Brian Alverson
1. As the chair of the AAP Section on Hospital medicine, what are your thoughts on the transition of pediatric hospital medicine in becoming an accredited subspecialty? Where do you think our biggest challenges lie?
Thanks so much for the opportunity to write some words here, I think this forum is absolutely great. For the record, I’ve now handed the chair job over to Matt Garber, and am now “ex-officio”. But I did spend the last two years working hard for the Section as the chair.
I’ll be honest I was pretty agnostic about becoming a subspecialty. I can see potential benefits and also potential troubles ahead. The obvious benefit in defining ourselves as a subspecialty is that we will be able to craft the future for our field better. Also (and more importantly), I see us starting to really improve the quality of care hospitalized children receive. Think about our predecessors. It wasn’t until sub-specialization that ER and PICU became a strong academic force. Now millions of dollars of grants go towards the improvement of care for children in the ER and the ICU. The hospitalist literature, both QI and primary clinical research, is largely unwritten. By “forcing the hand” of free standing children’s hospitals, and creating a benchmark for hospitalist credentialing in hospitals with residencies and professorships, I believe we will emerge from a murky variability of practice to improve pediatric inpatient quality of care and outcomes. In terms of challenges, I’m a little worried about whether this improvement of care will spread beyond free standing children’s hospitals to community hospitals. The reality is there are far more positions for hospitalists than can be filled by ABP certified fellowship-trained physicians. I fear that by creating the “specialists” and the “non-specialists” we are at risk of ignoring the care of the vast majority of children who are hospitalized in community hospitals. Take, for example, the PHIS database. We can look and see how 40 children’s hospitals are managing infants with pneumonia, but what about the hundreds of hospitals in communities who are managing about two-thirds of these children? Who is tracking those data? And if those docs aren’t similarly trained as the ones in the PHIS hospitals, are we really improving care broadly across the country? We need to keep our eyes on all children.
2. Weigh in on the neonatal fever debate. It’s a constantly moving target for how much workup to do in the 28 day old with congestion and a temperature of 101⁰F. What is your policy?
I recently saw a study which showed that almost one in four infants under 28 days with fever do not get a spinal tap in the US. I know personally some specialists who might blow a gasket over that fact. Here’s the thing… I don’t think the answer to this problem is likely to be found in research, but rather in a soul search. Let me explain. Let’s say we did the largest prospective randomized trial with a billion children, and we proved, definitively, that the risk of an infant with RSV having concomitant meningitis who was relatively well appearing was 1 in 100,000. Even if we knew this number to be true, I’m sure there are doctors out there who will accept it, and other doctors who will not. Someone is thinking about that poor unfortunate 100,000th child who dies of untreated meningitis. Another person is thinking of the child admitted with a bloody uninterpretable tap and getting 2 weeks of empirical antibiotics for no reason and ends up on SQ LMW heparin for a clotted PICC line vein. Our perception of risk is entirely determined by our own personal denominator. Which is to say, the ID doctor who just managed a brain damaged infant in the ICU might feel one way, and a doctor who had a mother crying over her infant’s SQ shots might feel another way. What I think is interesting is our complete lack of ability to viscerally understand uncertainty. If I told you there was a 1:10,000 chance the child had meningitis you would probably get a tap, but the odds of a person dying in a car accident in one year is 1:10,000, and we send kids home in cars all the time.
So, to answer your question, what do I do? I look at all the details of the case and make my best guess, using evidence to guide me, but using the case and sometimes the parents’ wishes to make the final decision. I don’t think there is a “right answer” out there.
3. In January 2017, you wrote an article for Hospital Pediatrics entitled, “Seriously. Clowns.” In it, you suggest that we should consider using humor in place of acetaminophen or ranitidine if the only concern if reassuring the parents and making the child feel better. This was based on a study by Sanchez et al showing that salivary cortisol levels go down in children who are exposed to humor therapists in the inpatient setting. So, seriously? Clowns?
Oh no. I should be more careful about publishing things. So yes, not clowns. I actually don’t really like clowns all that much. But humor? Oh heck, yes. One of the most influential sessions I went to at PHM was a session where a magician taught us magic tricks we can do at the bedside. Just last week on the wards I got this note from a child with pancreatitis who caught wind of my infantile magic efforts: “Make my purple crayon change color. I dare you,” and the crayon was taped to the paper. You know what? I turned that crayon to pink, using her pink doll’s dress (that was the magic). And the child laughed. According to Sanchez et al, the child’s salivary cortisol went down. But you know what? The kid laughed, the parents laughed, and they trusted me, and I had fun, and everyone was happy. Yeah, her pancreas was going to get better all on its own, and all I did was check triglycerides and give IV fluids and feed early (following a new EBM guideline that was published this month in JPGN – shout out!). But the FUN part was the magic trick and the smile on the child’s face. I think that’s why I became a pediatric hospitalist, rather than an adult hospitalist. The magic part.
4. Over 10 years ago, a past chair of our section gave the talk, “So you want to be a Hospitalist?” The talk mentioned numerous misconceptions, including stealing patients from PCPs, revenue not covering the costs of the program, and being “super residents.” Which of these misconceptions still exist and are there any that have taken their place?
That was probably Jack. He’s such an awesome dude, he’s been such a great mentor to me. It’s really interesting, but the way folks phrase those questions – “stealing” and “super residents” is inherently pejorative. I think people were upset back then because we were making changes and change is hard. I think that’s what makes folks “bristle” about being super-residents is the title, rather than the activity. I mean, heck, we ARE super residents, right? There are several hospitals where we do the work residents do (minus presenting to the attending who fixes our mistakes). So, I guess that’s a “super-resident.” Yeah, we do so much more: improve throughput, quality, safety, etc. But personally, I think the residents I work with are amazing. I’m honored to work with them, so if you call me a “super-resident,” I’m honored. Nobody called me a “super resident” when I was a resident! Getting back to the point, though, I think it’s partially about respect and partially about misperceptions. Regarding respect, I think we have to go out and earn it. We have to become experts because we own it, not because we claim to be. We need to take the advice from the consultant and then do something else that’s evidence-based and prove we were right. The reality is that a lot of this struggle has to do with shared “turf.” I think ID docs are threatened by us because we see the patients that they used to see (remember when it was a PMD who consulted about a straightforward pneumonia?). But it shouldn’t be a threatened relationship; it should be an alteration of our jobs so that everyone is as happy as possible.
But the question was what are the new misperceptions? I think one is “not academic enough a field.” I think that we need to create a generation of researchers (rather than a handful) who are commanding R01 grants from the NIH. The reality is our residents love us but our chairs won’t be impressed until we bring them the all-mighty research dollar. They already love us because QI and safety and all that, but we need to start bringing in the NIH dollars if we want to command our boss’ respect. When my chair is balancing the books, a few million from NIH is going to substantively improve the perception of my field. Until then, they will only see us as “super-residents.” Of course, that’s fine by me, but maybe not the best for the field. Another is “lazy when you’re not on service.” We need to work towards having folks understand what is and what is not sustainable, and further understand our value to the system. To do that we need to do a better job of benchmarking what we’re doing, and presenting that to our administrators.
5. In your article, “Association between resource utilization and patient satisfaction at a tertiary care medical center” [J Hosp Med. 2016 Nov;11(11):785-791], the data suggests that hospitals with higher per-patient expenditures may receive higher ratings. Why is this study important and how does this impact our care?
Well, it’s interesting, that study was on adult patients, not kids, but I do think it applies to us too. I’m actually working with one of our hospitalists on a similar project using pediatric data. I think this is important from two perspectives. First, from the CMS perspective, we are being reimbursed partially based on patient satisfaction in the near future. That is to say, CMS wants to adjust our reimbursement for care based on quality and patient satisfaction. This also affects our public perception, through our hospitals’ “Star Ratings.” Go to the CMS website and see what your hospital’s “Star Rating” is here: https://www.medicare.gov/hospitalcompare/search.html?
Now what’s sad about this is patient satisfaction, as measured by the HCAHPS survey (part of your hospital’s Press-Ganey survey, if they use that service), is maybe not measured as well as we might hope. I totally laud patients being satisfied. Of course, there are adult data that patients who like their doctor are (gulp!) more likely to die. There’s a lot of potential bias in that, but the HCAHPS isn’t free of its own bias. We didn’t publish it in our study, but we found, to a highly statistically significant degree, was that there is a strong association between how much a patient likes their doctor and how warm their food is. Now, we can draw one of three assumptions: 1) good doctors go to rooms with warm food, 2) warm food is delivered mostly to rooms where they have good doctors or 3) the HCAHPS suffers from recall bias. I’m sticking with the last one as the truth. But now, our reimbursement is based on that? This is a big problem. So we need to see what the underlying trends are, and show CMS how to adjust their data, and also inform ourselves how to boost our patient satisfaction. In that adult study, we found that hospitals with old people are more likely to get worse evaluations. But more importantly, patients where we spend a lot of money will in fact rank their hospitals higher. This is an incentive in the exact opposite direction CMS actually wants to go! I can’t wait to see what the pediatric data show…
6. You have extensively studied bronchiolitis, especially pulse oximetry. What do you think is driving the persistence of continuous pulse oximetry monitoring in bronchiolitis?
There is a pervasive misunderstanding that oxygen actually matters. It just doesn’t. Look, I’ll give you that an O2 saturation under 70% is potentially problematic and can cause brain damage. But transient desaturation above 70% (by transient I mean, say, less than 24 hours)… just… doesn’t… matter. Do I have proof? Sure! First off, take a look at this youtube video: https://www.youtube.com/watch?v=kUfF2MTnqAw&t=12s
Here, some volunteer is dropping his pulse ox to 67%. A few things DON’T happen. First, he doesn’t get short of breath (this was figured out in 1911 by Hasselbach, but still seemingly tricky to remember). Also, he doesn’t turn blue. Interesting. Now, experiment: put a pulse ox on and hold your breath as long as you can. Chances are you can’t get below 100% before you have to breathe. So, being hypoxic doesn’t make you short of breath. It’s lack of lung movement and acidosis from hypercarbia. The corollary, then, is if you’re short of breath, oxygen isn’t going to do a whole lot for you. Yet we continue to watch the pulse ox because nobody can seemingly develop a transcutaneous easy-to measure CO2 monitor, which is the gas we all really care about. The pulse ox provides a way for us to stop thinking about our patient and gives us something to talk about while the virus gets better on its own.
Here’s the thing I’m going to say, though, that will surprise you. I question whether the continuous pulse ox is actually all that harmful. Yes, it’s a pain to explain to the family why you’re okay sending their kid home when the pulse ox is 90%, but really is that all that much work? Is alarm fatigue truly problematic in pediatrics (there are virtually zero studies on this)? I guess I’m not that excited about this. Rusty McCulloh and I did a large randomized controlled trial of continuous pulse ox versus intermittent pulse ox. You know what we showed? It doesn’t matter. So, in the scope of things, I guess I take the EBM approach… I don’t really care all that much. I spend my time talking about parental inhalation-powered nose-sucking. Until someone does a study… then maybe I’ll get excited about something else, because, probably, nothing works in bronchiolitis except time…
7. In October 2016 in The Hospitalist, a group of pediatric hospitalists wrote an opinion piece entitled, “Why Required Pediatric Hospital Medicine Fellowships Are Unnecessary.” In it, they discuss that residency provides adequate training and requiring fellowship may reduce the number of trainees selecting the field. What is your response to this?
If we were all “super-residents,” I guess this might be true. I agree, I think the majority of us don’t need a fellowship. I think we’re great with clinical work. But two phenomena are occurring. First, residency education is shorter. Not by time, but by clinical inpatient experience. My residents see no more than two-thirds of the number of patients I saw as a resident. Work hours rules have substantially reduced the number of patient interactions. Second, shift-work has led residents to less “ownership” of patients, resulting in a poorer quality of learning. Third, no resident, not today or yesterday, knew how to do QI, or how to write a paper, or how to apply for a grant. If we’re going to advance quality of care for children, we need fellowship trainees. But fellowship is not for all of us. Just for some of us. And that’s the plan.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
I have a life-mentor named Steve Ludwig, who was my residency director. At the end of my chief resident year he gave me a wooden box that still sits on my desk. In the lid are inscribed words from James Taylor which I live by: “The secret of life is enjoying the passage of time.”
Those are words that are wiser than we think upon first perusal. I imagine that my career is moving along a trajectory on a graph, from left to right. Along the y-axis is “how much fun am I having”. The x-axis is time. I might sacrifice now, and the dot will move lower as I progress along, but the reward will be later, and the line will move up. The goal is to maximize the area under the curve. Ok, so this is really dorky, but I think it makes sense. We are all, essentially, slaves to our limbic system. The founders said “the pursuit of happiness” is an inalienable right, and they nailed it. So if I can impart one piece of wisdom: make sure what you’re doing is fun. If it isn’t, brainstorm a way to make it so. From my standpoint, I’m having a complete blast, and I’m so happy I’m a pediatric hospitalist. This has been, and continues to be, an awesome ride.
Thanks so much for the opportunity to write some words here, I think this forum is absolutely great. For the record, I’ve now handed the chair job over to Matt Garber, and am now “ex-officio”. But I did spend the last two years working hard for the Section as the chair.
I’ll be honest I was pretty agnostic about becoming a subspecialty. I can see potential benefits and also potential troubles ahead. The obvious benefit in defining ourselves as a subspecialty is that we will be able to craft the future for our field better. Also (and more importantly), I see us starting to really improve the quality of care hospitalized children receive. Think about our predecessors. It wasn’t until sub-specialization that ER and PICU became a strong academic force. Now millions of dollars of grants go towards the improvement of care for children in the ER and the ICU. The hospitalist literature, both QI and primary clinical research, is largely unwritten. By “forcing the hand” of free standing children’s hospitals, and creating a benchmark for hospitalist credentialing in hospitals with residencies and professorships, I believe we will emerge from a murky variability of practice to improve pediatric inpatient quality of care and outcomes. In terms of challenges, I’m a little worried about whether this improvement of care will spread beyond free standing children’s hospitals to community hospitals. The reality is there are far more positions for hospitalists than can be filled by ABP certified fellowship-trained physicians. I fear that by creating the “specialists” and the “non-specialists” we are at risk of ignoring the care of the vast majority of children who are hospitalized in community hospitals. Take, for example, the PHIS database. We can look and see how 40 children’s hospitals are managing infants with pneumonia, but what about the hundreds of hospitals in communities who are managing about two-thirds of these children? Who is tracking those data? And if those docs aren’t similarly trained as the ones in the PHIS hospitals, are we really improving care broadly across the country? We need to keep our eyes on all children.
2. Weigh in on the neonatal fever debate. It’s a constantly moving target for how much workup to do in the 28 day old with congestion and a temperature of 101⁰F. What is your policy?
I recently saw a study which showed that almost one in four infants under 28 days with fever do not get a spinal tap in the US. I know personally some specialists who might blow a gasket over that fact. Here’s the thing… I don’t think the answer to this problem is likely to be found in research, but rather in a soul search. Let me explain. Let’s say we did the largest prospective randomized trial with a billion children, and we proved, definitively, that the risk of an infant with RSV having concomitant meningitis who was relatively well appearing was 1 in 100,000. Even if we knew this number to be true, I’m sure there are doctors out there who will accept it, and other doctors who will not. Someone is thinking about that poor unfortunate 100,000th child who dies of untreated meningitis. Another person is thinking of the child admitted with a bloody uninterpretable tap and getting 2 weeks of empirical antibiotics for no reason and ends up on SQ LMW heparin for a clotted PICC line vein. Our perception of risk is entirely determined by our own personal denominator. Which is to say, the ID doctor who just managed a brain damaged infant in the ICU might feel one way, and a doctor who had a mother crying over her infant’s SQ shots might feel another way. What I think is interesting is our complete lack of ability to viscerally understand uncertainty. If I told you there was a 1:10,000 chance the child had meningitis you would probably get a tap, but the odds of a person dying in a car accident in one year is 1:10,000, and we send kids home in cars all the time.
So, to answer your question, what do I do? I look at all the details of the case and make my best guess, using evidence to guide me, but using the case and sometimes the parents’ wishes to make the final decision. I don’t think there is a “right answer” out there.
3. In January 2017, you wrote an article for Hospital Pediatrics entitled, “Seriously. Clowns.” In it, you suggest that we should consider using humor in place of acetaminophen or ranitidine if the only concern if reassuring the parents and making the child feel better. This was based on a study by Sanchez et al showing that salivary cortisol levels go down in children who are exposed to humor therapists in the inpatient setting. So, seriously? Clowns?
Oh no. I should be more careful about publishing things. So yes, not clowns. I actually don’t really like clowns all that much. But humor? Oh heck, yes. One of the most influential sessions I went to at PHM was a session where a magician taught us magic tricks we can do at the bedside. Just last week on the wards I got this note from a child with pancreatitis who caught wind of my infantile magic efforts: “Make my purple crayon change color. I dare you,” and the crayon was taped to the paper. You know what? I turned that crayon to pink, using her pink doll’s dress (that was the magic). And the child laughed. According to Sanchez et al, the child’s salivary cortisol went down. But you know what? The kid laughed, the parents laughed, and they trusted me, and I had fun, and everyone was happy. Yeah, her pancreas was going to get better all on its own, and all I did was check triglycerides and give IV fluids and feed early (following a new EBM guideline that was published this month in JPGN – shout out!). But the FUN part was the magic trick and the smile on the child’s face. I think that’s why I became a pediatric hospitalist, rather than an adult hospitalist. The magic part.
4. Over 10 years ago, a past chair of our section gave the talk, “So you want to be a Hospitalist?” The talk mentioned numerous misconceptions, including stealing patients from PCPs, revenue not covering the costs of the program, and being “super residents.” Which of these misconceptions still exist and are there any that have taken their place?
That was probably Jack. He’s such an awesome dude, he’s been such a great mentor to me. It’s really interesting, but the way folks phrase those questions – “stealing” and “super residents” is inherently pejorative. I think people were upset back then because we were making changes and change is hard. I think that’s what makes folks “bristle” about being super-residents is the title, rather than the activity. I mean, heck, we ARE super residents, right? There are several hospitals where we do the work residents do (minus presenting to the attending who fixes our mistakes). So, I guess that’s a “super-resident.” Yeah, we do so much more: improve throughput, quality, safety, etc. But personally, I think the residents I work with are amazing. I’m honored to work with them, so if you call me a “super-resident,” I’m honored. Nobody called me a “super resident” when I was a resident! Getting back to the point, though, I think it’s partially about respect and partially about misperceptions. Regarding respect, I think we have to go out and earn it. We have to become experts because we own it, not because we claim to be. We need to take the advice from the consultant and then do something else that’s evidence-based and prove we were right. The reality is that a lot of this struggle has to do with shared “turf.” I think ID docs are threatened by us because we see the patients that they used to see (remember when it was a PMD who consulted about a straightforward pneumonia?). But it shouldn’t be a threatened relationship; it should be an alteration of our jobs so that everyone is as happy as possible.
But the question was what are the new misperceptions? I think one is “not academic enough a field.” I think that we need to create a generation of researchers (rather than a handful) who are commanding R01 grants from the NIH. The reality is our residents love us but our chairs won’t be impressed until we bring them the all-mighty research dollar. They already love us because QI and safety and all that, but we need to start bringing in the NIH dollars if we want to command our boss’ respect. When my chair is balancing the books, a few million from NIH is going to substantively improve the perception of my field. Until then, they will only see us as “super-residents.” Of course, that’s fine by me, but maybe not the best for the field. Another is “lazy when you’re not on service.” We need to work towards having folks understand what is and what is not sustainable, and further understand our value to the system. To do that we need to do a better job of benchmarking what we’re doing, and presenting that to our administrators.
5. In your article, “Association between resource utilization and patient satisfaction at a tertiary care medical center” [J Hosp Med. 2016 Nov;11(11):785-791], the data suggests that hospitals with higher per-patient expenditures may receive higher ratings. Why is this study important and how does this impact our care?
Well, it’s interesting, that study was on adult patients, not kids, but I do think it applies to us too. I’m actually working with one of our hospitalists on a similar project using pediatric data. I think this is important from two perspectives. First, from the CMS perspective, we are being reimbursed partially based on patient satisfaction in the near future. That is to say, CMS wants to adjust our reimbursement for care based on quality and patient satisfaction. This also affects our public perception, through our hospitals’ “Star Ratings.” Go to the CMS website and see what your hospital’s “Star Rating” is here: https://www.medicare.gov/hospitalcompare/search.html?
Now what’s sad about this is patient satisfaction, as measured by the HCAHPS survey (part of your hospital’s Press-Ganey survey, if they use that service), is maybe not measured as well as we might hope. I totally laud patients being satisfied. Of course, there are adult data that patients who like their doctor are (gulp!) more likely to die. There’s a lot of potential bias in that, but the HCAHPS isn’t free of its own bias. We didn’t publish it in our study, but we found, to a highly statistically significant degree, was that there is a strong association between how much a patient likes their doctor and how warm their food is. Now, we can draw one of three assumptions: 1) good doctors go to rooms with warm food, 2) warm food is delivered mostly to rooms where they have good doctors or 3) the HCAHPS suffers from recall bias. I’m sticking with the last one as the truth. But now, our reimbursement is based on that? This is a big problem. So we need to see what the underlying trends are, and show CMS how to adjust their data, and also inform ourselves how to boost our patient satisfaction. In that adult study, we found that hospitals with old people are more likely to get worse evaluations. But more importantly, patients where we spend a lot of money will in fact rank their hospitals higher. This is an incentive in the exact opposite direction CMS actually wants to go! I can’t wait to see what the pediatric data show…
6. You have extensively studied bronchiolitis, especially pulse oximetry. What do you think is driving the persistence of continuous pulse oximetry monitoring in bronchiolitis?
There is a pervasive misunderstanding that oxygen actually matters. It just doesn’t. Look, I’ll give you that an O2 saturation under 70% is potentially problematic and can cause brain damage. But transient desaturation above 70% (by transient I mean, say, less than 24 hours)… just… doesn’t… matter. Do I have proof? Sure! First off, take a look at this youtube video: https://www.youtube.com/watch?v=kUfF2MTnqAw&t=12s
Here, some volunteer is dropping his pulse ox to 67%. A few things DON’T happen. First, he doesn’t get short of breath (this was figured out in 1911 by Hasselbach, but still seemingly tricky to remember). Also, he doesn’t turn blue. Interesting. Now, experiment: put a pulse ox on and hold your breath as long as you can. Chances are you can’t get below 100% before you have to breathe. So, being hypoxic doesn’t make you short of breath. It’s lack of lung movement and acidosis from hypercarbia. The corollary, then, is if you’re short of breath, oxygen isn’t going to do a whole lot for you. Yet we continue to watch the pulse ox because nobody can seemingly develop a transcutaneous easy-to measure CO2 monitor, which is the gas we all really care about. The pulse ox provides a way for us to stop thinking about our patient and gives us something to talk about while the virus gets better on its own.
Here’s the thing I’m going to say, though, that will surprise you. I question whether the continuous pulse ox is actually all that harmful. Yes, it’s a pain to explain to the family why you’re okay sending their kid home when the pulse ox is 90%, but really is that all that much work? Is alarm fatigue truly problematic in pediatrics (there are virtually zero studies on this)? I guess I’m not that excited about this. Rusty McCulloh and I did a large randomized controlled trial of continuous pulse ox versus intermittent pulse ox. You know what we showed? It doesn’t matter. So, in the scope of things, I guess I take the EBM approach… I don’t really care all that much. I spend my time talking about parental inhalation-powered nose-sucking. Until someone does a study… then maybe I’ll get excited about something else, because, probably, nothing works in bronchiolitis except time…
7. In October 2016 in The Hospitalist, a group of pediatric hospitalists wrote an opinion piece entitled, “Why Required Pediatric Hospital Medicine Fellowships Are Unnecessary.” In it, they discuss that residency provides adequate training and requiring fellowship may reduce the number of trainees selecting the field. What is your response to this?
If we were all “super-residents,” I guess this might be true. I agree, I think the majority of us don’t need a fellowship. I think we’re great with clinical work. But two phenomena are occurring. First, residency education is shorter. Not by time, but by clinical inpatient experience. My residents see no more than two-thirds of the number of patients I saw as a resident. Work hours rules have substantially reduced the number of patient interactions. Second, shift-work has led residents to less “ownership” of patients, resulting in a poorer quality of learning. Third, no resident, not today or yesterday, knew how to do QI, or how to write a paper, or how to apply for a grant. If we’re going to advance quality of care for children, we need fellowship trainees. But fellowship is not for all of us. Just for some of us. And that’s the plan.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
I have a life-mentor named Steve Ludwig, who was my residency director. At the end of my chief resident year he gave me a wooden box that still sits on my desk. In the lid are inscribed words from James Taylor which I live by: “The secret of life is enjoying the passage of time.”
Those are words that are wiser than we think upon first perusal. I imagine that my career is moving along a trajectory on a graph, from left to right. Along the y-axis is “how much fun am I having”. The x-axis is time. I might sacrifice now, and the dot will move lower as I progress along, but the reward will be later, and the line will move up. The goal is to maximize the area under the curve. Ok, so this is really dorky, but I think it makes sense. We are all, essentially, slaves to our limbic system. The founders said “the pursuit of happiness” is an inalienable right, and they nailed it. So if I can impart one piece of wisdom: make sure what you’re doing is fun. If it isn’t, brainstorm a way to make it so. From my standpoint, I’m having a complete blast, and I’m so happy I’m a pediatric hospitalist. This has been, and continues to be, an awesome ride.