- Douglas Carlson
1. You have published numerous papers and given many talks about pediatric sedation. Many hospitals only allow anesthesiologists and sometimes intensivists to perform sedation. What is your opinion on pediatric hospitalists doing sedation, and how do you suggest hospitalists get training if it’s not something they are currently doing?
Efficient, effective, timely and safe sedation can be provided by specialists from many areas including pediatric hospital medicine. Safety is more about the systems of care than about the specialty of the provider. Sedation is currently part of pediatric hospital medicine fellowships but is not part of a core pediatric residency. Therefore, pediatric hospitalists that have not been fellowship trained need to develop the skills necessary to provide safe sedation through a continuing medical education process. There are no national standards for this training. Training and competency requirements are developed by individual hospitals. Training requirements should include significant supervised practice, simulation and possibly operating room time.
It has been clearly shown that moderate and deep sedation can be appropriately provided by pediatric hospitalists. Sedation systems of care work best when there is cooperation and respect by all sedation providers. I am often asked about how a pediatric hospitalist can convince their anesthesia or intensive care colleagues to support them in providing sedation for their patients. I suggest making the argument patient centric. Pediatric hospitalists understand well the sedation needs within a hospital setting. If those needs are not being met, the pediatric hospitalists should discuss that with the groups that provide sedation. There are then two appropriate answers. First is “we didn’t realize there was an unmet need, we will meet that need”. It is important then that the hospitalists make sure those sedation providers are held accountable for meeting that need. The other appropriate answer by current sedation providers is “we do not have enough staff to meet that need, we will help you gain the experience to provide sedations safely.” Unfortunately, the response sometimes is “we are unable to meet that need, we will not allow you to do it either.” That answer is unsafe, it leads to the provision of sedation by well-meaning clinicians but without all the backup support mechanisms necessary.
2. As an attending physician in both the Emergency Department and Pediatric Hospital Medicine, how does that change your perspective about admitting patients versus observing them in the ED? For example, a patient with anaphylaxis who receives epinephrine or a patient who falls and requires several more hours of observation based on PECARN criteria—do you usually admit to the floor or keep in the ED?
Pediatric emergency physicians and pediatric hospitalists have similar but different skill sets. I think the differences in mind set leads to different approaches to extended observation. For emergency physicians a few hours is a long time. For hospitalists a few hours is a short time. Neither of the approaches to observation care is superior to the other. In general, I think that treatment plans that extend beyond four hours should be moved out of the emergency department. This can be to an observation area run by emergency physicians or hospitalists or to observation status in a general inpatient unit. A key to making any system of transfer of care work is to make sure that those transitions are easy for all. In all institutions that I have worked the only necessary hurdle for a patient to be admitted is the request of the emergency physician. All too often unintended barriers are placed. For transfer of care to work well it does take a good working relationship between emergency physicians and hospitalists, with neither believing the other is taking advantage of them. This can generally be done through ongoing professional communication, trying to understand the goals and perspective of the other. A good working relationship between the emergency department and inpatient service is essential to provide best care. It is a relationship that I often see as strained.
3. “Development of a performance tracking tool for a pediatric hospitalist division” was published in Hospital Pediatrics in 2013. Can you tell us more about the tool?
I think this article is a good example of taking daily work and turning it into scholarship. At Washington University we had a large diverse pediatric hospital medicine division. As we looked into national standardized quality metrics we realized that there was a paucity of them. We adopted standard process improvement methodology to develop a set of potential processes to measure. We prioritized those that were both important and could be measured easily. That seems obvious but was harder than we anticipated. In the end we came up with a robust set of quality metrics which could be measured mostly electronically, only going to chart review if the metric was essential and not otherwise easily measured. Early in the process we realized that this work might be of interest to others. Hopefully others can use this work to try to achieve similar goals in measurement of performance quality in a pediatric hospital medicine division/group.
4. You are a reviewer for multiple journals including Pediatrics, Journal of Hospital Medicine, and Journal of Pediatrics and on the editorial board for the Journal of Hospital Medicine—what makes a good journal article? What advice do you have for a hospitalist looking to publish for the first time?
In a simplistic way a good article is one that advances knowledge. Not all articles will have immediate impact but should have the purpose of improving care or stimulating the discussion of ideas. Being succinct with appropriate scope is important. Too often authors take a minor finding and then extrapolate into a review article. There is clearly a need for review articles but every finding does not justify a review of literature and the author’s interpretation of that literature. Stick to the findings of your study and the direct implications of your findings.
I see a lot of good work that never makes it to a published manuscript. This is generally has do with the lack of putting the work into the form for submission rather than the quality of the work. The data and findings languish because no one takes the final effort to write the manuscript. I have found that there is more often success when people work together. Each holding the other responsible. Potentially dividing up the work and setting expectations for each other. Often it is easy to procrastinate when you are the only one affected, but when others are depending on you it may provide motivation. Someone needs to put in the most work, and they should be rewarded by being first author. On another project the roles may be switched.
We all have busy lives professionally and personally. Most pediatric hospitalists have the daily work of patient care and education as their first work priority. Completing a study and writing a manuscript are important but often give way to busy days. It is important to find a way to prioritize the effort so that important work is submitted for peer-review.
5. How did you get involved with the Ethics Committee at St. John’s Hospital? What do you recommend for other hospitalists that may also want to get involved with their ethics committee?
My work on the ethics committee at St. John’s Hospital is important and rewarding. It is not something that I actively sought out but was asked to participate. It was an easy yes and was pleased to be asked. I have found in my career that many of my opportunities have come because others asked me to do something. In retrospect I am glad that I have said yes to nearly every opportunity given to me. Each position that I have held in academic and clinical work has broadened my perspective and I have used the gained knowledge to apply in other areas of professional work. I often hear the advice to be willing to say no to opportunities. I agree with that advice but there can be a downside of limiting your future growth by not taking advantage of the opportunities that are proposed to you. Pediatric hospitalists are generalists in our clinical work. I think most pediatric hospitalists are also generalists in our academic and leadership roles. If someone has a singular focus, which is well-defined, then saying no to opportunities is very reasonable, if those opportunities are not within your career focus. I believe that most pediatric hospitalists benefit from saying yes to opportunities whenever we can.
6. You co-wrote an editorial titled “Pediatric neurohospitalists: An idea that has come of age?” in Neurology in 2013. Can you tell us more about the concept and your thoughts about it 7 years later?
I wrote this editorial with Dr. Nina Schor. Dr. Schor is a pediatric neurologist and at the time was Chair of Pediatrics at the University of Rochester. In the seven years since that editorial pediatric neuro-hospitalists have become more common. Mostly concentrated in large children’s hospitals. Dr. Schor saw this as primarily a role of specialization within pediatric neurology. I anticipated that the role may be filled by pediatric hospitalists focusing in neurology care. It turns out that Dr. Schor’s prediction was more accurate than mine. This has become a viable career option, although still not that common. Care of neurology patients is core to pediatric hospital medicine. Most hospitals are not large enough to support pediatric neuro-hospitalists so that care coordination between pediatric neurology specialists and pediatric hospitalist specialists is needed.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
As I reflect on my pathway through my career, I realize how much I have depended upon others for my opportunities and successes. I have been lucky enough to have several mentors that I depended upon throughout my career. The idea of sponsorship is one that I have focused on recently. Sponsorship is different from mentorship. Some of my mentors I have had for many years and some for a short period of time. I have also had many peer mentors that I have reached out to for advice and counsel. These mentors have often also been sponsors in supporting and suggesting new roles for me. I have also had sponsorship that came from those that were not mentors. Having someone to seek advice from and be willing to give me the time necessary has been a blessing for me. It is the basis for my success. I really try every day to pay that forward by being open and accessible to those who ask for my help. I hope that I am successful with that. I have tried to be focused on sponsoring a diverse group of talented physicians to local, regional and national positions. It is important that we all support each other as the field of pediatric hospital medicine grows.
Efficient, effective, timely and safe sedation can be provided by specialists from many areas including pediatric hospital medicine. Safety is more about the systems of care than about the specialty of the provider. Sedation is currently part of pediatric hospital medicine fellowships but is not part of a core pediatric residency. Therefore, pediatric hospitalists that have not been fellowship trained need to develop the skills necessary to provide safe sedation through a continuing medical education process. There are no national standards for this training. Training and competency requirements are developed by individual hospitals. Training requirements should include significant supervised practice, simulation and possibly operating room time.
It has been clearly shown that moderate and deep sedation can be appropriately provided by pediatric hospitalists. Sedation systems of care work best when there is cooperation and respect by all sedation providers. I am often asked about how a pediatric hospitalist can convince their anesthesia or intensive care colleagues to support them in providing sedation for their patients. I suggest making the argument patient centric. Pediatric hospitalists understand well the sedation needs within a hospital setting. If those needs are not being met, the pediatric hospitalists should discuss that with the groups that provide sedation. There are then two appropriate answers. First is “we didn’t realize there was an unmet need, we will meet that need”. It is important then that the hospitalists make sure those sedation providers are held accountable for meeting that need. The other appropriate answer by current sedation providers is “we do not have enough staff to meet that need, we will help you gain the experience to provide sedations safely.” Unfortunately, the response sometimes is “we are unable to meet that need, we will not allow you to do it either.” That answer is unsafe, it leads to the provision of sedation by well-meaning clinicians but without all the backup support mechanisms necessary.
2. As an attending physician in both the Emergency Department and Pediatric Hospital Medicine, how does that change your perspective about admitting patients versus observing them in the ED? For example, a patient with anaphylaxis who receives epinephrine or a patient who falls and requires several more hours of observation based on PECARN criteria—do you usually admit to the floor or keep in the ED?
Pediatric emergency physicians and pediatric hospitalists have similar but different skill sets. I think the differences in mind set leads to different approaches to extended observation. For emergency physicians a few hours is a long time. For hospitalists a few hours is a short time. Neither of the approaches to observation care is superior to the other. In general, I think that treatment plans that extend beyond four hours should be moved out of the emergency department. This can be to an observation area run by emergency physicians or hospitalists or to observation status in a general inpatient unit. A key to making any system of transfer of care work is to make sure that those transitions are easy for all. In all institutions that I have worked the only necessary hurdle for a patient to be admitted is the request of the emergency physician. All too often unintended barriers are placed. For transfer of care to work well it does take a good working relationship between emergency physicians and hospitalists, with neither believing the other is taking advantage of them. This can generally be done through ongoing professional communication, trying to understand the goals and perspective of the other. A good working relationship between the emergency department and inpatient service is essential to provide best care. It is a relationship that I often see as strained.
3. “Development of a performance tracking tool for a pediatric hospitalist division” was published in Hospital Pediatrics in 2013. Can you tell us more about the tool?
I think this article is a good example of taking daily work and turning it into scholarship. At Washington University we had a large diverse pediatric hospital medicine division. As we looked into national standardized quality metrics we realized that there was a paucity of them. We adopted standard process improvement methodology to develop a set of potential processes to measure. We prioritized those that were both important and could be measured easily. That seems obvious but was harder than we anticipated. In the end we came up with a robust set of quality metrics which could be measured mostly electronically, only going to chart review if the metric was essential and not otherwise easily measured. Early in the process we realized that this work might be of interest to others. Hopefully others can use this work to try to achieve similar goals in measurement of performance quality in a pediatric hospital medicine division/group.
4. You are a reviewer for multiple journals including Pediatrics, Journal of Hospital Medicine, and Journal of Pediatrics and on the editorial board for the Journal of Hospital Medicine—what makes a good journal article? What advice do you have for a hospitalist looking to publish for the first time?
In a simplistic way a good article is one that advances knowledge. Not all articles will have immediate impact but should have the purpose of improving care or stimulating the discussion of ideas. Being succinct with appropriate scope is important. Too often authors take a minor finding and then extrapolate into a review article. There is clearly a need for review articles but every finding does not justify a review of literature and the author’s interpretation of that literature. Stick to the findings of your study and the direct implications of your findings.
I see a lot of good work that never makes it to a published manuscript. This is generally has do with the lack of putting the work into the form for submission rather than the quality of the work. The data and findings languish because no one takes the final effort to write the manuscript. I have found that there is more often success when people work together. Each holding the other responsible. Potentially dividing up the work and setting expectations for each other. Often it is easy to procrastinate when you are the only one affected, but when others are depending on you it may provide motivation. Someone needs to put in the most work, and they should be rewarded by being first author. On another project the roles may be switched.
We all have busy lives professionally and personally. Most pediatric hospitalists have the daily work of patient care and education as their first work priority. Completing a study and writing a manuscript are important but often give way to busy days. It is important to find a way to prioritize the effort so that important work is submitted for peer-review.
5. How did you get involved with the Ethics Committee at St. John’s Hospital? What do you recommend for other hospitalists that may also want to get involved with their ethics committee?
My work on the ethics committee at St. John’s Hospital is important and rewarding. It is not something that I actively sought out but was asked to participate. It was an easy yes and was pleased to be asked. I have found in my career that many of my opportunities have come because others asked me to do something. In retrospect I am glad that I have said yes to nearly every opportunity given to me. Each position that I have held in academic and clinical work has broadened my perspective and I have used the gained knowledge to apply in other areas of professional work. I often hear the advice to be willing to say no to opportunities. I agree with that advice but there can be a downside of limiting your future growth by not taking advantage of the opportunities that are proposed to you. Pediatric hospitalists are generalists in our clinical work. I think most pediatric hospitalists are also generalists in our academic and leadership roles. If someone has a singular focus, which is well-defined, then saying no to opportunities is very reasonable, if those opportunities are not within your career focus. I believe that most pediatric hospitalists benefit from saying yes to opportunities whenever we can.
6. You co-wrote an editorial titled “Pediatric neurohospitalists: An idea that has come of age?” in Neurology in 2013. Can you tell us more about the concept and your thoughts about it 7 years later?
I wrote this editorial with Dr. Nina Schor. Dr. Schor is a pediatric neurologist and at the time was Chair of Pediatrics at the University of Rochester. In the seven years since that editorial pediatric neuro-hospitalists have become more common. Mostly concentrated in large children’s hospitals. Dr. Schor saw this as primarily a role of specialization within pediatric neurology. I anticipated that the role may be filled by pediatric hospitalists focusing in neurology care. It turns out that Dr. Schor’s prediction was more accurate than mine. This has become a viable career option, although still not that common. Care of neurology patients is core to pediatric hospital medicine. Most hospitals are not large enough to support pediatric neuro-hospitalists so that care coordination between pediatric neurology specialists and pediatric hospitalist specialists is needed.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
As I reflect on my pathway through my career, I realize how much I have depended upon others for my opportunities and successes. I have been lucky enough to have several mentors that I depended upon throughout my career. The idea of sponsorship is one that I have focused on recently. Sponsorship is different from mentorship. Some of my mentors I have had for many years and some for a short period of time. I have also had many peer mentors that I have reached out to for advice and counsel. These mentors have often also been sponsors in supporting and suggesting new roles for me. I have also had sponsorship that came from those that were not mentors. Having someone to seek advice from and be willing to give me the time necessary has been a blessing for me. It is the basis for my success. I really try every day to pay that forward by being open and accessible to those who ask for my help. I hope that I am successful with that. I have tried to be focused on sponsoring a diverse group of talented physicians to local, regional and national positions. It is important that we all support each other as the field of pediatric hospital medicine grows.