Dr. Barrett Fromme
1. On the list-serve, you once commented that you face-time your residents at night in your pajamas to discuss patients. Why is this face-to-face interaction important and what advice do you have for education of residents and management of patients from home?
Situated learning is the fancy reason – the idea that we learn best when we are active learners in a community of practice. The community for my night team is usually me, a senior resident, and intern and a student. If I just call on the phone, more often than not, I just get the senior. The other two don’t engage actively. Even if we use speaker phone, it doesn’t have the same investment. So, by being face-to-face, I have the privilege of really engaging with the whole team. Learners of all levels ask more questions, and I get to know them a bit better. The best advice I can give to those managing clinical care and education from home is to be available and engaged (there’s that word again). I let my team know they can call me anytime, but they do not have to call me if they are comfortable. I set expectations for the things that are a “must call” but I give them as much autonomy as I can. I also take time the next night to provide feedback on what happened the night prior, or to discuss cases that challenged them. “Running the list” is the last thing I want to do; I want a learner-centered experience with the same level of expectations and feedback that the day team gets.
2. A recent study in the Journal of Women’s Health studied Grand Rounds introductions at academic hospitals and showed that females introduce male colleagues with the title of “doctor” 95% of the time, but males only did the same for their female colleagues 49% of the time. As a female and leader in PHM, have you encountered any gender bias and how do you handle those situations?
This is a great question, and one that is impossible to answer well in a short, written response. The short answer is “yes, I have encountered gender bias”, more than I should, but not as often as some. I am fortunate to have a more masculine name, so if I am not in front of someone and they have not met me, they assume I am male. So that helps half the time. But in person, I have seen it all. I have been called “nurse” countless times. I have been ignored when a male medical student arrived in the room. To be fair, I have introduced my female colleague by her name, and my male colleague by doctor. Women are just as prone to some of this bias as men. But, I have also been harassed within my career both professionally and (at the lesser end of this spectrum) sexually, which is a step beyond gender bias, but the start to solutions are similar for both. The reality is that sometimes I have handled these encounters “well” (assertively, directly, confidently), and sometimes I have let things go longer than I should or completely because I didn’t want to be “that” person. And to me that is the key first step in any solution. We need to start address this when it happens as a group – not just women, not just men, but all of us. When we see or do any of the examples I just noted (or any of the countless others), we need to immediately speak up. Both the men and the women in the room need to reiterate the woman is the attending. The individual and the team need to tell the patient that the woman is not a nurse, not because being a nurse is any less than being a doctor, but because it’s not what we are. We, as men and women, need to speak up openly and declaratively when we see harassment or bias of any kind – against women, against minorities, against patients, and against men. We need to stand for ourselves and with each other.
3. You clearly have a passion for medical education as well as pediatric hospital medicine. How do you see these two fields intersecting as PHM moves toward becoming an American Board of Pediatrics (ABP) subspecialty?
This is a unique and energizing time in PHM. It’s a true privilege to be present as we become a formal specialty within the ABP. But the reality is that we have existed as a subspecialty for twenty years, and there are generations of pediatric hospitalists who are practicing without subspecialty certification and will continue to do so, as well as those who will go for certification. For all these individuals, we need to create educational opportunities to enhance their practice as pediatric hospitalists. For those that are taking the boards, with or without fellowship training, we need to create focused, active learning opportunities for preparation. And we can think creatively about how to deliver that content beyond the standard review courses: how to do it with engaging, practical formats that really teach the material, not just teach for the test. At the same time, we must continue to offer opportunities for those who do not want to take the boards. The PHM Winter Clinical Course is a great example of that – offering practical, immediately applicable content for practicing clinicians. Similar offerings should be made in leadership skills, teaching skills, and other areas of PHM. As we become a specialty that is now recognized by governing bodies and other board-certified specialties, we need to have pediatric hospitalists who will be leaders and innovators for years to come, and that requires education. To be sure, it’s a great time to be an educator in PHM.
4. In November 2017, you published “What's the Purpose of Rounds? A Qualitative Study Examining the Perceptions of Faculty and Students” [J Hosp Med. 2017 Nov;12(11):892-897]. What do you think IS the purpose of rounds?
This study actually started when a fantastic medical student on my team, asked, with two days left on her rotation with us, “Dr. Fromme, what’s the point of rounds?” I was floored; how could she not know after spending nearly three weeks with us. But then I realized, that there were a lot of stakeholders on rounds, and I was not sure now if they all had the same goals. The above study is just part of the story. We also asked residents (“Rounds Today: A Qualitative Study of Internal Medicine and Pediatric Perspectives. JGME. 2016 Oct;8(4):523-531). What becomes clear from this study, which by the way, did not include patients/families or nurses, which are two other very important stakeholder groups, is that residents have a different perspective than faculty and medical students. The former are focused on patient care, and the latter see more in communication and education, though all see a bit of each. I would offer that the purpose of rounds is everything they noted and more… and that’s why it is so difficult. Faculty need to have the skills necessary to lead and teach; they need to set clear expectations for what are the priorities of rounds; they need to call attention to the teaching opportunities that are occurring in the process of clinical work. To paraphrase Kermit the Frog, “it ain’t easy being a hospitalist.” I encourage faculty to find opportunities for development as teachers specifically in the inpatient realm. [Shameless plug: the Advancing Pediatric Educator eXcellence (APEX) Teaching Program is one such opportunity; next applicant cycle in November)
5. To quote you, “if a child falls septic in the woods, but no one is there to hear it, does he/she make a sound?” In the case of culture negative sepsis, how would you like to see our management change?
We just had a great joint PHM/PICU/ID conference locally about just this, which is why I originally posted to the listserv (shameless plug #2: the ListServ knows all. Use it!). What I took home from my research to prepare for the conference and the discussion at the conference is that we need to be willing to pull back on antibiotics for culture-negative sepsis, but only after we have made sure there are no non-infectious or infectious etiologies. If you had pre-antibiotic cultures that are negative, and the patient is improving, stop the antibiotics after 36-48 hours. Make sure you aren’t missing something (e.g. ischemia, drug effects, inflammatory diseases, metabolic diseases), and then send home when they are ready. But inherent in this is that you should talk to you PICU colleagues so you have a strong sense of what concerned them in the first place. We only see them after they are decompensating and then improving; use the wisdom of those who were there, and then make a thoughtful decision based on what you know.
6. Feedback is another major interest of yours and you co-authored an article on barriers to effective feedback [J Grad Med Educ. 2015 Jun; 7(2): 214–219]. In the midst of time pressures due to clinical work and discomfort with giving negative feedback, how do you suggest that we give and receive more meaningful feedback?
I love talking about feedback. It’s one of my favorite topics, which puts me in a very small group of quirky people. I have always held that there is no education (or effective education) without feedback. It’s how we improve. It’s how we understand ourselves from the view of others. It’s how we progress. And there are many great models to deliver feedback, including the ATA model, the ADAPT model, feedback scripts (final shameless plug: can be found on this very website, under Education), but I will back up for a second. Before any of that, we have to change the culture of feedback: how we as a group expect and invite feedback openly and with the right goals. And this is a collaborative project – it’s not only about the teacher giving feedback, but also the learner receiving it. We need to establish a climate where feedback is viewed only as a formative process, and learners and teachers are engaged together in a dialogue about how each of them can improve. Much like a coach and a high performing athlete, we should have shared goals and work together towards them (there is a great study looking at medicine vs. sports/music and feedback). Once that is established, then we can start by focusing our efforts on brief feedback – the kind you give after a presentation, or after a procedure, or after rounds. I tap my team members on the shoulder throughout rounds and give them feedback after presentations. It doesn’t take much time, and the learners engage in it. This should be both constructive and reinforcing feedback, but it should be often. It does not replace formal feedback (“Feedback Fridays”) but it helps build to that more formal, structured encounter, and it helps both parties be prepared. Also, I highly recommend establishing the learning goals of both the learners and the hospitalist on service at the outset of the rotation; then push each other to give feedback on those items throughout your time together. We are all learners, after all.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Can I have 25 cents? No? Okay. Then let’s go with simple stuff. Have fun and don’t lose the passion that brought you to this career. Find your support crew – shout out to my MTB (Mentor By Text) Crew. Revel in the small victories. Don’t get overly impressed by your larger successes. Get involved; you have worlds to contribute. And never forget that we have the true privilege to work in PHM with the greatest colleagues, patients, and families.
Situated learning is the fancy reason – the idea that we learn best when we are active learners in a community of practice. The community for my night team is usually me, a senior resident, and intern and a student. If I just call on the phone, more often than not, I just get the senior. The other two don’t engage actively. Even if we use speaker phone, it doesn’t have the same investment. So, by being face-to-face, I have the privilege of really engaging with the whole team. Learners of all levels ask more questions, and I get to know them a bit better. The best advice I can give to those managing clinical care and education from home is to be available and engaged (there’s that word again). I let my team know they can call me anytime, but they do not have to call me if they are comfortable. I set expectations for the things that are a “must call” but I give them as much autonomy as I can. I also take time the next night to provide feedback on what happened the night prior, or to discuss cases that challenged them. “Running the list” is the last thing I want to do; I want a learner-centered experience with the same level of expectations and feedback that the day team gets.
2. A recent study in the Journal of Women’s Health studied Grand Rounds introductions at academic hospitals and showed that females introduce male colleagues with the title of “doctor” 95% of the time, but males only did the same for their female colleagues 49% of the time. As a female and leader in PHM, have you encountered any gender bias and how do you handle those situations?
This is a great question, and one that is impossible to answer well in a short, written response. The short answer is “yes, I have encountered gender bias”, more than I should, but not as often as some. I am fortunate to have a more masculine name, so if I am not in front of someone and they have not met me, they assume I am male. So that helps half the time. But in person, I have seen it all. I have been called “nurse” countless times. I have been ignored when a male medical student arrived in the room. To be fair, I have introduced my female colleague by her name, and my male colleague by doctor. Women are just as prone to some of this bias as men. But, I have also been harassed within my career both professionally and (at the lesser end of this spectrum) sexually, which is a step beyond gender bias, but the start to solutions are similar for both. The reality is that sometimes I have handled these encounters “well” (assertively, directly, confidently), and sometimes I have let things go longer than I should or completely because I didn’t want to be “that” person. And to me that is the key first step in any solution. We need to start address this when it happens as a group – not just women, not just men, but all of us. When we see or do any of the examples I just noted (or any of the countless others), we need to immediately speak up. Both the men and the women in the room need to reiterate the woman is the attending. The individual and the team need to tell the patient that the woman is not a nurse, not because being a nurse is any less than being a doctor, but because it’s not what we are. We, as men and women, need to speak up openly and declaratively when we see harassment or bias of any kind – against women, against minorities, against patients, and against men. We need to stand for ourselves and with each other.
3. You clearly have a passion for medical education as well as pediatric hospital medicine. How do you see these two fields intersecting as PHM moves toward becoming an American Board of Pediatrics (ABP) subspecialty?
This is a unique and energizing time in PHM. It’s a true privilege to be present as we become a formal specialty within the ABP. But the reality is that we have existed as a subspecialty for twenty years, and there are generations of pediatric hospitalists who are practicing without subspecialty certification and will continue to do so, as well as those who will go for certification. For all these individuals, we need to create educational opportunities to enhance their practice as pediatric hospitalists. For those that are taking the boards, with or without fellowship training, we need to create focused, active learning opportunities for preparation. And we can think creatively about how to deliver that content beyond the standard review courses: how to do it with engaging, practical formats that really teach the material, not just teach for the test. At the same time, we must continue to offer opportunities for those who do not want to take the boards. The PHM Winter Clinical Course is a great example of that – offering practical, immediately applicable content for practicing clinicians. Similar offerings should be made in leadership skills, teaching skills, and other areas of PHM. As we become a specialty that is now recognized by governing bodies and other board-certified specialties, we need to have pediatric hospitalists who will be leaders and innovators for years to come, and that requires education. To be sure, it’s a great time to be an educator in PHM.
4. In November 2017, you published “What's the Purpose of Rounds? A Qualitative Study Examining the Perceptions of Faculty and Students” [J Hosp Med. 2017 Nov;12(11):892-897]. What do you think IS the purpose of rounds?
This study actually started when a fantastic medical student on my team, asked, with two days left on her rotation with us, “Dr. Fromme, what’s the point of rounds?” I was floored; how could she not know after spending nearly three weeks with us. But then I realized, that there were a lot of stakeholders on rounds, and I was not sure now if they all had the same goals. The above study is just part of the story. We also asked residents (“Rounds Today: A Qualitative Study of Internal Medicine and Pediatric Perspectives. JGME. 2016 Oct;8(4):523-531). What becomes clear from this study, which by the way, did not include patients/families or nurses, which are two other very important stakeholder groups, is that residents have a different perspective than faculty and medical students. The former are focused on patient care, and the latter see more in communication and education, though all see a bit of each. I would offer that the purpose of rounds is everything they noted and more… and that’s why it is so difficult. Faculty need to have the skills necessary to lead and teach; they need to set clear expectations for what are the priorities of rounds; they need to call attention to the teaching opportunities that are occurring in the process of clinical work. To paraphrase Kermit the Frog, “it ain’t easy being a hospitalist.” I encourage faculty to find opportunities for development as teachers specifically in the inpatient realm. [Shameless plug: the Advancing Pediatric Educator eXcellence (APEX) Teaching Program is one such opportunity; next applicant cycle in November)
5. To quote you, “if a child falls septic in the woods, but no one is there to hear it, does he/she make a sound?” In the case of culture negative sepsis, how would you like to see our management change?
We just had a great joint PHM/PICU/ID conference locally about just this, which is why I originally posted to the listserv (shameless plug #2: the ListServ knows all. Use it!). What I took home from my research to prepare for the conference and the discussion at the conference is that we need to be willing to pull back on antibiotics for culture-negative sepsis, but only after we have made sure there are no non-infectious or infectious etiologies. If you had pre-antibiotic cultures that are negative, and the patient is improving, stop the antibiotics after 36-48 hours. Make sure you aren’t missing something (e.g. ischemia, drug effects, inflammatory diseases, metabolic diseases), and then send home when they are ready. But inherent in this is that you should talk to you PICU colleagues so you have a strong sense of what concerned them in the first place. We only see them after they are decompensating and then improving; use the wisdom of those who were there, and then make a thoughtful decision based on what you know.
6. Feedback is another major interest of yours and you co-authored an article on barriers to effective feedback [J Grad Med Educ. 2015 Jun; 7(2): 214–219]. In the midst of time pressures due to clinical work and discomfort with giving negative feedback, how do you suggest that we give and receive more meaningful feedback?
I love talking about feedback. It’s one of my favorite topics, which puts me in a very small group of quirky people. I have always held that there is no education (or effective education) without feedback. It’s how we improve. It’s how we understand ourselves from the view of others. It’s how we progress. And there are many great models to deliver feedback, including the ATA model, the ADAPT model, feedback scripts (final shameless plug: can be found on this very website, under Education), but I will back up for a second. Before any of that, we have to change the culture of feedback: how we as a group expect and invite feedback openly and with the right goals. And this is a collaborative project – it’s not only about the teacher giving feedback, but also the learner receiving it. We need to establish a climate where feedback is viewed only as a formative process, and learners and teachers are engaged together in a dialogue about how each of them can improve. Much like a coach and a high performing athlete, we should have shared goals and work together towards them (there is a great study looking at medicine vs. sports/music and feedback). Once that is established, then we can start by focusing our efforts on brief feedback – the kind you give after a presentation, or after a procedure, or after rounds. I tap my team members on the shoulder throughout rounds and give them feedback after presentations. It doesn’t take much time, and the learners engage in it. This should be both constructive and reinforcing feedback, but it should be often. It does not replace formal feedback (“Feedback Fridays”) but it helps build to that more formal, structured encounter, and it helps both parties be prepared. Also, I highly recommend establishing the learning goals of both the learners and the hospitalist on service at the outset of the rotation; then push each other to give feedback on those items throughout your time together. We are all learners, after all.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Can I have 25 cents? No? Okay. Then let’s go with simple stuff. Have fun and don’t lose the passion that brought you to this career. Find your support crew – shout out to my MTB (Mentor By Text) Crew. Revel in the small victories. Don’t get overly impressed by your larger successes. Get involved; you have worlds to contribute. And never forget that we have the true privilege to work in PHM with the greatest colleagues, patients, and families.