- Clota Snow
1. At PHM last year, you were going to lead “Caring for Yourself While Caring for Hospitalized Children: A Roadmap to Personal and Institutional Wellness in Community Settings”. Can you share why wellness is so important to focus on for pediatric hospitalists? How has that changed with COVID19?
There has been growing realization that burnout is a problem among physicians. Although some hospitalists have access to wellness programs at their institution, many don’t have anything formal, and we felt this would be a worthy topic to explore in our annual community hospitalist pre-conference at PHM. We partnered with the Subcommittee on Provider Wellness to draw on their wealth of knowledge on the topic. I am admittedly not an expert on wellness and am as much in need of attending this course as anyone else! We started planning before COVID hit, but the presence of a crisis has only heightened the need to focus on caring for ourselves while caring for others. This is especially true when caring for patients becomes more difficult, such as facing more frequent patient death, putting your own health at risk, or the disruption of our daily routines at work and home. Given all of the challenges we are currently facing, it is an even more important time to stop and reflect on what we can do to prioritize personal wellness. It is also critical to learn how we can promote wellness in our institutions by developing a culture that prioritizes physician well-being as well as equity and inclusivity. Although we are disappointed we won’t be able to host the conference in person, we are going to try doing it virtually, so stay tuned!
2. A few years ago, the AAP Section of Hospital Medicine Subcommittee on Community Hospitals conducted a survey to characterize the number and clinical scope of pediatric hospitalists outside of a tertiary/quaternary care center. What were some of the more surprising results and conclusions from that survey?
Jacques Corriveau and I worked on the survey to try and establish exactly how many pediatric hospitalists were working in community settings. We started with the suspicion that there were many more out there than previously thought, since many work in small hospitals or rural areas and aren’t necessarily connected with the SOHM and other national groups. Our goals were to better quantify the work force, and to provide outreach to introduce people to the resources, mentorship and networking opportunities within the SOHM. Working in a community setting can be isolating, but many of us are sharing the same struggles and can find benefit from connecting with the larger community. We found that many of our suspicions proved true. Of the 535 hospitals that responded to our survey, 349 identified themselves as community hospitals, which confirmed that the majority of pediatric hospitalist programs exist in community settings (although the majority of FTEs identified work in tertiary/children’s hospitals, since community programs are usually smaller.) The clinical scope of community hospitalists, as we suspected, was broad: 72% covered the newborn nursery, 44% attended deliveries, 38% staffed some sort of NICU, 88% provided inpatient pediatric care, 52% provided subspecialty or surgical co-management, 76% provided ED consultations, 14% provided primary ED coverage, and 24% provided PICU and/or intermediate level of care. It confirmed that community hospitalists are often “jacks of all trades” and function as the pediatric specialist in their institutions, which is part of what makes the job so interesting! It also helps to identify the particular skills needed by hospitalists working in the community, which can help guide residency and fellowship training.
3. You gave a talk about “Newborn Nursery Controversies.” What do you think are some of the big ones, and how do you approach them?
There have been some big shifts recently in newborn medicine which have changed how we approach some relatively common conditions. Just in the last few years, we’ve changed our approach to infants born to mothers with chorioamnionitis and have switched from Finnegan scoring to Eat, Sleep, Console for opiate-exposed newborns. Although these aren’t exactly controversies, they have been major changes in newborn medicine and have sparked a lot of interesting discussion. Another issue, which I addressed in my talk, is parental refusal of recommended interventions, most specifically intramuscular vitamin K. We started seeing a surprising uptick in the number of refusals a few years ago, and I heard from colleagues around the country that they were seeing much the same. There is considerable debate about how to approach these families (Do you make them sign a refusal form? Do you make a CPS report?) and what to do if they prefer oral vitamin K (Do you provide dosing recommendation? Or does that make you complicit by aiding in an inferior intervention?) I personally start by assessing why the family has chosen not to give IM vitamin K. Often I can identify a misconception that I can correct, and the families will ultimately give it. As part of my counseling, I am frank about the risks of not giving IM vitamin K, and the inferiority of oral vitamin K (especially in the US, where the products families often want to use are not FDA approved or validated in any way.) If a family continues insist on oral vitamin K, I personally do provide some dosing recommendations (based on the most effective regimens used in Europe) because I feel that if they’re going to do the oral route, it is in the baby’s best interest to make sure they are getting the most effective possible dosing. All the while, I remind the family of the possibility of emesis, poor absorption, unreliable formulations and the importance of not missing any doses. Our hospital does not currently supply oral vitamin K to families, and we don’t put it in as a physician order; families administer it themselves. It was the consensus of our group that a physician order would be complicit in a non-proven therapy, but I personally feel that guidance is appropriate. There is great variability in how others approach this, some of which is guided by local laws, which makes it interesting to discuss!
4. At PHM19, you presented about a MOC part 4 project for community pediatric hospitalists regarding supplementing vitamin D in the newborn nursery. Can you share more about your project and advice you have for other community pediatric hospitalists who want to undertake a QI project at their hospital?
I personally have minimal formal QI training, so I did a lot of learning on the fly. Seek mentors, and seek the resources already in place at your institution; you may be surprised that there are people in your institution you can reach out to, often outside of your department, who can be helpful in structuring your project. I’d recommend starting out with something relatively achievable while you learn the ropes, and then move on to bigger projects once you feel more comfortable. Always be on the lookout for stakeholders, whether it is a nurse who is working on an advanced certification and looking for a project, or an RT with an interest in pediatrics. If you start asking around, usually you can find enthusiastic people to help out!
5. As a community pediatric hospitalist who is very involved on the national level with PHM conferences and the AAP section of hospital medicine subcommittee on community hospitalists, what advice do you have for others that want to get more involved?
Volunteer for things! The AAP and other national groups are often looking for community hospitalist input on a variety of projects and committees, so there are ample opportunities to get involved. Apply for things, even if they seem “out of your league.” Take advantage of national meetings, especially PHM, where there is a ton of great networking. Most of my opportunities have come from connecting with the right people at the right time, and from getting to know people at meetings. We are an approachable group, so don’t hesitate to contact the Subcommittee on Community Hospitalist leadership, we’re always looking for help and new ideas!
6. In January 2019, you were the “Doctor of the Day” at the Maine Senate. Can you tell us more about this program and your experience?
Every day the Maine legislature is in session, they look for a volunteer “Doctor of the Day.” Your main purpose is to respond to any medical emergencies that occur in the building (which thankfully rarely happen – as a pediatrician I was nervous since the average age of the legislators is well over 60!) but really it is an opportunity to observe the legislative process. I got to chat with both my state representative and senator and share my thoughts on some current legislation. At the time, Maine was debating a law to eliminate non-medical vaccine exemptions, and several lawmakers approached me to ask my opinion. There are several physicians in the legislature, and I got to meet them as well. I spent time with some medical advocacy groups and learned about their work. I was surprised how approachable the lawmakers were, and how genuinely interested they were in my thoughts. I had no idea that anyone can just walk into the chambers and interact with the legislators; it made the legislative process seem so much more accessible, at least in my small state. The experience sparked an interest advocacy work, which I hope to become more involved with in the future.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
I encourage trainees interested in hospital medicine, or any hospitalist looking for a change of scene, to consider working in a community setting. No two jobs are alike, and many of us are the only pediatrician in the building at any given time. Although this can be daunting, it also means you have to keep all of your clinical skills sharp because you never know what might walk in the door; you could go from helping stabilize a critically ill child in the ED for transport, to attending the delivery of an extremely premature infant, to caring for a teenager with asthma, to counseling new parents about their healthy newborn. You also get to be a voice for children in your institution and community, with the potential for great impact. There are challenges for sure, but overall it’s a rewarding job!
There has been growing realization that burnout is a problem among physicians. Although some hospitalists have access to wellness programs at their institution, many don’t have anything formal, and we felt this would be a worthy topic to explore in our annual community hospitalist pre-conference at PHM. We partnered with the Subcommittee on Provider Wellness to draw on their wealth of knowledge on the topic. I am admittedly not an expert on wellness and am as much in need of attending this course as anyone else! We started planning before COVID hit, but the presence of a crisis has only heightened the need to focus on caring for ourselves while caring for others. This is especially true when caring for patients becomes more difficult, such as facing more frequent patient death, putting your own health at risk, or the disruption of our daily routines at work and home. Given all of the challenges we are currently facing, it is an even more important time to stop and reflect on what we can do to prioritize personal wellness. It is also critical to learn how we can promote wellness in our institutions by developing a culture that prioritizes physician well-being as well as equity and inclusivity. Although we are disappointed we won’t be able to host the conference in person, we are going to try doing it virtually, so stay tuned!
2. A few years ago, the AAP Section of Hospital Medicine Subcommittee on Community Hospitals conducted a survey to characterize the number and clinical scope of pediatric hospitalists outside of a tertiary/quaternary care center. What were some of the more surprising results and conclusions from that survey?
Jacques Corriveau and I worked on the survey to try and establish exactly how many pediatric hospitalists were working in community settings. We started with the suspicion that there were many more out there than previously thought, since many work in small hospitals or rural areas and aren’t necessarily connected with the SOHM and other national groups. Our goals were to better quantify the work force, and to provide outreach to introduce people to the resources, mentorship and networking opportunities within the SOHM. Working in a community setting can be isolating, but many of us are sharing the same struggles and can find benefit from connecting with the larger community. We found that many of our suspicions proved true. Of the 535 hospitals that responded to our survey, 349 identified themselves as community hospitals, which confirmed that the majority of pediatric hospitalist programs exist in community settings (although the majority of FTEs identified work in tertiary/children’s hospitals, since community programs are usually smaller.) The clinical scope of community hospitalists, as we suspected, was broad: 72% covered the newborn nursery, 44% attended deliveries, 38% staffed some sort of NICU, 88% provided inpatient pediatric care, 52% provided subspecialty or surgical co-management, 76% provided ED consultations, 14% provided primary ED coverage, and 24% provided PICU and/or intermediate level of care. It confirmed that community hospitalists are often “jacks of all trades” and function as the pediatric specialist in their institutions, which is part of what makes the job so interesting! It also helps to identify the particular skills needed by hospitalists working in the community, which can help guide residency and fellowship training.
3. You gave a talk about “Newborn Nursery Controversies.” What do you think are some of the big ones, and how do you approach them?
There have been some big shifts recently in newborn medicine which have changed how we approach some relatively common conditions. Just in the last few years, we’ve changed our approach to infants born to mothers with chorioamnionitis and have switched from Finnegan scoring to Eat, Sleep, Console for opiate-exposed newborns. Although these aren’t exactly controversies, they have been major changes in newborn medicine and have sparked a lot of interesting discussion. Another issue, which I addressed in my talk, is parental refusal of recommended interventions, most specifically intramuscular vitamin K. We started seeing a surprising uptick in the number of refusals a few years ago, and I heard from colleagues around the country that they were seeing much the same. There is considerable debate about how to approach these families (Do you make them sign a refusal form? Do you make a CPS report?) and what to do if they prefer oral vitamin K (Do you provide dosing recommendation? Or does that make you complicit by aiding in an inferior intervention?) I personally start by assessing why the family has chosen not to give IM vitamin K. Often I can identify a misconception that I can correct, and the families will ultimately give it. As part of my counseling, I am frank about the risks of not giving IM vitamin K, and the inferiority of oral vitamin K (especially in the US, where the products families often want to use are not FDA approved or validated in any way.) If a family continues insist on oral vitamin K, I personally do provide some dosing recommendations (based on the most effective regimens used in Europe) because I feel that if they’re going to do the oral route, it is in the baby’s best interest to make sure they are getting the most effective possible dosing. All the while, I remind the family of the possibility of emesis, poor absorption, unreliable formulations and the importance of not missing any doses. Our hospital does not currently supply oral vitamin K to families, and we don’t put it in as a physician order; families administer it themselves. It was the consensus of our group that a physician order would be complicit in a non-proven therapy, but I personally feel that guidance is appropriate. There is great variability in how others approach this, some of which is guided by local laws, which makes it interesting to discuss!
4. At PHM19, you presented about a MOC part 4 project for community pediatric hospitalists regarding supplementing vitamin D in the newborn nursery. Can you share more about your project and advice you have for other community pediatric hospitalists who want to undertake a QI project at their hospital?
I personally have minimal formal QI training, so I did a lot of learning on the fly. Seek mentors, and seek the resources already in place at your institution; you may be surprised that there are people in your institution you can reach out to, often outside of your department, who can be helpful in structuring your project. I’d recommend starting out with something relatively achievable while you learn the ropes, and then move on to bigger projects once you feel more comfortable. Always be on the lookout for stakeholders, whether it is a nurse who is working on an advanced certification and looking for a project, or an RT with an interest in pediatrics. If you start asking around, usually you can find enthusiastic people to help out!
5. As a community pediatric hospitalist who is very involved on the national level with PHM conferences and the AAP section of hospital medicine subcommittee on community hospitalists, what advice do you have for others that want to get more involved?
Volunteer for things! The AAP and other national groups are often looking for community hospitalist input on a variety of projects and committees, so there are ample opportunities to get involved. Apply for things, even if they seem “out of your league.” Take advantage of national meetings, especially PHM, where there is a ton of great networking. Most of my opportunities have come from connecting with the right people at the right time, and from getting to know people at meetings. We are an approachable group, so don’t hesitate to contact the Subcommittee on Community Hospitalist leadership, we’re always looking for help and new ideas!
6. In January 2019, you were the “Doctor of the Day” at the Maine Senate. Can you tell us more about this program and your experience?
Every day the Maine legislature is in session, they look for a volunteer “Doctor of the Day.” Your main purpose is to respond to any medical emergencies that occur in the building (which thankfully rarely happen – as a pediatrician I was nervous since the average age of the legislators is well over 60!) but really it is an opportunity to observe the legislative process. I got to chat with both my state representative and senator and share my thoughts on some current legislation. At the time, Maine was debating a law to eliminate non-medical vaccine exemptions, and several lawmakers approached me to ask my opinion. There are several physicians in the legislature, and I got to meet them as well. I spent time with some medical advocacy groups and learned about their work. I was surprised how approachable the lawmakers were, and how genuinely interested they were in my thoughts. I had no idea that anyone can just walk into the chambers and interact with the legislators; it made the legislative process seem so much more accessible, at least in my small state. The experience sparked an interest advocacy work, which I hope to become more involved with in the future.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
I encourage trainees interested in hospital medicine, or any hospitalist looking for a change of scene, to consider working in a community setting. No two jobs are alike, and many of us are the only pediatrician in the building at any given time. Although this can be daunting, it also means you have to keep all of your clinical skills sharp because you never know what might walk in the door; you could go from helping stabilize a critically ill child in the ED for transport, to attending the delivery of an extremely premature infant, to caring for a teenager with asthma, to counseling new parents about their healthy newborn. You also get to be a voice for children in your institution and community, with the potential for great impact. There are challenges for sure, but overall it’s a rewarding job!