Dan Rauch
1. You are the former chair of the AAP Section on Hospital Medicine and also former chair of the APA Hospital Medicine Special Interest Group (SIG). What have those 2 roles taught you? What are your thoughts on the transition of pediatric hospital medicine in becoming an accredited subspecialty?
I learned so much from both experiences. The AAP and APA are tremendous organizations that do incredible things for Pediatrics (capitalization on purpose). They are foremost concerned with improving the care of children. I know many pediatricians who belong to those organizations who write their annual dues checks only out of a sense of obligation and many who don't because of the cost or lack of appreciation for what the AAP and APA do. Being involved at a leadership level allowed me to see the impact of both organizations and how important they are for Pediatrics. I also learned how each organization functions which was critical in advocating for PHM.
Both have served invaluable roles in my career development and I remain active in both. I will add to that by saying both are always looking for pediatricians to get involved and there are so many opportunities at regional/state/national level. The first step is to show up and raise your hand. That's what I did.
As for PHM transitioning to an ABP subspecialty I was very much in favor because I believe it’s the next step in the growth of the field. I encourage everyone to read the article from the ABP about why they recognized PHM:
2. You co-edited the main handbook that many pediatric hospitalists use: Caring for the Hospitalized Child. Any advice or dogmas that you live by when facing a difficult diagnosis or clinical conundrum? Is there an updated version of the book in the works?
The second edition is at the publisher in the final stages of copy editing. Dr. Gershel and I are gratified by all the positive feedback we've received about the handbook and I'd like to thank all the expert contributors.
My advice for facing conundrums is to have faith that you are both right and wrong. Believe what you know are the facts - your history, exam findings, and tests. If you're not sure about any of those go back and do them again (if possible). Don't ignore what you know to fit a diagnosis. At the same time, leave your pride behind and go back to the beginning of the case to review all your decisions. Where did you lean one way instead of another, weigh some factors more heavily than others and where can you use some help? A truism in medicine is that you will never make a diagnosis that you didn't think of so I try to see where I've committed early diagnostic certainty/closure that may have prevented me from thinking more broadly.
3. You have worked at public hospitals, university hospitals, and a children's hospital. What’s your preference and why?
Each has its strengths and weaknesses. I've enjoyed the mission of public hospitals and practicing in New York City has exposed me to an incredibly diverse patient population from all over the world, most of them immigrants or first generation Americans who came to the US to seek a better life for themselves and their children. Working in lower resourced settings has made me a better clinician because I can't just get another consult or test. I worry that the current political and economic climate will impact on the survival of our public safety net hospitals. Working at a University Hospital allowed me a broader range of patients because of the availability of tertiary and quaternary care services both in terms of a larger department and onsite diagnostic capabilities. It also was a more academic environment and facilitated more interaction with adult medicine colleagues. However, pediatrics was still a minor player in the larger scale of the institution. A children's hospital provides an environment where everyone is focused on the care of children. The ongoing challenging is to keep that care to an appropriate level and not do things just because we can.
I've enjoyed working in all those environments. If someone knows of the perfect setting, please contact me.
4. What advice do you have for new pediatric hospitalists as they are embarking on their careers? How essential do you think that PHM fellowship is for new pediatric graduates?
When I was interviewing for a position just out of residency I was told by one prospective employer that the first three years out are a fellowship regardless of the formal title (or salary). I have found that to be true. The key is being in an environment that will foster your continued growth as a physician. Formal fellowships are not unique in that regard so I don't think they are necessary for the practice of PHM. I am not fellowship trained. I did ultimately choose my first position based on what I hoped would be the most supportive of my interests. If a young hospitalist wants to be a strong practitioner who provides excellent patient care and participates in quality work and maybe even enrolls patients in studies then there are many ways to accomplish that without fellowship training. If a young hospitalist knows they want to forge a career in an academic division then that path will be much easier with fellowship training. If someone was unsure or had to start paying off loans then start practice and the fellowships will be there later. It comes down to some healthy self-reflection on what you want to achieve and how the different choices will help you attain that goal. Mentorship is vital so lean on your mentors. Networking is critical too because at the end of residency a trainee will have experienced at most 2-3 regions/systems of care and every local practice has unique features that may or may not be generalizable.
5. You have hosted numerous pediatric Sirius radio broadcasts, “On Call for Kids.” How did you get involved and what was your favorite guest/topic?
The show and channel is a joint venture between SiriusXM and the institution and the studio is in the hospital lobby. Every department was responsible for a show and my chair at the time selected me as one of the rotating hosts. I've really enjoyed the experience. It’s not that dissimilar from attending rounds in that I know the topic ahead of time just like I usually know the patients' working diagnoses and then I have to respond to whatever comes up. Just like in rounds I have to admit that I don't know a lot. I have had great producers who either supply me with fun guests or work hard on my suggestions. Some of my best shows have been with colleagues and friends, including once with my wife who is PEM. Alternatively I had a riveting hour with the author of the Lancet article discrediting Andrew Wakefield. I vividly remember a caller who was crying as she described how a prior show I had hosted had led her to treatment for her child that had changed their lives so I'm hopeful that I've had some positive impact.
6. What do you see as the biggest challenge facing pediatric hospital medicine in the next 5 years and why?
The biggest challenge ahead I think is to remain a generalist field. The growth of PHM and fellowships has allowed people to practice PHM with no experience as a general pediatrician. I started in an ambulatory clinic and did outpatient care for ten years. I have an understanding of what happens in a ten minute visit and how much is covered and why some things aren't. That experience helps me to understand why the PMD did what they did. I think it is important that the inpatient services not get siloed. Good communication and handoffs are supported by a baseline respect for each other's role in the care of the child. The other side of being a generalist is understanding the role of a generalist. This reflects a little on the strengths/weaknesses of different hospital settings. In lower resourced venues within larger hospitals the pediatric hospitalist must be the advocate for pediatric care while acknowledging the limitations of the site. In children's' hospitals the pediatric hospitalist must be able to establish a broad width of practice and not allow overuse and over treatment.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
In my training program we had weekly 'Chairman's Rounds' where the faculty bet on the case and the ante was a nickel. So I will give my five cents worth.
The above questions helped me reflect on where I've been and the path I've taken. It hasn't been straight and it isn't anything like I would have predicted 20 years ago. I remember a comment I received early on that I had real potential as an academic if I could stay focused on a single area. I'm certain that part of what drew me into PHM was that I didn't have to focus on a narrow area. I've been able to pursue being a good clinician, develop traditional academic interests and get involved in national organizations. Most important, in retrospect, has been to do things that I was interested in and motivated me. My day job has certainly required me to do things that I was less interested in but I've always been able to follow my interests and passions. And those have included non-medical pursuits as well like prioritizing time with my family. Every job has compromises but if you don't include what you love you won't last very long. So keep that in mind when you are offered the 'once-in-a lifetime" opportunity. If it isn't right for you at the time, for whatever reason (family, finances, location, too soon...) then don't take it. I promise another "once-in-a-lifetime" opportunity will come.
I learned so much from both experiences. The AAP and APA are tremendous organizations that do incredible things for Pediatrics (capitalization on purpose). They are foremost concerned with improving the care of children. I know many pediatricians who belong to those organizations who write their annual dues checks only out of a sense of obligation and many who don't because of the cost or lack of appreciation for what the AAP and APA do. Being involved at a leadership level allowed me to see the impact of both organizations and how important they are for Pediatrics. I also learned how each organization functions which was critical in advocating for PHM.
Both have served invaluable roles in my career development and I remain active in both. I will add to that by saying both are always looking for pediatricians to get involved and there are so many opportunities at regional/state/national level. The first step is to show up and raise your hand. That's what I did.
As for PHM transitioning to an ABP subspecialty I was very much in favor because I believe it’s the next step in the growth of the field. I encourage everyone to read the article from the ABP about why they recognized PHM:
- Pediatric Hospital Medicine: A Proposed New Subspecialty. Douglas J. Barrett, Gail A. McGuinness, Christopher A. Cunha, S. Jean Emans, William T. Gerson, Mary F. Hazinski, George Lister, Karen F. Murray, Joseph W.St. Geme, Patricia N. Whitley-Williams. Pediatric. 2017:139(3).
2. You co-edited the main handbook that many pediatric hospitalists use: Caring for the Hospitalized Child. Any advice or dogmas that you live by when facing a difficult diagnosis or clinical conundrum? Is there an updated version of the book in the works?
The second edition is at the publisher in the final stages of copy editing. Dr. Gershel and I are gratified by all the positive feedback we've received about the handbook and I'd like to thank all the expert contributors.
My advice for facing conundrums is to have faith that you are both right and wrong. Believe what you know are the facts - your history, exam findings, and tests. If you're not sure about any of those go back and do them again (if possible). Don't ignore what you know to fit a diagnosis. At the same time, leave your pride behind and go back to the beginning of the case to review all your decisions. Where did you lean one way instead of another, weigh some factors more heavily than others and where can you use some help? A truism in medicine is that you will never make a diagnosis that you didn't think of so I try to see where I've committed early diagnostic certainty/closure that may have prevented me from thinking more broadly.
3. You have worked at public hospitals, university hospitals, and a children's hospital. What’s your preference and why?
Each has its strengths and weaknesses. I've enjoyed the mission of public hospitals and practicing in New York City has exposed me to an incredibly diverse patient population from all over the world, most of them immigrants or first generation Americans who came to the US to seek a better life for themselves and their children. Working in lower resourced settings has made me a better clinician because I can't just get another consult or test. I worry that the current political and economic climate will impact on the survival of our public safety net hospitals. Working at a University Hospital allowed me a broader range of patients because of the availability of tertiary and quaternary care services both in terms of a larger department and onsite diagnostic capabilities. It also was a more academic environment and facilitated more interaction with adult medicine colleagues. However, pediatrics was still a minor player in the larger scale of the institution. A children's hospital provides an environment where everyone is focused on the care of children. The ongoing challenging is to keep that care to an appropriate level and not do things just because we can.
I've enjoyed working in all those environments. If someone knows of the perfect setting, please contact me.
4. What advice do you have for new pediatric hospitalists as they are embarking on their careers? How essential do you think that PHM fellowship is for new pediatric graduates?
When I was interviewing for a position just out of residency I was told by one prospective employer that the first three years out are a fellowship regardless of the formal title (or salary). I have found that to be true. The key is being in an environment that will foster your continued growth as a physician. Formal fellowships are not unique in that regard so I don't think they are necessary for the practice of PHM. I am not fellowship trained. I did ultimately choose my first position based on what I hoped would be the most supportive of my interests. If a young hospitalist wants to be a strong practitioner who provides excellent patient care and participates in quality work and maybe even enrolls patients in studies then there are many ways to accomplish that without fellowship training. If a young hospitalist knows they want to forge a career in an academic division then that path will be much easier with fellowship training. If someone was unsure or had to start paying off loans then start practice and the fellowships will be there later. It comes down to some healthy self-reflection on what you want to achieve and how the different choices will help you attain that goal. Mentorship is vital so lean on your mentors. Networking is critical too because at the end of residency a trainee will have experienced at most 2-3 regions/systems of care and every local practice has unique features that may or may not be generalizable.
5. You have hosted numerous pediatric Sirius radio broadcasts, “On Call for Kids.” How did you get involved and what was your favorite guest/topic?
The show and channel is a joint venture between SiriusXM and the institution and the studio is in the hospital lobby. Every department was responsible for a show and my chair at the time selected me as one of the rotating hosts. I've really enjoyed the experience. It’s not that dissimilar from attending rounds in that I know the topic ahead of time just like I usually know the patients' working diagnoses and then I have to respond to whatever comes up. Just like in rounds I have to admit that I don't know a lot. I have had great producers who either supply me with fun guests or work hard on my suggestions. Some of my best shows have been with colleagues and friends, including once with my wife who is PEM. Alternatively I had a riveting hour with the author of the Lancet article discrediting Andrew Wakefield. I vividly remember a caller who was crying as she described how a prior show I had hosted had led her to treatment for her child that had changed their lives so I'm hopeful that I've had some positive impact.
6. What do you see as the biggest challenge facing pediatric hospital medicine in the next 5 years and why?
The biggest challenge ahead I think is to remain a generalist field. The growth of PHM and fellowships has allowed people to practice PHM with no experience as a general pediatrician. I started in an ambulatory clinic and did outpatient care for ten years. I have an understanding of what happens in a ten minute visit and how much is covered and why some things aren't. That experience helps me to understand why the PMD did what they did. I think it is important that the inpatient services not get siloed. Good communication and handoffs are supported by a baseline respect for each other's role in the care of the child. The other side of being a generalist is understanding the role of a generalist. This reflects a little on the strengths/weaknesses of different hospital settings. In lower resourced venues within larger hospitals the pediatric hospitalist must be the advocate for pediatric care while acknowledging the limitations of the site. In children's' hospitals the pediatric hospitalist must be able to establish a broad width of practice and not allow overuse and over treatment.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
In my training program we had weekly 'Chairman's Rounds' where the faculty bet on the case and the ante was a nickel. So I will give my five cents worth.
The above questions helped me reflect on where I've been and the path I've taken. It hasn't been straight and it isn't anything like I would have predicted 20 years ago. I remember a comment I received early on that I had real potential as an academic if I could stay focused on a single area. I'm certain that part of what drew me into PHM was that I didn't have to focus on a narrow area. I've been able to pursue being a good clinician, develop traditional academic interests and get involved in national organizations. Most important, in retrospect, has been to do things that I was interested in and motivated me. My day job has certainly required me to do things that I was less interested in but I've always been able to follow my interests and passions. And those have included non-medical pursuits as well like prioritizing time with my family. Every job has compromises but if you don't include what you love you won't last very long. So keep that in mind when you are offered the 'once-in-a lifetime" opportunity. If it isn't right for you at the time, for whatever reason (family, finances, location, too soon...) then don't take it. I promise another "once-in-a-lifetime" opportunity will come.