Catching up with...Dr. Tony Tarchichi
1. A lot of pediatric hospitalists feel like they know you personally because they are used to hearing your voice on your dynamic pediatric podcast (http://pedhospmed.libsyn.com/). In fact, as of September 2019, you had a range of 1000 to 5000 downloads per episode with a total of 68,000 downloads in 67 countries. How did the concept of the podcast first come about? How long does it typically take you to prepare for an episode? Why do you like bad dad jokes so much?
First, let me just say thank you. It’s a real honor to be asked to be on hospitalist corner.
I’ve had a few hospitalist colleagues tell me something like, “I feel like I already know you because I listen to you in the car” and it’s very nice. I like that people feel more comfortable with me, it takes some of the formality out of meeting someone for the first time.
The saying, “necessity is the mother of invention” is the best way to explain how the origin of the podcast. After it looked like pediatric hospital medicine (PHM) was going to become an accredited fellowship and I would have to take the boards, I looked for a way I could study while commuting to work. Like many people, I have a wonderful spouse, and 3 wonderful kids, and I didn’t know where I was going find time to study. I looked at all the available podcasts and nothing was good for PHM. Then I thought, I’m likely not the only one in this situation and I decided to create a podcast to review the core competencies of PHM. Before coming to Pittsburgh I worked in a very small community hospital in northwest New Jersey doing adult and pediatric hospital medicine with ED and delivery room coverage. I thought the podcast idea would have helped me then because we didn’t have any consultants and I was fresh out of my chief residency year. It was terrifying because of how inexperienced I felt. I remember reading more that first year than I had ever read before. That experience gave me the incentive to create something for others in similar positions. Our division was also starting a PHM fellowship and I thought a podcast on the core competencies of PHM could be a good supplement to the didactic curriculum for our fellows.
Before starting the podcast, I had no experience with audio recording or podcasting. My colleague and office neighbor, Dr. Kishore Vellody, started the Western Pennsylvania Down’s syndrome podcast, and he helped me with some of the basics. The rest was trial and error and YouTube videos. I have a very supportive division who were quick to get behind me and help in any way they could. And, our field is full of people who are generous with their time. I’ve had PHM greats such Drs. Samir Shah, Ricardo Quinonez, Basil Zitelli and Matt Hall on the show and they couldn’t have been friendlier. For preparation, each show is different. The first episode on a clinical educational topic was osteomyelitis and I spent a month preparing for that episode. The shortest time I have spent preparing is 10 hours but it’s typical for a show to require 50-60 hours for research, writing, practicing, recording, editing and getting CME credit. The dad jokes also came out of necessity and I just like them. I was fearful of people listening to me in their cars and falling asleep from boredom. I wanted a way to change things up a bit from just medical conversation. I wasn’t yet skilled enough with audio editing to add in music (like NPR or The Daily do) so I thought of jokes. It’s not a secrete (if you’ve ever listened to a podcast episode) that I genuinely enjoy these jokes.
I think media, like podcasting, will become more prevalent and popular for continuing medical education. Even since I started, the number of podcasts by hospitals, and pediatricians of any kind, have grown a lot. More subspecialties have their own podcast as well. People like it for the convenience of tailoring their education to areas they prefer, on their time.
2. You have previously presented on decreased hospitalization and effective outpatient treatment for pediatric failure to thrive following an interdisciplinary consult at the Diagnostic Referral Group at Children’s Hospital of Pittsburgh. Can you tell us more on who was part of that interdisciplinary team and why you think it was effective in reducing hospitalizations?
The Diagnostic Referral group is our group’s previous name. We formerly had a Diagnostic Referral Clinic where community pediatricians and subspecialists referred patients for a second set of eyes on to make sure they weren’t missing anything. It was started by the founder of our group (and the person the group is named after) Dr. Paul C. Gaffney. We saw a wide variety of patients from failure to thrive, to chronic abdominal pain of unknown origin, to recurrent fevers with concern for periodic fever syndromes, and others. When patients were referred to us the PCP was unsure of what was going on but one of the things on their mind was potentially admitting the patient to get faster answers. We were able to see these patients on the outpatient side and we showed that we avoided hospital admission in a number of those scenarios. We were able to do this because we were given 1 hour per visit and had the time to comb through the charts and do a very thorough history and physical. Like anything else, the longer someone did it, the better they got at it. I remember Dr. Zitelli used to get consults from all over the country for his expert opinion. To answer your question, the reason we were effective in reducing hospitalizations was we were able to handle some issues that a PCP in a more remote area didn’t the resources to address and we had the trust of the community. We had good communication and spent a lot of time counseling and explaining what we felt was going on to the family. We closed the clinic in April 2018 and focused solely on our hospital medicine service.
3. At PHM 2019, you were a co-presenter on the workshop “We Are Fam-i-lee: Cultivating a Culture of Camaraderie.” This presentation focused on creating an ideal work environment. For those of us that might have missed the talk, can you highlight the key points to creating PHM utopia?
We talked about a culture of camaraderie in our division which we think is due to three important building blocks, community building, leadership and trust. There is a focus on wellness now for physicians, which is great, but one of the best ways to promote wellness is to have a positive, uplifting, and supportive working environment. This culture was started by Dr. Paul C. Gaffney, the inspiring physician for whom our division is named. Community building is developing a culture of “we”, where all voices in the division are valued and there is a strong sense of inclusion for everyone. This is done by good and humble leadership which demonstrates transparency, models community in simple ways like having an open door policy, shows gratitude which then creates trust and fosters hope. This is also helped by regular formal and informal meetings. We meet in our division once weekly for a business meeting where everyone has input in the agenda. We also have a weekly journal club meeting along with a monthly Balint group. There are also many informal meetings such as afternoon coffee where a division member will make a pot of coffee with a French press in their office and anyone can come and have some; we also meet for “happy hours” and other social events. When all this is done the community is further enhanced and a “next person up” model develops. This is a naturally developing phenomenon when there’s trust in your leadership and you feel valued as a division member. When that occurs you will not think twice about helping when it’s needed. Mentoring at all levels is important as well. Everyone should feel like their career goals are important and get help in achieving them. However, this isn’t Shang-Ri-La. We have issues like any other hospital division, but conflict resolution is easier when there is trust and good transparent leadership. These and more are the things that are going on in our division which have created a culture of camaraderie and cohesiveness that makes it a pleasure to work at the Paul C. Gaffney Division of Pediatric Hospital Medicine at UPMC Children’s Hospital of Pittsburgh. That’s a short summary of what we discussed in our workshop.
4. In August 2019, you published a brief summary in Academic Pediatrics entitled, “PediaLITE: A Refreshing Way to Keep Up with Pediatric Research.” PediaLITE was created in March 2018 with the goal of providing monthly email updates on current pediatric research that entertain and stimulate residents to read further. First, how did you get 68% of the residents to read half of their emails? Most residents I know don’t read any emails! Second, can you tell us more about this program and the study?
That was an abstract from the 2019 Association of Pediatric Program Directors conference which was published in that journal. It is important to say that PediaLITE was the work of Drs. Tiffany Yang and Elizabeth Landzberg. They started it when they were pediatric residents at the UPMC Children’s Hospital of Pittsburgh. The entire concept, design and implementation was theirs. They needed a faculty sponsor and mentor for the projects and due to my work with the podcast, they felt I would be a good mentor. I was there for mentoring, advice, assisting in getting academic credit for the project and helping them edit and approve the abstract. If you have never read PediaLITE, you should - the writing is smart, clever, and funny. They condense interesting research articles into bite size bits which you can read in the time it takes you to eat a small snack. One email a month is sent out and they contain concise summaries (three paragraphs or fewer) of two recent studies accompanied by links to the original articles, and a review of a general pediatrics topic. The study was done to measure the impact. The study we did was measure the impact of PediaLITE by measuring how much residents report they read the pediatric literature before and after the intervention of PediaLITE. My favorite result from that study was 54% of residents surveyed felt they were reading more of the pediatric literature because of PediaLITE. One of my colleagues taught me to embrace change, the only constant is that things will always change. I think residents want to read more of the literature and want to be more up to date but their schedule is very rigorous. Many of them have other responsibilities besides residency as well, which makes doing it very difficult. I hope to continue to promote these innovative ways to reach all learners in ways that fit their life and learning styles. To sign up for PediaLITE you can either email your name and email address to Pedialite.email@example.com and the they will manually add you on or you can also subscribe at this link: Subscribe HERE!
5. In October 2019, you co-authored an article entitled, “Continuing Medical Education in an On-Demand World: Is Podcasting the Netflix of Medical Education?” In the article, you talk about how pediatricians need to create “digital medical education products for board review and CME to continue promoting high-quality, evidence-based care for children across the country in a manner that meets the needs and preferences of an increasingly on-demand society.” Between podcasts and the pediaLITE, study you have done a lot of work to help learners obtain evidence-based learning in a digital format. Ken Roberts recently posted on the listserv that “the skill to look things up is key in the 21st century - so what are we doing to assure that our trainees are skillful?” Do you worry about the lost art of researching an answer when so much is provided to our students, residents, and fellows digitally? How do you teach that to your learners?
I’m a strong believer in life-long learning. Honestly, when I finished my residency I was only pretty good at effectively looking things up. I got better searching for information when I was moonlighting during my chief residency year and in my first year as an attending. Those were by far the scariest times for me in medicine. I have improved as I’ve progressed in my career. Expecting our residents to be great at looking up information using PubMed or google scholar immediately after residency is not realistic. We need to give them the tools to know how to do it and they will continue to progress. I think we also forget that not everyone has a huge database to access. Even if we teach people how to look things up effectively, they may not have access to all the journals in order to read the articles unless they work at a large institution. In hospital medicine that’s less of an issue but my first job (after chief residency) was in a very small community hospital which did not have any subscriptions and it was up to me to pay for whatever I wanted to read. I couldn’t afford every journal, I bought the New England journal of Medicine, Pediatrics in Review and the Annals of Internal Medicine. I would have loved a free, reputable source to review PHM topics that I was seeing on a regular basis. I think it’s very important for people to know how and where to look things up but people are busier than ever now. Some of this is also a function of maturity in your craft. When I first graduated residency I was more concerned with being a good clinician and taking care of my patients. I was less concerned with making sure I read the seminal literature than I was making sure I knew what was going on with my patients. The day to day aspect of patient care, improving my physical exam skills and honing my bedside manner took precedence. It’s only as I progressed in my career that I began asking, “how do we know what we think we know” and began looking at the literature and teaching it through the podcast. That only happened for me because of an increased level of comfort that came with time and experience. Now we have fellowships where those who want to pursue specialized training in hospital medicine will have more time to harness these skills. That protected time to improve these skill with only benefit those who take advantage of them. As long as we have great teachers like Dr. Roberts and others, I am not worried that researching an answer will be a lost art.
6. Being a med-peds trained and running the PHM fellowship at Children’s Hospital of Pittsburgh, you must receive questions about what med-peds residents should do if they desire to pursue hospitalist work. What do you advise them? Do you see the potential for a separate med-peds hospitalist fellowship on the horizon?
The first thing I do is get to know the resident. I want to know where they see themselves in 5 and 10 years. What are they looking for in a career? Are they tied to a certain region of the country, what other factors are important to them? One way to give good advice is to know your audience; no two people are the same so no two people are going to get the exact same advice. I also explain where the field is right now. We talk about what they want in a fellowship program. Do they want to do some Internal Medicine hospitalist rotations as part of their fellowship rotations or would they prefer to moonlight only? If they want it as part of their fellowship rotations, how much time in Internal Medicine would be adequate in their minds? Do they want a primary research project in fellowship to cross both specialties? I have advised Med-Peds residents to be up front about their wishes when applying to a PHM fellowship. I usually have them contact the fellowship programs they’re interested in advance to see they can accommodate a Med-Peds fellow. There are some fellowship programs that have already accommodated a Med-Peds residents and I let them know who they are. I think Med-Peds trained residents bring a different perspective which is nice for a program to have (but then again, I’m not objective here).
This is an area of great interest to me. I’m a part of a group of Med-Peds and Pediatric physicians looking into what Med-Peds resident want in a PHM fellowship and how they feel about the specialty. We have surveyed a third of the residents nationally and will be sharing our results in the near future.
I do not see the potential yet for a separate Med-Peds hospitalist fellowship. Internal Medicine (IM) hospitalists have a workforce issue which is why (in my opinion) they have not tried to become a subspecialty like pediatrics. There are just a lot more hospitals that need IM hospitalists and if they created one more hoop for people to jump through they would have a serious work force shortage. Pediatrics is different because there are now fewer hospitals who admit and are comfortable treating children. Internal medicine trainees who go into a hospital medicine fellowship do it as part of an academic fellowship. There is no ACGME accreditation for academic fellowships so there is less oversight and paperwork. Creating a joint fellowship now would be very challenging because you have ACGME accredited (soon hopefully) PHM fellowships and non-ACGME accredited fellowship. I don’t yet know the paperwork or logistics required to make that happen but I can’t imagine it’s simple or easy. I think it would be possible but this ACGME accreditation is new for all of us and we need some time to figure it out before we venture out into that territory.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
I’m very thankful and lucky to be a part of this new, vibrant, and growing pediatric hospitalist community. There are so many great people and we have the ability to look at things from a new and different perspective that I think our impact is just starting to be felt. I feel fortunate to be of service to my colleagues around the country and hope to continue to do so.