Ken Roberts
1. You were famously quoted as saying something to the effect that, “if a baby smiles at me, that’s enough for me to avoid LPing them.” Do you practice what you preach in regards to neonatal fever? Why?
There’s actually a fair amount of background behind that flip comment. It starts with some observations Paul McCarthy shared when he was developing what came to be known as the Yale Observation Scales (YOS). First, he recognized that the individuals acknowledged to be excellent clinicians seemed totally incapable of following his instructions to “just observe.” Instead, they could not resist interacting with the infants, smiling at them and trying to elicit a response. What came of this is two-fold: Paul created the category of “response to social overture” because of its importance to the clinicians, and, when he analyzed the data, he noted that no infant with a serious illness had a social smile and no infant with a social smile had a serious illness. That stuck with me. Some years later, a letter to the editor appeared reporting an infant with bacterial meningitis who retained a social smile, but that has been the extent of the refutation I have seen of the YOS data. But there is a real limitation to the use of the social smile when trying to apply it to very young febrile infants: Babies don’t respond to a smile with a smile of their own in the first few weeks of life. Some babies have an irreproducible social smile at the end of the first month of life but it generally isn’t until the second month of life that the social smile is reproducible. It is one of the two developmental milestones of the second month of life that I associate with survival of our species, the other being sleeping through the night. So, to answer your question, yes, I do use the social smile to reassure me, but it is not the only factor I consider regarding the decision to perform an LP or not.
2. Your presentation on UTIs packed the lecture hall at PHM this past year. For those who missed it, can you give us the highlights on the new guidelines coming down the pipeline? What is driving those changes?
As to what is “coming down the pipeline” regarding UTI guidelines, the Reaffirmation of the 2011 Guideline was published in December, 2016, but I don’t think it likely to be the final word on the subject. It is very exciting to me to see all the activity and research regarding urinary tract infections. At the time of the first AAP guideline in the 1990s, there was an extensive weight of tradition but little insight. Tom Newman shared a cartoon with me that applies: it depicts a Research Institute with two arrows pointing in opposite directors for unanswered questions and unquestioned answers. In the mid-1990s, we had considerably more of the latter. I think we will continue to see evidence coming forward that will improve our diagnostic ability and refine our understanding of renal injury. In fact, there are some articles in the pipeline that will do just that.
3. What do you see as the biggest challenge facing pediatric hospital medicine in the next 5 years and why?
Actually, my answer to this question also relates to your questions #5 and #6 as well. One of my perspectives about our field derives from a conversation with a colleague who held the Internal Medicine position comparable to mine in our hospital. Internal Medicine is ahead of us in the maturation of hospital medicine, and he observed that IM was well into its second generation of IM hospitalists. When I asked what that meant, he explained: The first generation he observed were the clinicians in group practices who preferred rounding in the hospital to remaining in the office. They and their partners worked out a mutually agreeable and beneficial arrangement, whereby they represented the practice in the hospital, and their partners remained in the office. Their previous experience and continued relationships made it second nature to these “hospitalists” to stay in touch with the primary care practitioners and facilitate transitions of care. My colleague bemoaned that the second generation came straight from residency and lacked the experience in a community-based practice and, as a result, the ingrained importance of close relationships with the community practitioners. As I thought about his observations, it struck me that we, in PHM, pretty much jumped over what he called the first generation of hospitalists and started largely with the second. This creates the potential for a hospitalist-practitioner gap that concerns me. I see us as extensions of the practices in our catchment areas, serving both as the representatives of the practices and a safety net when a higher level of care is required. We can either keep the house of pediatric care in order or fracture it. I would hope we recognize and address this challenge.
4. In your visual diagnosis lecture, you stated “Even if things resolve clinically, the story may not yet be over.” What do you mean by this and do you have an example?
Fortunately, most illnesses incurred by children are self-limited. Some may involve a constellation of signs and symptoms that we can’t identify—and we and the families are relieved when the signs and symptoms appear to resolve. For some processes, however, that apparent resolution can be deceiving, with a greater threat remaining. Familiar examples include Kawasaki disease, with the resolution of the cardinal features but the underlying threat of coronary artery disease. Another is Henoch-Schonlein syndrome with its delayed and silent onset of microscopic hematuria and the possibility of chronic renal disease. I made the comment during the Visual Diagnosis session to point out that we should not set aside our curiosity if a condition we cannot diagnose seems to resolve. Such a condition should prompt us to increase our attention to detail and consider whether the child is at continued risk. Moreover, some conditions that appear to resolve will recur and catch us off guard. One of our chief residents tried to inspire his troops with the following admonition: “It’s not alright to not know the same thing twice.” You have to get past the double negative to appreciate the importance of his statement. Unexplained observations, questions, and difficult to interpret data come at us all day, and, if unaddressed, remain unresolved as a new set appears the next day. And sometimes, with great embarrassment, we are confronted by the same unexplained observation, question, or difficult to interpret data. Particularly when that happens and we feel guilty about not have pursued the answer previously, the words of the chief resident right truest: “It’s not alright to not know the same thing twice.”
5. What advice do you have for new pediatric hospitalists as they are embarking on their careers?
See question #3 and #6.
6. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
My advice (and two cents worth)? Two things, one of which has already been touched upon. Recognize, value, and respect the role of the primary care clinician. It is all too easy as a hospitalist to think of one’s self as at a higher level because the patients are receiving a higher level of care. We have the comfort of 24 hour nursing observation and care for our relatively small number of patients, whereas the primary care clinicians are making the important decisions regarding who, among many children, can be cared for at home and who needs the services of a hospital. Not every decision will be accurate, and we will see the “mistakes,” but we need to maintain humility and avoid thinking we are above errors in judgment. Second, see all that you can see. I see us as a safety net for children admitted to the hospital, including those who come “pre-packaged” with a diagnosis and plan. Pay attention to detail and question what you do not recognize. Knowledge only takes you so far; some things need to be seen and filed away for future recognition. So if a colleague has a patient with a finding you haven’t seen before, drop what you’re doing and expand your ability: Heliotrope hue? Rose spots? Rash of Still disease? Pericardial friction rub? Go for it!
There’s actually a fair amount of background behind that flip comment. It starts with some observations Paul McCarthy shared when he was developing what came to be known as the Yale Observation Scales (YOS). First, he recognized that the individuals acknowledged to be excellent clinicians seemed totally incapable of following his instructions to “just observe.” Instead, they could not resist interacting with the infants, smiling at them and trying to elicit a response. What came of this is two-fold: Paul created the category of “response to social overture” because of its importance to the clinicians, and, when he analyzed the data, he noted that no infant with a serious illness had a social smile and no infant with a social smile had a serious illness. That stuck with me. Some years later, a letter to the editor appeared reporting an infant with bacterial meningitis who retained a social smile, but that has been the extent of the refutation I have seen of the YOS data. But there is a real limitation to the use of the social smile when trying to apply it to very young febrile infants: Babies don’t respond to a smile with a smile of their own in the first few weeks of life. Some babies have an irreproducible social smile at the end of the first month of life but it generally isn’t until the second month of life that the social smile is reproducible. It is one of the two developmental milestones of the second month of life that I associate with survival of our species, the other being sleeping through the night. So, to answer your question, yes, I do use the social smile to reassure me, but it is not the only factor I consider regarding the decision to perform an LP or not.
2. Your presentation on UTIs packed the lecture hall at PHM this past year. For those who missed it, can you give us the highlights on the new guidelines coming down the pipeline? What is driving those changes?
As to what is “coming down the pipeline” regarding UTI guidelines, the Reaffirmation of the 2011 Guideline was published in December, 2016, but I don’t think it likely to be the final word on the subject. It is very exciting to me to see all the activity and research regarding urinary tract infections. At the time of the first AAP guideline in the 1990s, there was an extensive weight of tradition but little insight. Tom Newman shared a cartoon with me that applies: it depicts a Research Institute with two arrows pointing in opposite directors for unanswered questions and unquestioned answers. In the mid-1990s, we had considerably more of the latter. I think we will continue to see evidence coming forward that will improve our diagnostic ability and refine our understanding of renal injury. In fact, there are some articles in the pipeline that will do just that.
3. What do you see as the biggest challenge facing pediatric hospital medicine in the next 5 years and why?
Actually, my answer to this question also relates to your questions #5 and #6 as well. One of my perspectives about our field derives from a conversation with a colleague who held the Internal Medicine position comparable to mine in our hospital. Internal Medicine is ahead of us in the maturation of hospital medicine, and he observed that IM was well into its second generation of IM hospitalists. When I asked what that meant, he explained: The first generation he observed were the clinicians in group practices who preferred rounding in the hospital to remaining in the office. They and their partners worked out a mutually agreeable and beneficial arrangement, whereby they represented the practice in the hospital, and their partners remained in the office. Their previous experience and continued relationships made it second nature to these “hospitalists” to stay in touch with the primary care practitioners and facilitate transitions of care. My colleague bemoaned that the second generation came straight from residency and lacked the experience in a community-based practice and, as a result, the ingrained importance of close relationships with the community practitioners. As I thought about his observations, it struck me that we, in PHM, pretty much jumped over what he called the first generation of hospitalists and started largely with the second. This creates the potential for a hospitalist-practitioner gap that concerns me. I see us as extensions of the practices in our catchment areas, serving both as the representatives of the practices and a safety net when a higher level of care is required. We can either keep the house of pediatric care in order or fracture it. I would hope we recognize and address this challenge.
4. In your visual diagnosis lecture, you stated “Even if things resolve clinically, the story may not yet be over.” What do you mean by this and do you have an example?
Fortunately, most illnesses incurred by children are self-limited. Some may involve a constellation of signs and symptoms that we can’t identify—and we and the families are relieved when the signs and symptoms appear to resolve. For some processes, however, that apparent resolution can be deceiving, with a greater threat remaining. Familiar examples include Kawasaki disease, with the resolution of the cardinal features but the underlying threat of coronary artery disease. Another is Henoch-Schonlein syndrome with its delayed and silent onset of microscopic hematuria and the possibility of chronic renal disease. I made the comment during the Visual Diagnosis session to point out that we should not set aside our curiosity if a condition we cannot diagnose seems to resolve. Such a condition should prompt us to increase our attention to detail and consider whether the child is at continued risk. Moreover, some conditions that appear to resolve will recur and catch us off guard. One of our chief residents tried to inspire his troops with the following admonition: “It’s not alright to not know the same thing twice.” You have to get past the double negative to appreciate the importance of his statement. Unexplained observations, questions, and difficult to interpret data come at us all day, and, if unaddressed, remain unresolved as a new set appears the next day. And sometimes, with great embarrassment, we are confronted by the same unexplained observation, question, or difficult to interpret data. Particularly when that happens and we feel guilty about not have pursued the answer previously, the words of the chief resident right truest: “It’s not alright to not know the same thing twice.”
5. What advice do you have for new pediatric hospitalists as they are embarking on their careers?
See question #3 and #6.
6. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
My advice (and two cents worth)? Two things, one of which has already been touched upon. Recognize, value, and respect the role of the primary care clinician. It is all too easy as a hospitalist to think of one’s self as at a higher level because the patients are receiving a higher level of care. We have the comfort of 24 hour nursing observation and care for our relatively small number of patients, whereas the primary care clinicians are making the important decisions regarding who, among many children, can be cared for at home and who needs the services of a hospital. Not every decision will be accurate, and we will see the “mistakes,” but we need to maintain humility and avoid thinking we are above errors in judgment. Second, see all that you can see. I see us as a safety net for children admitted to the hospital, including those who come “pre-packaged” with a diagnosis and plan. Pay attention to detail and question what you do not recognize. Knowledge only takes you so far; some things need to be seen and filed away for future recognition. So if a colleague has a patient with a finding you haven’t seen before, drop what you’re doing and expand your ability: Heliotrope hue? Rose spots? Rash of Still disease? Pericardial friction rub? Go for it!