- Jenny Reese
1. As the Section Head of the Section of Pediatric Hospital Medicine at Children’s Hospital Colorado, how do you balance your administrative duties with your clinical ones?
I am very fortunate to have a lot of autonomy in my various roles. Working clinically allows me to connect with my passion for caring for patients and their families, work alongside my colleagues, and see firsthand what is happening in our environments of care. When I am on service for a week at a time, I try to limit my administrative duties as much as possible, and keep up with urgent emails, but catch up on non-urgent matters when I’m not on service. Also, being on service in my clinical role gives me firsthand experience of how our systems are operating, allows me to identify additional system issues needing attention, and appreciate the outcomes of our successful improvement efforts.
2. In 2015, you formed the University of Colorado School Of Medicine Resilience Program for Faculty, Residents and Fellows, and you are now the Medical Director for Provider Well-being at Children’s Hospital Colorado and Associate Vice Chair for Faculty Well-being for the Department of Pediatrics, University of Colorado School of Medicine. What can pediatric hospitalists do both individually and as a group to reduce burnout and increase resiliency?
There are a lot of evidence-based resilience practices that pediatric hospitalists can employ. Mindfulness is probably the best studied resilience intervention there is. Even a brief daily “formal” practice of “present moment awareness, on purpose, without judgement” can have benefits. Taking small breaks throughout the day to check in, and slow down can actually help improve energy and efficiency.
We also refer to Martin Seligman’s Total Model of Well-being and the PERMAH Model when discussing individual well-being practices. The elements of the PERMAH model are: Positive Emotion, Engagement, Positive Relationships, Meaning, Accomplishment and Health. Paying attention to each of these domains, thinking about life-balance as more of a “wobble board” phenomenon, and attending to areas that might need more attention allow us to have an overall sense of well-being in our lives. No one should feel they need to achieve a “perfect” balance, that is a myth. Rather, we aim to pay attention to the things that inspire and energize us and bring us a sense of purpose and fulfillment. In order to do that, we also focus on “Values Clarification”…understanding what our guiding principles are, the things that are most important to us, and look for ways that we can make choices that are in alignment with these values.
There are numerous well-studied “Positive Psychology Interventions” that are proven to help us cultivate positivity (https://pubmed.ncbi.nlm.nih.gov/23390882/. Remembering Barbara Fredrickson’s quote “The negative screams at us, but the positive only whispers” we realize that we are hardwired to scan our environment for threats. Also, our brains at positive work better than they do at negative neutral or stressed. So practices that allow us to cultivate positivity are beneficial. These include reflecting on 3 Good Things at the end of each day, writing a gratitude letter, socializing, and even practicing random acts of kindness. Many of these things can be done in the midst of our busy days, and don’t require additional time (or even time off) to practice them and achieve the benefits. A few ideas that hospitalists can do during rounds are to take a pause with the team for a positive reflection or gratitude practice (e.g. go around the team and have everyone say something they appreciate about the person to their left, or their favorite part of being on the team, or have everyone pull out their phone and send a text message to someone they appreciate).
Regarding systems factors to reduce burnout, teams can work together to clarify their group’s values, and work together to identify goals and action items that align with these values. Leadership practices such as ensuring each person has the opportunity to work on things that are meaningful to them are shown to reduce burnout. Caring about each other as individuals and promoting the sense of camaraderie and “esprit de corps” can be protective of burnout among teams. Peer Support programs have also been shown to benefit providers after adverse clinical events. This allows for a sense of just culture and avoiding the “suffering in silence and isolation” phenomenon we see all too often in medicine.
3. Can you tell us more about your current research on the impact of peer support training to address the second victim phenomenon in healthcare?
We have implemented a Peer Support Network Program at CHCO, and as part of this program have trained over 120 medical staff providers in our 2-hour Peer Support and Coaching Training curriculum. This training emphasizes having colleagues speak to each other about adverse clinical events they have experienced and practice using the peer support skills of “Ask, Listen, Connect.” Participants are also taught some basics of coaching skills, focusing on asking good questions and reflective listening, and also given time to practice these skills in small groups. A study of this program is underway. Course evaluations from our training program are universally positive, and participants report what they enjoy most about the training is having a chance to connect with their peers. The recent annual Medical Staff Satisfaction Survey included questions about use and impact of the peer support program and results show that those who are aware of the program have benefited from it. A survey to all peer supporters to evaluate the impact of being a peer supporter will be disseminated in the next 1-2 months. Our hypothesis is that peer supporters will report positive experiences in their roles.
4. You completed your residency at Children’s Hospital Colorado and have since worked there. What advice do you have for residents deciding between staying at their home institution and going to a new hospital after graduation?
I think any big life decision, first job after residency being one of the biggest, should be driven by that “gut feeling” and all of the factors that weigh into work-life satisfaction. I have absolutely loved spending my entire career at Children’s Hospital Colorado and have never really considered being anywhere else. The main drivers of my satisfaction are that I love living in Denver, and the people that I get to work with are phenomenal colleagues. I would suggest that graduating residents identify what they value most in their work and outside of work life, and choose a job where those values will be most in alignment…that may mean moving on to a different place after residency or staying in the same place. It’s all about finding the best fit!
5. As a frequent invited speaker for departmental grand rounds, conferences, retreats, and workshops, what is your favorite lecture you have given? And a favorite place you’ve visited?
I love public speaking, and I’m always honored to be asked. I have had several favorite speaking engagements. Among them was a mini-plenary at the PHM National Meeting in Seattle in 2019, and another was the CHCO Team Leader Conference in 2018. The Team Leader Conference consisted of about 700 leaders from Children’s, and I invited all of the attendees to participate in a mindfulness practice. Asking a room full of my peers to close their eyes and focus on their breath took some courage, and I am proud I did it! I was excited to have a plenary presentation accepted at the International Conference on Physician Health that was scheduled in London in 2020, unfortunately cancelled due to Covid. My favorite visit was a visiting professorship to University of Louisville, where I made some great connections with new colleagues, including Martin Huecker, who recently established the Journal of Wellness…check it out! https://ir.library.louisville.edu/jwellness/
6. You are a co-author of “AutoPEWS: Automating Pediatric Early Warning Score Calculation Improves Accuracy Without Sacrificing Predictive Ability” (https://pubmed.ncbi.nlm.nih.gov/32426639/). Please tell us more about this work and your results.
I am fortunate to be a mentor for Justin Lockwood since he was an intern and now is a leader in Care Escalation work at our organization and nationally. This work was part of a larger project being led by Dr. Lockwood at our institution to improve use of PEWS to identify deteriorating patients. We noticed that there was a lot of variability in the accuracy of PEWS, as all of the elements of the scores were being entered manually and there was subjectivity in the scoring. By automating elements of the PEWS that are objective (e.g. respiratory rate) we found that accuracy improved (as compared to manual entry) yet automating elements of the PEWS did not adversely impact predictability of PEWS at identifying clinical deterioration. This work is important to consider when relying on PEWS as a clinical decision tool to trigger interventions automatically.
7. In recent years, there has been much discussion and research about treating asthmatics with dexamethasone instead of prednisone. What does your article “Steroid variability in pediatric inpatient asthmatics: survey on provider preferences of dexamethasone versus prednisone” (https://pubmed.ncbi.nlm.nih.gov/31113252/) add to this conversation?
As with many publications in the field of pediatric medicine, this study highlighted the fact that there is a lot of variability in practice. This study was a survey to better understand prescribing practices (of hospitalists and pulmonologists) when patients were admitted for asthma exacerbations and were started on dexamethasone in the emergency department. We found that hospitalists were more likely to continue dexamethasone than pulmonologists, and that certain factors influenced providers’ decisions on whether to continue dexamethasone or change to prednisone, such as severity of exacerbation and asthma history. While there are studies that demonstrate that dexamethasone is not inferior to prednisone when evaluating asthma relapse rate and admission rate, that parents often prefer it, it is more palatable and cost effective, many providers are still not comfortable continuing dexamethasone in the inpatient setting. We used findings of this study to modify our asthma care pathway to provide parameters for steroid prescribing for inpatients. We suggest that if patients are stable and/or improving that repeating a dose of dexamethasone 24 to 36 hours after the first dose (based on timing convenience) is recommended. If patients are admitted on continuous albuterol and/or are worsening clinically then changing to prednisone is recommended. We have not seen an increased length of stay, nor increased readmission rate of our asthma patients at our institution.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
I hope everyone is finding a sense of relief as we recover from the pandemic. We have learned so much as we were challenged in ways we never could have imagined before early spring 2020. I am happy to connect with anyone on these or any other topics of interest. Feel free to get in touch at jennifer.reese@childrenscolorado.org
I am very fortunate to have a lot of autonomy in my various roles. Working clinically allows me to connect with my passion for caring for patients and their families, work alongside my colleagues, and see firsthand what is happening in our environments of care. When I am on service for a week at a time, I try to limit my administrative duties as much as possible, and keep up with urgent emails, but catch up on non-urgent matters when I’m not on service. Also, being on service in my clinical role gives me firsthand experience of how our systems are operating, allows me to identify additional system issues needing attention, and appreciate the outcomes of our successful improvement efforts.
2. In 2015, you formed the University of Colorado School Of Medicine Resilience Program for Faculty, Residents and Fellows, and you are now the Medical Director for Provider Well-being at Children’s Hospital Colorado and Associate Vice Chair for Faculty Well-being for the Department of Pediatrics, University of Colorado School of Medicine. What can pediatric hospitalists do both individually and as a group to reduce burnout and increase resiliency?
There are a lot of evidence-based resilience practices that pediatric hospitalists can employ. Mindfulness is probably the best studied resilience intervention there is. Even a brief daily “formal” practice of “present moment awareness, on purpose, without judgement” can have benefits. Taking small breaks throughout the day to check in, and slow down can actually help improve energy and efficiency.
We also refer to Martin Seligman’s Total Model of Well-being and the PERMAH Model when discussing individual well-being practices. The elements of the PERMAH model are: Positive Emotion, Engagement, Positive Relationships, Meaning, Accomplishment and Health. Paying attention to each of these domains, thinking about life-balance as more of a “wobble board” phenomenon, and attending to areas that might need more attention allow us to have an overall sense of well-being in our lives. No one should feel they need to achieve a “perfect” balance, that is a myth. Rather, we aim to pay attention to the things that inspire and energize us and bring us a sense of purpose and fulfillment. In order to do that, we also focus on “Values Clarification”…understanding what our guiding principles are, the things that are most important to us, and look for ways that we can make choices that are in alignment with these values.
There are numerous well-studied “Positive Psychology Interventions” that are proven to help us cultivate positivity (https://pubmed.ncbi.nlm.nih.gov/23390882/. Remembering Barbara Fredrickson’s quote “The negative screams at us, but the positive only whispers” we realize that we are hardwired to scan our environment for threats. Also, our brains at positive work better than they do at negative neutral or stressed. So practices that allow us to cultivate positivity are beneficial. These include reflecting on 3 Good Things at the end of each day, writing a gratitude letter, socializing, and even practicing random acts of kindness. Many of these things can be done in the midst of our busy days, and don’t require additional time (or even time off) to practice them and achieve the benefits. A few ideas that hospitalists can do during rounds are to take a pause with the team for a positive reflection or gratitude practice (e.g. go around the team and have everyone say something they appreciate about the person to their left, or their favorite part of being on the team, or have everyone pull out their phone and send a text message to someone they appreciate).
Regarding systems factors to reduce burnout, teams can work together to clarify their group’s values, and work together to identify goals and action items that align with these values. Leadership practices such as ensuring each person has the opportunity to work on things that are meaningful to them are shown to reduce burnout. Caring about each other as individuals and promoting the sense of camaraderie and “esprit de corps” can be protective of burnout among teams. Peer Support programs have also been shown to benefit providers after adverse clinical events. This allows for a sense of just culture and avoiding the “suffering in silence and isolation” phenomenon we see all too often in medicine.
3. Can you tell us more about your current research on the impact of peer support training to address the second victim phenomenon in healthcare?
We have implemented a Peer Support Network Program at CHCO, and as part of this program have trained over 120 medical staff providers in our 2-hour Peer Support and Coaching Training curriculum. This training emphasizes having colleagues speak to each other about adverse clinical events they have experienced and practice using the peer support skills of “Ask, Listen, Connect.” Participants are also taught some basics of coaching skills, focusing on asking good questions and reflective listening, and also given time to practice these skills in small groups. A study of this program is underway. Course evaluations from our training program are universally positive, and participants report what they enjoy most about the training is having a chance to connect with their peers. The recent annual Medical Staff Satisfaction Survey included questions about use and impact of the peer support program and results show that those who are aware of the program have benefited from it. A survey to all peer supporters to evaluate the impact of being a peer supporter will be disseminated in the next 1-2 months. Our hypothesis is that peer supporters will report positive experiences in their roles.
4. You completed your residency at Children’s Hospital Colorado and have since worked there. What advice do you have for residents deciding between staying at their home institution and going to a new hospital after graduation?
I think any big life decision, first job after residency being one of the biggest, should be driven by that “gut feeling” and all of the factors that weigh into work-life satisfaction. I have absolutely loved spending my entire career at Children’s Hospital Colorado and have never really considered being anywhere else. The main drivers of my satisfaction are that I love living in Denver, and the people that I get to work with are phenomenal colleagues. I would suggest that graduating residents identify what they value most in their work and outside of work life, and choose a job where those values will be most in alignment…that may mean moving on to a different place after residency or staying in the same place. It’s all about finding the best fit!
5. As a frequent invited speaker for departmental grand rounds, conferences, retreats, and workshops, what is your favorite lecture you have given? And a favorite place you’ve visited?
I love public speaking, and I’m always honored to be asked. I have had several favorite speaking engagements. Among them was a mini-plenary at the PHM National Meeting in Seattle in 2019, and another was the CHCO Team Leader Conference in 2018. The Team Leader Conference consisted of about 700 leaders from Children’s, and I invited all of the attendees to participate in a mindfulness practice. Asking a room full of my peers to close their eyes and focus on their breath took some courage, and I am proud I did it! I was excited to have a plenary presentation accepted at the International Conference on Physician Health that was scheduled in London in 2020, unfortunately cancelled due to Covid. My favorite visit was a visiting professorship to University of Louisville, where I made some great connections with new colleagues, including Martin Huecker, who recently established the Journal of Wellness…check it out! https://ir.library.louisville.edu/jwellness/
6. You are a co-author of “AutoPEWS: Automating Pediatric Early Warning Score Calculation Improves Accuracy Without Sacrificing Predictive Ability” (https://pubmed.ncbi.nlm.nih.gov/32426639/). Please tell us more about this work and your results.
I am fortunate to be a mentor for Justin Lockwood since he was an intern and now is a leader in Care Escalation work at our organization and nationally. This work was part of a larger project being led by Dr. Lockwood at our institution to improve use of PEWS to identify deteriorating patients. We noticed that there was a lot of variability in the accuracy of PEWS, as all of the elements of the scores were being entered manually and there was subjectivity in the scoring. By automating elements of the PEWS that are objective (e.g. respiratory rate) we found that accuracy improved (as compared to manual entry) yet automating elements of the PEWS did not adversely impact predictability of PEWS at identifying clinical deterioration. This work is important to consider when relying on PEWS as a clinical decision tool to trigger interventions automatically.
7. In recent years, there has been much discussion and research about treating asthmatics with dexamethasone instead of prednisone. What does your article “Steroid variability in pediatric inpatient asthmatics: survey on provider preferences of dexamethasone versus prednisone” (https://pubmed.ncbi.nlm.nih.gov/31113252/) add to this conversation?
As with many publications in the field of pediatric medicine, this study highlighted the fact that there is a lot of variability in practice. This study was a survey to better understand prescribing practices (of hospitalists and pulmonologists) when patients were admitted for asthma exacerbations and were started on dexamethasone in the emergency department. We found that hospitalists were more likely to continue dexamethasone than pulmonologists, and that certain factors influenced providers’ decisions on whether to continue dexamethasone or change to prednisone, such as severity of exacerbation and asthma history. While there are studies that demonstrate that dexamethasone is not inferior to prednisone when evaluating asthma relapse rate and admission rate, that parents often prefer it, it is more palatable and cost effective, many providers are still not comfortable continuing dexamethasone in the inpatient setting. We used findings of this study to modify our asthma care pathway to provide parameters for steroid prescribing for inpatients. We suggest that if patients are stable and/or improving that repeating a dose of dexamethasone 24 to 36 hours after the first dose (based on timing convenience) is recommended. If patients are admitted on continuous albuterol and/or are worsening clinically then changing to prednisone is recommended. We have not seen an increased length of stay, nor increased readmission rate of our asthma patients at our institution.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
I hope everyone is finding a sense of relief as we recover from the pandemic. We have learned so much as we were challenged in ways we never could have imagined before early spring 2020. I am happy to connect with anyone on these or any other topics of interest. Feel free to get in touch at jennifer.reese@childrenscolorado.org