can be difficult to give to anyone but especially to our colleagues. Please tell us about your work with faculty peer observation and feedback.
The idea for peer observations came from an exercise I did as part of the APEX Teaching Program where a mentor observes you on rounds and gives you feedback. I felt like we could learn a lot from each other and potentially grow more cohesive as a division, and I think you can also learn just as much about yourself when you observe someone else. Using available literature about what makes a good hospitalist, the above mentor and I put together a checklist of objective and subjective items to focus on, and I think that took the edge off a bit. This has evolved some, and more recently I’ve paired people with opposing (perceived) strengths and weakness, although the pandemic ran interference, and we had to put this on hold. As I mentioned before, my colleagues are truly amazing people who are humble and constantly working on improvement, and this exercise has felt more natural than difficult.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
My pre-pandemic self really lived by the tagline “fake it til you make it.” In fact, I have artwork with that phrase that was created by a very talented former resident and is displayed in my office. I had been out of residency and in new roles long enough to feel less like an imposter, but would still marvel from time to time that people entrusted me to take on some of those leadership roles. My mid-pandemic self still marvels, but like so many of you I have spent a significant amount of time far from my comfort zone since March, and the phrase has taken on a slightly different meaning. The unknown is uncomfortable for many of us, especially in a year where the world turned upside down and inside out. I have found it easier to deal with it if I “fake it til I make it” – roll with the changes even though it sucks to not be on solid ground, be patient with others even though my to-do list is actively growing, give myself some grace even though I know I could be doing a better job, and answer these questions while respecting the caliber of the people who have done this before me.