Erin Stucky Fisher
1. You wrote a blog about a day in your life (http://blogs.hospitalmedicine.org/Blog/a-day-in-the-life-of-a-pediatric-hospitalist/). Your day certainly seems jam-packed. How do you juggle it all and what advice do you have for others who want to do the same?
That is a great question. If you ask anyone who has grey hair, s/he would likely tell you that identifying what you balance, when, and why comes with practice. For me, there is a clear hierarchy: patient care always comes first. When on service/call, any other work whether administrative or educational must take a back seat. This sounds quite simplistic and logical, but it does take mindful practice.
Second - Mindfulness. I am a fan of “live in the now”. This means that we give full attention to what is in front of us. That usually means not double/triple tasking, which is its own art form I agree. That all typed, a successful busy day is one where each piece receive its due attention and focus.
Third – Double/triple tasking. This is not what you may think it means. This means looking for linkages in what we do, and then identifying where doing something for one project is also a step in a different project/task. I encourage people to write SMART aims for their year; I do this as well. I keep a list on desk called the “BIG LIST,” and then I have actions for different work on separate lists/files, and I note where one action can help move something elsewhere.
2. In looking at the programs for PHM, PAS and other conferences, your name appears over and over again as part of various workshops. What advice do you have for those who have an idea for a workshop and want the best chance for acceptance at a national conference?
This is where saying “yes” helps. As with any educational/scholarly activity, workshops have a “developmental’ trajectory. This is not quite “see one, do one, teach one”, but it is close. Some I have had the pleasure of working with many amazing people in many settings. I am lucky to have had the opportunity to do this and learn every time from others. I love workshops because they address our craving for action and they give us some sort of product we can use. Find someone who delivered a successful workshop, and ask if you might see their outline proposal. Offer to participate as a facilitator in a future workshop. Know also that acceptance at a conference depends on the submission + the overall conference content. That is, if you have a solid workshop proposal and are turned down, ask why. You may be told something helpful or even that the conference “had something this already last year.” Consider then submitting to a different conference that may better match the audience to your work.
3. You created INQUIRY (Innovative Quality Improvement Research in Residency), a program to train residents and fellows in QI. Tell us more about what the program entails and why you created it.
This is a hard one to type in a short space, but I will try. In 2005, I was struck by the lack of engagement of trainees in QI and simultaneously was aware of the changes ongoing in medicine. My mentor, Dr Paul Kurtin, challenged me to think forward and see what could be done to train “our future” physicians. I firmly believed (and still believe) that healthcare must truly integrate the “implementation science” of quality and physician-led initiatives to improve healthcare. Over years and after many iterations (yes, PDSA cycles), the program has grown from 3 residents participating to over 70 involved annually with more than 20 projects ongoing at any time. We have level 1 with some on line work and 6 interactive workshop sessions, and level 2 which is mentored participation in a real QI project over time. I am a fan of “spaced education” and consider QI to be an “active sport” where you need to get into it to truly learn. We have pediatric subspecialty fellows (including surgical fellows), as well as residents involved. It is exciting to see how they can work in teams, and to see the “aha moment” on their faces when they have identified a barrier or a solution to a problem, or are describing why their participation and the project matters to kids and healthcare. I hope INQUIRY will last long past my time in healthcare.
4. As senior author on the publication, “Predictors of Clostridium difficile infections in hospitalized children” [Journal of Hospital Medicine, 2014; Volume 9(2)], what advice do you have for testing for C. difficile and what do you make of the high percentage of acid suppression medication use in patients with C. difficile infections?
This is a great question for the first author, my past fellow who is now at Lurie in Chicago, Dr Waheeda Samady. I will answer in brief, that testing for anything needs to be thoughtful and with awareness of the predictive value of a positive test. For your second question, I think that is a real concern. It is difficult to identify the risks involved in use of medications long term, except those that are quite severe, or reportable, or thought to be linked to the drug mechanism of action. As a clinician, I do worry that acid suppression is overused with unclear benefits and with potential risks that are “hidden” like this. My own thought, which is not novel or unique, is that it is time to “choose wisely” regarding acid suppression not just for GERD, but for other diagnoses or illness states as well.
5. There has been a big push recently in a lot of hospitals for timely discharges. You are the lead developer of PediBOOST, a pediatric discharge transitions toolkit. Can you explain how individual hospitalists and hospitals can use PediBOOST to their advantage?
Thank you for asking about PediBOOST. One of the key drivers for this discharge toolkit was a “better” discharge and transition. That is, the metric of re-admission or of efficient discharge process(es) are not the primary targets of the package. Instead, the focus is on “what might go wrong short and long term after this child and family leave us?” About half of PediBOOST (free, on line) is about how to run a QI project, and the other half is about discharges, metrics, and tools that can be used to identify barriers and address them. The RISK tool focuses on not just medical, but social and behavioral aspects that can impact care delivery. Both patient and caregiver are included in this assessment. The Ticket to Home is an eye-opener and takes little time for a caregiver to complete. I would suggest that individuals or groups identify what failures in discharge are most evident and what your group or institution values. That is a key point. If you are in a site that uses BOOST, more power to you, then PediBOOST will resonate. If you are in a community site and are the lone voice for children, then it may be partnering with nursing or social work or a family advisory committee will matter. Every institution uses some sort of survey tool , and all tools have some questions on how families rate their discharge. This can be a great way to see where the institution has a “gap” that can be closed. In the end, PediBOOST is really a transition of care toolkit, rather than a discharge process toolkit.
6. As a leader in the continued development of pediatric hospital medicine fellowship, what steps are being taken in preparation for ACGME accreditation and how does PHM becoming a boarded subspecialty impact fellowship?
The PHM Fellowship Director’s Council has great leaders – Neha Shah, Lindsay Chase, Carrie Rassbach, and others – who have and will continue to move all programs forward. The ACGME process of accreditation does involve administrative steps as well as enhanced curriculum development. However, it should be noted that the group is far ahead of others who were “new specialties” over the past years in all areas. The Board subspecialty testing that will begin in 2019 will only increase attention and interest in fellowships.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Ha! Yes, I echo what he means when he says his “2 cents.” That is, it is only one perspective that we each have. What are my 2 cents? I am a Pollyana.
I see a vibrant future for PHM where we move child health forward with both research in and implementation of what is safe, reliable, and effective for the child’s short and long term health. As systems thinkers, this means identifying where care should be rendered, and at what time. As generalists, this means identifying the needs of the whole child. As hospitalists, we not only stabilize and manage acute illness, but also see what could make the child healthier. I admit this is a challenge, and that is would mean more than identifying who is due for a flu shot or failed their outpatient sickle follow-up visits. We certainly cannot do all for everyone all of the time. However, if we try we may be lucky enough (now and then) to bring children not just from illness back to “steady state,” but maybe even have a hand in helping them be healthier adults.
That is a great question. If you ask anyone who has grey hair, s/he would likely tell you that identifying what you balance, when, and why comes with practice. For me, there is a clear hierarchy: patient care always comes first. When on service/call, any other work whether administrative or educational must take a back seat. This sounds quite simplistic and logical, but it does take mindful practice.
Second - Mindfulness. I am a fan of “live in the now”. This means that we give full attention to what is in front of us. That usually means not double/triple tasking, which is its own art form I agree. That all typed, a successful busy day is one where each piece receive its due attention and focus.
Third – Double/triple tasking. This is not what you may think it means. This means looking for linkages in what we do, and then identifying where doing something for one project is also a step in a different project/task. I encourage people to write SMART aims for their year; I do this as well. I keep a list on desk called the “BIG LIST,” and then I have actions for different work on separate lists/files, and I note where one action can help move something elsewhere.
2. In looking at the programs for PHM, PAS and other conferences, your name appears over and over again as part of various workshops. What advice do you have for those who have an idea for a workshop and want the best chance for acceptance at a national conference?
This is where saying “yes” helps. As with any educational/scholarly activity, workshops have a “developmental’ trajectory. This is not quite “see one, do one, teach one”, but it is close. Some I have had the pleasure of working with many amazing people in many settings. I am lucky to have had the opportunity to do this and learn every time from others. I love workshops because they address our craving for action and they give us some sort of product we can use. Find someone who delivered a successful workshop, and ask if you might see their outline proposal. Offer to participate as a facilitator in a future workshop. Know also that acceptance at a conference depends on the submission + the overall conference content. That is, if you have a solid workshop proposal and are turned down, ask why. You may be told something helpful or even that the conference “had something this already last year.” Consider then submitting to a different conference that may better match the audience to your work.
3. You created INQUIRY (Innovative Quality Improvement Research in Residency), a program to train residents and fellows in QI. Tell us more about what the program entails and why you created it.
This is a hard one to type in a short space, but I will try. In 2005, I was struck by the lack of engagement of trainees in QI and simultaneously was aware of the changes ongoing in medicine. My mentor, Dr Paul Kurtin, challenged me to think forward and see what could be done to train “our future” physicians. I firmly believed (and still believe) that healthcare must truly integrate the “implementation science” of quality and physician-led initiatives to improve healthcare. Over years and after many iterations (yes, PDSA cycles), the program has grown from 3 residents participating to over 70 involved annually with more than 20 projects ongoing at any time. We have level 1 with some on line work and 6 interactive workshop sessions, and level 2 which is mentored participation in a real QI project over time. I am a fan of “spaced education” and consider QI to be an “active sport” where you need to get into it to truly learn. We have pediatric subspecialty fellows (including surgical fellows), as well as residents involved. It is exciting to see how they can work in teams, and to see the “aha moment” on their faces when they have identified a barrier or a solution to a problem, or are describing why their participation and the project matters to kids and healthcare. I hope INQUIRY will last long past my time in healthcare.
4. As senior author on the publication, “Predictors of Clostridium difficile infections in hospitalized children” [Journal of Hospital Medicine, 2014; Volume 9(2)], what advice do you have for testing for C. difficile and what do you make of the high percentage of acid suppression medication use in patients with C. difficile infections?
This is a great question for the first author, my past fellow who is now at Lurie in Chicago, Dr Waheeda Samady. I will answer in brief, that testing for anything needs to be thoughtful and with awareness of the predictive value of a positive test. For your second question, I think that is a real concern. It is difficult to identify the risks involved in use of medications long term, except those that are quite severe, or reportable, or thought to be linked to the drug mechanism of action. As a clinician, I do worry that acid suppression is overused with unclear benefits and with potential risks that are “hidden” like this. My own thought, which is not novel or unique, is that it is time to “choose wisely” regarding acid suppression not just for GERD, but for other diagnoses or illness states as well.
5. There has been a big push recently in a lot of hospitals for timely discharges. You are the lead developer of PediBOOST, a pediatric discharge transitions toolkit. Can you explain how individual hospitalists and hospitals can use PediBOOST to their advantage?
Thank you for asking about PediBOOST. One of the key drivers for this discharge toolkit was a “better” discharge and transition. That is, the metric of re-admission or of efficient discharge process(es) are not the primary targets of the package. Instead, the focus is on “what might go wrong short and long term after this child and family leave us?” About half of PediBOOST (free, on line) is about how to run a QI project, and the other half is about discharges, metrics, and tools that can be used to identify barriers and address them. The RISK tool focuses on not just medical, but social and behavioral aspects that can impact care delivery. Both patient and caregiver are included in this assessment. The Ticket to Home is an eye-opener and takes little time for a caregiver to complete. I would suggest that individuals or groups identify what failures in discharge are most evident and what your group or institution values. That is a key point. If you are in a site that uses BOOST, more power to you, then PediBOOST will resonate. If you are in a community site and are the lone voice for children, then it may be partnering with nursing or social work or a family advisory committee will matter. Every institution uses some sort of survey tool , and all tools have some questions on how families rate their discharge. This can be a great way to see where the institution has a “gap” that can be closed. In the end, PediBOOST is really a transition of care toolkit, rather than a discharge process toolkit.
6. As a leader in the continued development of pediatric hospital medicine fellowship, what steps are being taken in preparation for ACGME accreditation and how does PHM becoming a boarded subspecialty impact fellowship?
The PHM Fellowship Director’s Council has great leaders – Neha Shah, Lindsay Chase, Carrie Rassbach, and others – who have and will continue to move all programs forward. The ACGME process of accreditation does involve administrative steps as well as enhanced curriculum development. However, it should be noted that the group is far ahead of others who were “new specialties” over the past years in all areas. The Board subspecialty testing that will begin in 2019 will only increase attention and interest in fellowships.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Ha! Yes, I echo what he means when he says his “2 cents.” That is, it is only one perspective that we each have. What are my 2 cents? I am a Pollyana.
I see a vibrant future for PHM where we move child health forward with both research in and implementation of what is safe, reliable, and effective for the child’s short and long term health. As systems thinkers, this means identifying where care should be rendered, and at what time. As generalists, this means identifying the needs of the whole child. As hospitalists, we not only stabilize and manage acute illness, but also see what could make the child healthier. I admit this is a challenge, and that is would mean more than identifying who is due for a flu shot or failed their outpatient sickle follow-up visits. We certainly cannot do all for everyone all of the time. However, if we try we may be lucky enough (now and then) to bring children not just from illness back to “steady state,” but maybe even have a hand in helping them be healthier adults.