Amit Singh
1. In July 2013, you wrote a piece in Hospital Pediatrics called ““Mom, I’m going to be an INPATIENT doctor…” (My mom still tells people I do “hospice” medicine which leads to awkward conversations). In it, you talked about how you explain what a pediatric hospitalist does to your friends and family. Can you share that explanation with us?
Ha, it’s funny how time can change your perspective. When I was finishing fellowship I think I was thinking hard about why I chose to do it and the next phase of my career and was really excited and sharing that excitement with friends and family who wanted to know if I was a “real” doctor yet. Most didn’t understand it so I was trying to figure out how to craft the answer. The first thing I wanted was their ears and brains to hear the word “hospitalist”. I wanted them to know that was my “specialty”. Basically I tell people I am like your child’s general pediatrician you see in the clinic but on the inside of the hospital instead. Then I let them know that I help take care of children who are hospitalized with almost any condition whether it be simple or more complicated. I explain that some children require a lot of care by many subspecialists who may just work on their one part of the body and we help kind of keep the “forest for the trees” view of their care. I also explain that because the hospital is like our “organ” when we aren’t seeing patients we are often involved in all sorts of systems level work within the administrative side of the hospital. I remember feeling very strictly that our job was within the walls of the hospital and feeling pretty committed to that. Going back to what I said in the beginning about perspective though, having now been out as an attending for about 4.5 years, I think my mindset has changed and I realize that as hospitalists we have an ability to really impact health systems as a whole and think beyond just the hospital based on the work we are doing inside of it.
2. In a recent commentary, you wrote about technology in the medical field and asked, “why have our work environments not kept pace with the rest of the world?” Can you give us your theory about why medicine lags behind?
Tough question! There are so many different reasons it’s hard to say. In my opinion I think it’s a few big things. The first is that healthcare is just such a large and heterogenous entity that it’s hard for change to flow through. Think about all the different places you can get care nowadays…a clinic, a hospital, an urgent care or “minute clinic”, and now, telehealth or even on-demand physicians who can come to your home. Each one not only is a unique setting but may have a unique electronic health record or maybe not even an electronic health record and none of them talk to each other. Add on top of that the economic layer of how money is handled in medicine in general and those are big barriers to entry for any commercially available technology that might make our lives easier. Moreover, I think also the nature of our work and the issue of privacy puts a whole layer on top of technology that makes it difficult to implement because patients (rightly so) place a large value on keeping their health information secure. But the converse is we aren’t the only industry that deals with issues of privacy. One other reason is culture. In general, I feel that on the whole, physicians are fairly resistant to change. There’s a lot of “if it ain’t broke…” mentality I have encountered personally which I think is also mainly a generational thing? I think that the younger generation of trainees are entering the workforce with just a baseline use of technology in their every day lives that they are now demanding in their workplaces too. I mean these days I can track my amazon package every step of the way from my phone but I still have to get outside blood culture results faxed to me?
Finally, an important point is that I think that much of the technology we use in daily practice wasn’t developed by clinicians right from the get-go. This means that it may not be optimally designed for our workflows and if the foundation isn’t right, it’s hard to make improvements on top of it. Is that our fault? Some may say no. The enormous amount of time it takes to just learn medicine and complete training, we aren’t afforded the time to worry about anything else. We are working for years just to be a doctor. But, on the same token, other industries that require lots of training (say lawyers for example) don’t seem to let their field be dominated by others. I don’t know if we can continue to complain about technologies that we continue to accept and not make any effort to change ourselves. What I mean to say is that, instead of griping about how this EMR stinks, we should be working side-by-side with the developers and computer scientists to develop systems together that are simple, fit our workflows and needs, and can allow for ease of transfer of information so patients don’t have to repeat information over and over or be responsible for keeping up every detail of their instances of care.
3. What are the best resources and conferences for younger pediatric hospitalists looking to get involved in informatics and medical technology? How would you suggest integrating technology into patient care and research when first starting out?
Great questions. I think the first thing is to seek out opportunities for getting involved in your IS or IT department at your own institution. If you are a fellow, take some elective time to go meet with your CMIO and find out if there are projects that you can get involved in. In my experience, people working in healthcare IT love the input from front-line providers and really appreciate the clinical perspective. The other is to consider maybe spending some time pursuing introductory informatics coursework if you are really interested. If your local university setting doesn’t have one, then consider an online course or going to conferences beyond the “usual” ones you might attend. The American Medical Informatics Association’s annual symposium is a great forum for a resident, fellow, or faculty to see what all is going on at a national level and network with other like-minded individuals. I was really impressed when I went for the first time a few years ago. I also enjoy learning new things from people who share on Twitter. I know, I know, learning from social media…it sounds crazy right? I would have thought the same too until I used it after having being asked to be a social media co-chair for the PHM conferences. I was surprised at just how many abstracts or articles I would see in my twitter feed when I first joined that I wasn’t seeing in my traditional journals or listservs. People sharing information is basically all Twitter is at its core. Don’t let it intimidate you, just join and follow people or subjects you’re interested in and see what you want. Many “famous” pediatric hospitalists who have been here in the Hospitalist Corner are active themselves posting some great content all the time.
With regards to your second question, there are two things to think about from my experience: the things you would love to do and research questions you would love to explore and reality J. Reality flows from what I said before about just finding out what is going on at your hospital first from an IT perspective. Finding out what the strategic plan and goals are for the fiscal year for your health IT department is a very important first step to align yourself. If you can find a project or an idea that fits, this is very important from a financial perspective because budgets are often created with those larger goals and initiatives in mind by an organization. This makes it easier to get funded or “bought” out time to work on them. Additionally, if you are able to show your value with one of these projects, it makes it easier to try to get your own ideas for projects off the ground since people will know what you can bring to the table. Going back to the question about integrating technology into patient care, these days almost everything we do has a technological aspect. What I like to do when thinking of research questions and interests is to make a list of two things: what excites me the most about patient care and clinical work and what annoys me the most. Between those two lists, you will often find a research question or two. Then you can take it a step further and ask yourself, could technology help solve this problem? Does it exist? Are we using it? If you aren’t or even if you are, then I think you have a good opportunity to study it to see if it truly helps. Technology can’t solve all of our problems so its up to us as clinicians to make sure its being used (or not used) appropriately.
4. You have previously said, “being a PHM fellow is the best career decision I have made.” Why? Do you feel like fellowship will change as it begins being viewed as a requirement for board certification?
Fellowship and the reasons for pursuing it have changed quite a bit since my time, I already feel like an old fogie! For me, it was predominantly for my career aspirations. I knew at the time of finishing residency I wanted to work in a free-standing, university-affiliated, children’s hospital with medical students and residents. The traditional “academic” teaching job. I knew that fellowship was the path to get me there based on my experience searching for that job as a 3rd year resident. I knew it would provide me dedicated time to hone my clinical skills independently along with time spent learning all the research tools I would need for my career. One added benefit that I didn’t know at the time was the mentorship and networking. We owe so much to our teachers and leaders that came before us and I really felt that during fellowship. I wouldn’t be where I am today without my fellowship director’s guidance. She really invested in us and made sure we were well-trained when we finished and I can’t say enough about her mentorship. I was also able to make lifelong friends from networking at the fellows conference and other conferences which I am thankful for.
I do think fellowship will change though as we move forward with this process of being a boarded subspecialty. The best part of when I was applying to fellowship was that they were all so different and you could find a program that was tailored to your interests or even tailor your experience at one. I additionally had a lot of autonomy in my clinical responsibilities which may not be the case anymore for a lot of programs due to the ACGME. That part I think is a real detriment to the fellowship experience. Residency trains you to be an inpatient physician and so most fellows if they decided to go work would be practicing independently. The flip-side is that with standardization, I think fellows may be better trained to work in any inpatient environment rather than the traditional “teaching” hospital job which is what I was trained for. For example, my co-fellows and I didn’t really get much newborn or NICU experience in our fellowship unless we wanted it. However, depending on the jobs available to you after finishing, you may need these skills, skills I admittedly am lacking in now. And these days, that prized attending job on a teaching team isn’t so plentiful so you have to be prepared to take a job anywhere. I also think that with accreditation and eventually being a boarded subspecialty in Pediatrics, this will add legitimacy to our field and our breadth of work that maybe in previous generations wasn’t present. It will force our colleagues who still think of us as glorified or super residents to think otherwise. I think it also forces fellows to reconsider what they think is an “academic” environment. I would argue that the traditional “community” settings previously seen as only clinical are most ripe for research. Putting fellowship trained people in those places can only improve our care of hospitalized children given the amount of care that happens outside of a free-standing children’s hospital. Overall, fellowship is still a very individual choice and should be weighed heavily before embarking upon. It’s definitely not for everyone, and it’s not absolutely necessary to be a hospitalist. You just have to see if it aligns with your aspirations and if it can be a tool for you.
5. Some of your research (and a Hospital Pediatrics article) focuses on using an electronic tool to improve hospital team member identification. You have looked specifically at increasing parent/caregiver ability to correctly identify the attending in charge and define terminology of treatment team members. Tell me more about the tool, how it works, and any future directions.
As a senior resident on a busy call night I used to get frustrated by the pages from bedside nurses about parents being upset that they haven’t seen a doctor all day. I would visit those families and then find out it was simply that they just didn’t know who everyone was on rounds and after some small explanation about who was who, they weren’t upset. This really bothered me…this idea that we really don’t set the stage for families about what it’s like to be a teaching hospital, who is taking care of them, what the words mean (what’s a “resident”, what’s a “fellow”?). These words mean nothing to the uninitiated. And, this is completely OUR fault. We expect them to just be on board with the whole process without any prompting or education. How is that fair? If I told you that you had reservations to a fancy French restaurant and the menu was in French and you spent all this time learning it and showed up and the menu was in Italian, how would you feel? Lost? Frustrated? And that’s just food. Think about being a parent with a hospitalized child.
The literature shows that patients and families really don’t know who is taking care of them, especially in a teaching setting. So, while I was in fellowship, we were able to create a tool that displayed the care team to families. It was linked directly to our EMR where the list was so was updated in real-time just as we updated it in the system. It showed them their care team members’ names, pictures, and roles with a list of definitions of those roles so they could better understand just who everyone was. It was pretty successful at getting patients and families to be able to recognize and name their attendings significantly more than before.
I currently am involved in a project where we were able to this same thing now utilizing an interface with our hospital’s entertainment system. This was a difficult project to get going (goes back to that whole budget/funding thing) but we finally were able to do it. It isn’t completely the same as what I did in fellowship (different institution) and a little less streamlined but I am hoping to try and study to see if it has made any impact on our patients’ experience. The real problem I’ve faced is making sure the list is accurate and trying get everyone to assign themselves to patients in the EMR! There is also some work I am involved with utilizing a Real-Time Location System badge you can wear that can flash your picture and name up on the patient’s TV screens when you walk in the room to help with introductions. This is very, very new and we are still looking at how to study it.
6. You served as the Physician Lead for the Office of Patient Experience at Lucile Packard Children's Hospital Stanford from 2015-2017. What was the most challenging part of that role?
I think there were a number of challenges but probably my first one was just my inexperience in taking on such an administrative post that was fairly ill-defined. The previous person was also a pediatric hospitalist in our group so I was fortunate to have her experience to learn from as she was great in the role but left it to pursue other interests and research. I also had some difficulty just sinking my teeth into the role without much direction. Having only being at the institution for just under two years, I wasn’t known to a lot of the medical staff and so just trying to reach out was difficult. Many looked upon the office as one that was only focused on Press Ganey scores and patient satisfaction. It was hard to find ways to reach the ears of the medical staff to try to change this mentality and find ways for the office to be more in touch with the physicians in a positive light. I also found it challenging to know exactly what my role was. There was so much good work the office was doing, my first goal was to just publicize this. My second goal was to involve more trainees in the office’s work given that they are often providing the majority of the front-line care which means they are often the recipients of patient’s ire when things don’t go well. They had no real connection to the office and the office could have provided them an outlet for support and reinforcement for patients who felt they had a sub-optimal experience. The last challenge was funding. In a time where money and budgets are tight, having a physician lead for the office wasn’t an absolute necessity and so when times came for budget cuts this was seen as a post that was nice to have but not a “need” to have and so I was unable to continue my work. This was most difficult for me because I finally felt like I was in a place to move some projects forward. “Patient experience” can mean many things to many people but at the end of the day, to me it means, did we provide care that we would want for ourselves or our own families in every single aspect from the moment the walked in to the moment they walked out? This includes everything from the comfort and amenities to evidence-based, family-centered care. My job doesn’t exist without patients, right? So it behooves me to remember that and keep them in mind the whole way through. I think that’s forgotten sometimes.
7. As part of a collaborative project with the Stanford Computer Vision department, you are utilizing artificial intelligence and machine learning to monitor and improve hand hygiene in the hospital. Can you explain how and how others might utilize similar tools at their own institutions?
This is some really exciting work that I have been fortunate to be a part of. In a nutshell, we were able to put up some “depth” sensors which create these video images of just blobs/shapes of people and objects (to maintain employee privacy) and their movements. With some training, we were able to “teach” a computer algorithm (I say we, I mean the exceptionally smart computer scientists I worked with) to recognize the movements that were and were not consistent with hand hygiene using wall-mounted hand sanitizer. This means they were able to train the machine to recognize that a computer on wheels parked by a hand hygiene dispenser wasn’t a human performing hand-hygiene, and that just walking by the dispenser wasn’t performing it either…really amazing stuff! Once the computer was sufficiently trained, we compared it’s data to simultaneous in-person observers and it was 99% concordant. Moreover it’s better than our flawed gold-standard of “secret shoppers” because the sensors are up on the whole unit and monitoring 24/7. Wowza!
I think a big hurdle to getting this project done if someone was looking to do it in their own hospital is getting buy-in from the executive committee that can approve the project. This involved us presenting the proposal to them with our computer scientist partners and positioning this as something revolutionary and potentially money saving. The second (and probably largest hurdle) was installation. Being mindful of all the people you have to make aware of what you are doing is a big deal. It means front-line staff, unit managers, facilities, engineering, IT, patients…everyone! Getting those people all in a room together can be difficult. The installation was our biggest expense and biggest hurdle. But if you cross the first hurdle, someone up top has already blessed it and said “this will happen” which at least keeps the project moving. If I were giving someone advice it would be to think of trialing this if you have new construction coming up or in a contained unit that would minimize patient and employee disruption. Or try to mock up one room or a simulation room to demonstrate the benefit first so that you can say you aren’t using the hospital space to just test it out, you already have done that and are ready for “prime-time”.
8. You have accomplished a lot at a young age. What do you think has been the secret to your rapid success in the field?
Wow, I don’t know if I necessarily would say the same, “rapid success” is a strong sentiment, but thank you! I guess it’s how you might measure it? I feel like so many people who did fellowship before and after me have done so much more in their own careers whether it be becoming fellowship directors right away, medical directors, publishing papers, active in the national scene, the list goes on. But to answer your question, any success I’ve had personally I think has been from approaching things in general with a good attitude and a smile and building a network with people outside my local area. From attending the annual PHM conference every year since I started fellowship and meeting other like-minded folks, I’ve been given opportunities to do things nationally that I never would have otherwise. When I think about how that happened, I definitely think pursuing fellowship really pushed a lot of that along so I would definitely credit that. Finally, I have always been pretty committed to saying yes but also saying no, and I think that is tough when you are junior. I have been really dedicated to pursuing projects that I am really passionate about and not just doing something for the sake of doing it. This I think has really helped me move forward.
9. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Tough one! I am sure Jack’s $0.02 are worth a lot more in PHM currency than mine but I would say…know thyself. There is nothing worse than waking up every day and not feeling like you are doing things that matter and are important to you and your soul. Always strive to make that show through and not be who someone else thinks you should be. One of my closest friend says that your integrity is free. I think that is highly underrated.
Ha, it’s funny how time can change your perspective. When I was finishing fellowship I think I was thinking hard about why I chose to do it and the next phase of my career and was really excited and sharing that excitement with friends and family who wanted to know if I was a “real” doctor yet. Most didn’t understand it so I was trying to figure out how to craft the answer. The first thing I wanted was their ears and brains to hear the word “hospitalist”. I wanted them to know that was my “specialty”. Basically I tell people I am like your child’s general pediatrician you see in the clinic but on the inside of the hospital instead. Then I let them know that I help take care of children who are hospitalized with almost any condition whether it be simple or more complicated. I explain that some children require a lot of care by many subspecialists who may just work on their one part of the body and we help kind of keep the “forest for the trees” view of their care. I also explain that because the hospital is like our “organ” when we aren’t seeing patients we are often involved in all sorts of systems level work within the administrative side of the hospital. I remember feeling very strictly that our job was within the walls of the hospital and feeling pretty committed to that. Going back to what I said in the beginning about perspective though, having now been out as an attending for about 4.5 years, I think my mindset has changed and I realize that as hospitalists we have an ability to really impact health systems as a whole and think beyond just the hospital based on the work we are doing inside of it.
2. In a recent commentary, you wrote about technology in the medical field and asked, “why have our work environments not kept pace with the rest of the world?” Can you give us your theory about why medicine lags behind?
Tough question! There are so many different reasons it’s hard to say. In my opinion I think it’s a few big things. The first is that healthcare is just such a large and heterogenous entity that it’s hard for change to flow through. Think about all the different places you can get care nowadays…a clinic, a hospital, an urgent care or “minute clinic”, and now, telehealth or even on-demand physicians who can come to your home. Each one not only is a unique setting but may have a unique electronic health record or maybe not even an electronic health record and none of them talk to each other. Add on top of that the economic layer of how money is handled in medicine in general and those are big barriers to entry for any commercially available technology that might make our lives easier. Moreover, I think also the nature of our work and the issue of privacy puts a whole layer on top of technology that makes it difficult to implement because patients (rightly so) place a large value on keeping their health information secure. But the converse is we aren’t the only industry that deals with issues of privacy. One other reason is culture. In general, I feel that on the whole, physicians are fairly resistant to change. There’s a lot of “if it ain’t broke…” mentality I have encountered personally which I think is also mainly a generational thing? I think that the younger generation of trainees are entering the workforce with just a baseline use of technology in their every day lives that they are now demanding in their workplaces too. I mean these days I can track my amazon package every step of the way from my phone but I still have to get outside blood culture results faxed to me?
Finally, an important point is that I think that much of the technology we use in daily practice wasn’t developed by clinicians right from the get-go. This means that it may not be optimally designed for our workflows and if the foundation isn’t right, it’s hard to make improvements on top of it. Is that our fault? Some may say no. The enormous amount of time it takes to just learn medicine and complete training, we aren’t afforded the time to worry about anything else. We are working for years just to be a doctor. But, on the same token, other industries that require lots of training (say lawyers for example) don’t seem to let their field be dominated by others. I don’t know if we can continue to complain about technologies that we continue to accept and not make any effort to change ourselves. What I mean to say is that, instead of griping about how this EMR stinks, we should be working side-by-side with the developers and computer scientists to develop systems together that are simple, fit our workflows and needs, and can allow for ease of transfer of information so patients don’t have to repeat information over and over or be responsible for keeping up every detail of their instances of care.
3. What are the best resources and conferences for younger pediatric hospitalists looking to get involved in informatics and medical technology? How would you suggest integrating technology into patient care and research when first starting out?
Great questions. I think the first thing is to seek out opportunities for getting involved in your IS or IT department at your own institution. If you are a fellow, take some elective time to go meet with your CMIO and find out if there are projects that you can get involved in. In my experience, people working in healthcare IT love the input from front-line providers and really appreciate the clinical perspective. The other is to consider maybe spending some time pursuing introductory informatics coursework if you are really interested. If your local university setting doesn’t have one, then consider an online course or going to conferences beyond the “usual” ones you might attend. The American Medical Informatics Association’s annual symposium is a great forum for a resident, fellow, or faculty to see what all is going on at a national level and network with other like-minded individuals. I was really impressed when I went for the first time a few years ago. I also enjoy learning new things from people who share on Twitter. I know, I know, learning from social media…it sounds crazy right? I would have thought the same too until I used it after having being asked to be a social media co-chair for the PHM conferences. I was surprised at just how many abstracts or articles I would see in my twitter feed when I first joined that I wasn’t seeing in my traditional journals or listservs. People sharing information is basically all Twitter is at its core. Don’t let it intimidate you, just join and follow people or subjects you’re interested in and see what you want. Many “famous” pediatric hospitalists who have been here in the Hospitalist Corner are active themselves posting some great content all the time.
With regards to your second question, there are two things to think about from my experience: the things you would love to do and research questions you would love to explore and reality J. Reality flows from what I said before about just finding out what is going on at your hospital first from an IT perspective. Finding out what the strategic plan and goals are for the fiscal year for your health IT department is a very important first step to align yourself. If you can find a project or an idea that fits, this is very important from a financial perspective because budgets are often created with those larger goals and initiatives in mind by an organization. This makes it easier to get funded or “bought” out time to work on them. Additionally, if you are able to show your value with one of these projects, it makes it easier to try to get your own ideas for projects off the ground since people will know what you can bring to the table. Going back to the question about integrating technology into patient care, these days almost everything we do has a technological aspect. What I like to do when thinking of research questions and interests is to make a list of two things: what excites me the most about patient care and clinical work and what annoys me the most. Between those two lists, you will often find a research question or two. Then you can take it a step further and ask yourself, could technology help solve this problem? Does it exist? Are we using it? If you aren’t or even if you are, then I think you have a good opportunity to study it to see if it truly helps. Technology can’t solve all of our problems so its up to us as clinicians to make sure its being used (or not used) appropriately.
4. You have previously said, “being a PHM fellow is the best career decision I have made.” Why? Do you feel like fellowship will change as it begins being viewed as a requirement for board certification?
Fellowship and the reasons for pursuing it have changed quite a bit since my time, I already feel like an old fogie! For me, it was predominantly for my career aspirations. I knew at the time of finishing residency I wanted to work in a free-standing, university-affiliated, children’s hospital with medical students and residents. The traditional “academic” teaching job. I knew that fellowship was the path to get me there based on my experience searching for that job as a 3rd year resident. I knew it would provide me dedicated time to hone my clinical skills independently along with time spent learning all the research tools I would need for my career. One added benefit that I didn’t know at the time was the mentorship and networking. We owe so much to our teachers and leaders that came before us and I really felt that during fellowship. I wouldn’t be where I am today without my fellowship director’s guidance. She really invested in us and made sure we were well-trained when we finished and I can’t say enough about her mentorship. I was also able to make lifelong friends from networking at the fellows conference and other conferences which I am thankful for.
I do think fellowship will change though as we move forward with this process of being a boarded subspecialty. The best part of when I was applying to fellowship was that they were all so different and you could find a program that was tailored to your interests or even tailor your experience at one. I additionally had a lot of autonomy in my clinical responsibilities which may not be the case anymore for a lot of programs due to the ACGME. That part I think is a real detriment to the fellowship experience. Residency trains you to be an inpatient physician and so most fellows if they decided to go work would be practicing independently. The flip-side is that with standardization, I think fellows may be better trained to work in any inpatient environment rather than the traditional “teaching” hospital job which is what I was trained for. For example, my co-fellows and I didn’t really get much newborn or NICU experience in our fellowship unless we wanted it. However, depending on the jobs available to you after finishing, you may need these skills, skills I admittedly am lacking in now. And these days, that prized attending job on a teaching team isn’t so plentiful so you have to be prepared to take a job anywhere. I also think that with accreditation and eventually being a boarded subspecialty in Pediatrics, this will add legitimacy to our field and our breadth of work that maybe in previous generations wasn’t present. It will force our colleagues who still think of us as glorified or super residents to think otherwise. I think it also forces fellows to reconsider what they think is an “academic” environment. I would argue that the traditional “community” settings previously seen as only clinical are most ripe for research. Putting fellowship trained people in those places can only improve our care of hospitalized children given the amount of care that happens outside of a free-standing children’s hospital. Overall, fellowship is still a very individual choice and should be weighed heavily before embarking upon. It’s definitely not for everyone, and it’s not absolutely necessary to be a hospitalist. You just have to see if it aligns with your aspirations and if it can be a tool for you.
5. Some of your research (and a Hospital Pediatrics article) focuses on using an electronic tool to improve hospital team member identification. You have looked specifically at increasing parent/caregiver ability to correctly identify the attending in charge and define terminology of treatment team members. Tell me more about the tool, how it works, and any future directions.
As a senior resident on a busy call night I used to get frustrated by the pages from bedside nurses about parents being upset that they haven’t seen a doctor all day. I would visit those families and then find out it was simply that they just didn’t know who everyone was on rounds and after some small explanation about who was who, they weren’t upset. This really bothered me…this idea that we really don’t set the stage for families about what it’s like to be a teaching hospital, who is taking care of them, what the words mean (what’s a “resident”, what’s a “fellow”?). These words mean nothing to the uninitiated. And, this is completely OUR fault. We expect them to just be on board with the whole process without any prompting or education. How is that fair? If I told you that you had reservations to a fancy French restaurant and the menu was in French and you spent all this time learning it and showed up and the menu was in Italian, how would you feel? Lost? Frustrated? And that’s just food. Think about being a parent with a hospitalized child.
The literature shows that patients and families really don’t know who is taking care of them, especially in a teaching setting. So, while I was in fellowship, we were able to create a tool that displayed the care team to families. It was linked directly to our EMR where the list was so was updated in real-time just as we updated it in the system. It showed them their care team members’ names, pictures, and roles with a list of definitions of those roles so they could better understand just who everyone was. It was pretty successful at getting patients and families to be able to recognize and name their attendings significantly more than before.
I currently am involved in a project where we were able to this same thing now utilizing an interface with our hospital’s entertainment system. This was a difficult project to get going (goes back to that whole budget/funding thing) but we finally were able to do it. It isn’t completely the same as what I did in fellowship (different institution) and a little less streamlined but I am hoping to try and study to see if it has made any impact on our patients’ experience. The real problem I’ve faced is making sure the list is accurate and trying get everyone to assign themselves to patients in the EMR! There is also some work I am involved with utilizing a Real-Time Location System badge you can wear that can flash your picture and name up on the patient’s TV screens when you walk in the room to help with introductions. This is very, very new and we are still looking at how to study it.
6. You served as the Physician Lead for the Office of Patient Experience at Lucile Packard Children's Hospital Stanford from 2015-2017. What was the most challenging part of that role?
I think there were a number of challenges but probably my first one was just my inexperience in taking on such an administrative post that was fairly ill-defined. The previous person was also a pediatric hospitalist in our group so I was fortunate to have her experience to learn from as she was great in the role but left it to pursue other interests and research. I also had some difficulty just sinking my teeth into the role without much direction. Having only being at the institution for just under two years, I wasn’t known to a lot of the medical staff and so just trying to reach out was difficult. Many looked upon the office as one that was only focused on Press Ganey scores and patient satisfaction. It was hard to find ways to reach the ears of the medical staff to try to change this mentality and find ways for the office to be more in touch with the physicians in a positive light. I also found it challenging to know exactly what my role was. There was so much good work the office was doing, my first goal was to just publicize this. My second goal was to involve more trainees in the office’s work given that they are often providing the majority of the front-line care which means they are often the recipients of patient’s ire when things don’t go well. They had no real connection to the office and the office could have provided them an outlet for support and reinforcement for patients who felt they had a sub-optimal experience. The last challenge was funding. In a time where money and budgets are tight, having a physician lead for the office wasn’t an absolute necessity and so when times came for budget cuts this was seen as a post that was nice to have but not a “need” to have and so I was unable to continue my work. This was most difficult for me because I finally felt like I was in a place to move some projects forward. “Patient experience” can mean many things to many people but at the end of the day, to me it means, did we provide care that we would want for ourselves or our own families in every single aspect from the moment the walked in to the moment they walked out? This includes everything from the comfort and amenities to evidence-based, family-centered care. My job doesn’t exist without patients, right? So it behooves me to remember that and keep them in mind the whole way through. I think that’s forgotten sometimes.
7. As part of a collaborative project with the Stanford Computer Vision department, you are utilizing artificial intelligence and machine learning to monitor and improve hand hygiene in the hospital. Can you explain how and how others might utilize similar tools at their own institutions?
This is some really exciting work that I have been fortunate to be a part of. In a nutshell, we were able to put up some “depth” sensors which create these video images of just blobs/shapes of people and objects (to maintain employee privacy) and their movements. With some training, we were able to “teach” a computer algorithm (I say we, I mean the exceptionally smart computer scientists I worked with) to recognize the movements that were and were not consistent with hand hygiene using wall-mounted hand sanitizer. This means they were able to train the machine to recognize that a computer on wheels parked by a hand hygiene dispenser wasn’t a human performing hand-hygiene, and that just walking by the dispenser wasn’t performing it either…really amazing stuff! Once the computer was sufficiently trained, we compared it’s data to simultaneous in-person observers and it was 99% concordant. Moreover it’s better than our flawed gold-standard of “secret shoppers” because the sensors are up on the whole unit and monitoring 24/7. Wowza!
I think a big hurdle to getting this project done if someone was looking to do it in their own hospital is getting buy-in from the executive committee that can approve the project. This involved us presenting the proposal to them with our computer scientist partners and positioning this as something revolutionary and potentially money saving. The second (and probably largest hurdle) was installation. Being mindful of all the people you have to make aware of what you are doing is a big deal. It means front-line staff, unit managers, facilities, engineering, IT, patients…everyone! Getting those people all in a room together can be difficult. The installation was our biggest expense and biggest hurdle. But if you cross the first hurdle, someone up top has already blessed it and said “this will happen” which at least keeps the project moving. If I were giving someone advice it would be to think of trialing this if you have new construction coming up or in a contained unit that would minimize patient and employee disruption. Or try to mock up one room or a simulation room to demonstrate the benefit first so that you can say you aren’t using the hospital space to just test it out, you already have done that and are ready for “prime-time”.
8. You have accomplished a lot at a young age. What do you think has been the secret to your rapid success in the field?
Wow, I don’t know if I necessarily would say the same, “rapid success” is a strong sentiment, but thank you! I guess it’s how you might measure it? I feel like so many people who did fellowship before and after me have done so much more in their own careers whether it be becoming fellowship directors right away, medical directors, publishing papers, active in the national scene, the list goes on. But to answer your question, any success I’ve had personally I think has been from approaching things in general with a good attitude and a smile and building a network with people outside my local area. From attending the annual PHM conference every year since I started fellowship and meeting other like-minded folks, I’ve been given opportunities to do things nationally that I never would have otherwise. When I think about how that happened, I definitely think pursuing fellowship really pushed a lot of that along so I would definitely credit that. Finally, I have always been pretty committed to saying yes but also saying no, and I think that is tough when you are junior. I have been really dedicated to pursuing projects that I am really passionate about and not just doing something for the sake of doing it. This I think has really helped me move forward.
9. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Tough one! I am sure Jack’s $0.02 are worth a lot more in PHM currency than mine but I would say…know thyself. There is nothing worse than waking up every day and not feeling like you are doing things that matter and are important to you and your soul. Always strive to make that show through and not be who someone else thinks you should be. One of my closest friend says that your integrity is free. I think that is highly underrated.