Mark Shen
1. You clearly have a passion for resident education and morning reports. In an ideal world, how do you see morning report structured?
Well, let me tell you how I really feel. Morning report is often just a vehicle for either a novice to share an UpToDate chapter on a specific diagnosis (e.g. student/resident presentation) or for a senior faculty member to talk about their particular area of expertise, or frustration. And yet, this is also a highly regarded educational opportunity by learners; they are primed and activated. I think what we would all want is to use this valuable time for a highly engaging, focused exploration of some of the more difficult nuances in medicine, not to spend time on something Dr. Google can teach us. Now, this doesn’t mean every case is a diagnostic dilemma, though we all like those kinds of morning reports. The topic could be a difficult psychosomatic patient and family, or it could be how to Choose Wisely when ordering labs.
Hence, the structure of a morning report may vary considerably depending on the educational goal. The real difficulty is in actually getting to shared agreement on not just a goal, but an appropriate educational method for that objective. One of my pet peeves for hospitalist-educators is that we will spend all day going back and forth on the evidence for bronchiolitis but we spend almost no time discussing evidence-based techniques for teaching in the one forum that our learners value for high quality education. I realize that there are often political issues associated with changing morning report, but is it that hard for all of those academic hospitalists out there to come up with an EBE (Evidence-Based Education) journal club? And I’m not talking about just another lecture on feedback…
2. Another passion of yours is reducing overuse. In your opinion, what’s the biggest area for improvement in reduction of overuse in pediatric hospital medicine?
I’m not sure there is any one specific area that I care about. As has recently been discussed on the listserv, reducing overuse may not dramatically reduce healthcare costs, at least for the kinds of clinical conditions which hospitalists see with regularity. I think the greater potential lies in the overuse movement itself. I remember my first Internal Medicine rotation as a 3rd year medical student and I had a great intern who would lovingly take me through which specific electrolytes to order on our 86 year-old patient with 10 chronic diseases. I barely understood what she was talking about at the time, but it was the attention to not doing something reflexively that I loved. Later, as a 3rd year pediatrics resident, I learned about the principles of benign neglect and therapeutic nihilism from our Chair of Pediatrics. Those were defining moments in my own personal overuse career.
But I think I’m also wired that way. It’s like when I pack for a vacation. I’m always looking for the smallest piece of luggage for the job. Meanwhile, my wife cannot pack in less than a suitcase for an overnight trip. I’m never going to change her and she will always scoff at my attempts at efficiency. Similarly, I think the greatest challenge for overuse is addressing inherent biases, maybe even personality traits. That’s going to be the true success of “personalized medicine” in my opinion – how to overcome the genetic (overuse) predisposition of your doctor. I’m only partially joking here. The literature on how we think is fairly mature. The literature on how we compensate for those cognitive patterns in one individual in a complex clinical scenario is young at best. Thus, I think of overuse in terms of a movement. Just as health disparities must regularly enter our consciousness in order to be effectively addressed, so too must overuse be in the spotlight if we are to meaningfully scale our efforts. (If you look carefully at the origins of the attention to overuse, you will notice healthy tenets of a social movement at its core)
3. Recently, an article was published in Pediatrics about the possible connection between phototherapy and cancer risk (Wickremasinghe AC, Kuzniewicz MW, Grimes BA, et al. Neonatal Phototherapy and Infantile Cancer. Pediatrics. 2016;137(6): ). What are your thoughts on this article and does it change your practice habits?
I should disclose that I am on the AAP committee that is working on updating the 2004 Guidelines for the Management of Hyperbilirubinemia. We are just about to dive into the thousands of articles from the literature review and it will be very interesting to review recent reports on the risks of phototherapy. However, we have to keep in mind that ultimately, the decision to start phototherapy is and has always been a complex balance of risks vs. benefits, mostly at the population level. I am excited about that kind of discussion. At any given bedside, it’s really hard to translate this kind of work to a recommendation without a discussion of why we use phototherapy in the first place. Arguably, that is the more important discussion; it just happens to be at the other end of the balance, or scale.
4. You’ve given a lecture entitled, “View from the C Suite” about your transition from resident to hospitalist to president of a hospital (Dell Children’s in Austin, Texas). Tell about briefly about that transition and what made it possible for you.
From the perspective of a pediatric hospitalist, I would call that an accidental transition. Right or wrong, up until that time I had always been someone who wanted to dissociate the business of medicine from clinical decision-making. It was ironic then that I got involved in strategic planning for Dell Children’s Medical Center 5 years ago and then, perhaps after voicing a few too many opinions on the future of healthcare, ended up in the role of President after a sudden vacancy in the position. So this was not a planned career move but in reflecting on the transition, it is clear to me that for a long time, I have wanted to help heal our healthcare system and that continues to drive my current path. You don’t have to do much more than compare the aspirations in a medical student’s personal statement with the cynicism of a mid-career hospitalist to see how much healthcare is struggling.
But if healthcare is ailing, I have always felt that hospitalists are stem cells, perfectly positioned to differentiate into a myriad of healthcare leadership roles. I won’t recap all of the different kinds of leadership roles in which hospitalists have taken but my guess is that if there were a metric that looked at breadth and depth of healthcare leadership by specialty (balanced by age of the specialty), hospital medicine would come out on top. This is where I would also discourage a focus on titles and ask everyone to instead think through, what are contextual factors in the hospital medicine movement that have given us all a platform to be successful?
My own career continues to evolve as I am in the process of leaving the hospital-centric position to a broader systems role. As in many pediatric systems, we have to manage many things outside of the hospital, everything from insurance products to outpatient clinics to partnerships and alliances. These ventures are variably owned, managed or invested in by our larger (adult) system and are not just distinct business entities. They must be clinically and strategically integrated to provide a seamless continuum of care for patients and families who look to us as the pediatric experts in our community. Although the hospital may be the center of the universe for hospitalists, on a macro level, it is not the center of a more efficient and effective healthcare system.
5. You worked hand in hand with Deb Brown, who is an RN, BSN, and the COO and CNO of Dell Children’s. What was that like and how do you think that we as hospitalists could better interface with nursing or other staff?
Deb and I were a dyad. We complemented each other in our daily work. Specific to nursing and operations, she was the expert but we always worked together to make sure that there was alignment in the clinical and business missions of the hospital. We did not spend a lot of time on the hospitalist-nurse/staff interface and I think that is because we have great hospitalist leaders and nursing leaders at Dell Children’s. We have long had an emphasis on interdisciplinary leadership and communication such that administration didn’t need to be involved in improving those relationships. In fact, I think it would be dangerous to have administrators try to bridge that divide. But the basic model remains – this is a team sport.
From the perspective of a hospitalist who has now been intimately involved in hospital operations, I would say that hospitalists need to spend time trying to understand the basics of hospital operations (and administrative leaders could do a better job of educating and sharing those basics). Managing nurse scheduling to maximize efficient coverage on a given unit is no different conceptually from creating a hospitalist shift schedule – not that easy to make everyone happy. It can be very difficult for a full-time practicing physician to understand the difficult decisions that hospitals must make to remain viable as businesses, particularly when things like nursing shortages and drug price inflation throw your budget for a loop. But at a time as dynamic as this in healthcare, if hospitalists do not work towards at least a basic understanding of the system, then it becomes difficult to have rational conversations about how to improve the system.
6. What’s the best piece of career advice that you have ever been given?
Remember your passion. I was reminded of this when I watched La La Land recently – no, not the Oscar snafu, the actual movie. If you focus too much on any one job, or title, or career path, you can quickly lose sight of who you are because you will feel like you’re constantly auditioning for imperfect roles or not being true to your inner music. Hospitalists are blessed to have so many opportunities for differentiation in their careers. I have been blessed to be able to focus on clinical medicine, education, quality improvement and now healthcare systems improvement. If I had spent too much time mapping out my job-position-career path, I would have ended up somewhere that would definitely have been less fulfilling than where I am now. So remember your passion and stay true to it. That’s my advice.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Take advantage of the vibrant pediatric hospital medicine community. Nothing is more gratifying to me than being around other pediatric hospitalists because there are so many interests, so many great ideas and best of all, passionate people. I don’t mean to sound like a lecherous Matthew McConaughey in the movie Dazed and Confused, but it really is pretty cool to be able to hang out on the listserv and see a diagnostic dilemma get a litany of responses within minutes, or to be at a conference and get career advice from any number of folks at different stages of very different careers.
Well, let me tell you how I really feel. Morning report is often just a vehicle for either a novice to share an UpToDate chapter on a specific diagnosis (e.g. student/resident presentation) or for a senior faculty member to talk about their particular area of expertise, or frustration. And yet, this is also a highly regarded educational opportunity by learners; they are primed and activated. I think what we would all want is to use this valuable time for a highly engaging, focused exploration of some of the more difficult nuances in medicine, not to spend time on something Dr. Google can teach us. Now, this doesn’t mean every case is a diagnostic dilemma, though we all like those kinds of morning reports. The topic could be a difficult psychosomatic patient and family, or it could be how to Choose Wisely when ordering labs.
Hence, the structure of a morning report may vary considerably depending on the educational goal. The real difficulty is in actually getting to shared agreement on not just a goal, but an appropriate educational method for that objective. One of my pet peeves for hospitalist-educators is that we will spend all day going back and forth on the evidence for bronchiolitis but we spend almost no time discussing evidence-based techniques for teaching in the one forum that our learners value for high quality education. I realize that there are often political issues associated with changing morning report, but is it that hard for all of those academic hospitalists out there to come up with an EBE (Evidence-Based Education) journal club? And I’m not talking about just another lecture on feedback…
2. Another passion of yours is reducing overuse. In your opinion, what’s the biggest area for improvement in reduction of overuse in pediatric hospital medicine?
I’m not sure there is any one specific area that I care about. As has recently been discussed on the listserv, reducing overuse may not dramatically reduce healthcare costs, at least for the kinds of clinical conditions which hospitalists see with regularity. I think the greater potential lies in the overuse movement itself. I remember my first Internal Medicine rotation as a 3rd year medical student and I had a great intern who would lovingly take me through which specific electrolytes to order on our 86 year-old patient with 10 chronic diseases. I barely understood what she was talking about at the time, but it was the attention to not doing something reflexively that I loved. Later, as a 3rd year pediatrics resident, I learned about the principles of benign neglect and therapeutic nihilism from our Chair of Pediatrics. Those were defining moments in my own personal overuse career.
But I think I’m also wired that way. It’s like when I pack for a vacation. I’m always looking for the smallest piece of luggage for the job. Meanwhile, my wife cannot pack in less than a suitcase for an overnight trip. I’m never going to change her and she will always scoff at my attempts at efficiency. Similarly, I think the greatest challenge for overuse is addressing inherent biases, maybe even personality traits. That’s going to be the true success of “personalized medicine” in my opinion – how to overcome the genetic (overuse) predisposition of your doctor. I’m only partially joking here. The literature on how we think is fairly mature. The literature on how we compensate for those cognitive patterns in one individual in a complex clinical scenario is young at best. Thus, I think of overuse in terms of a movement. Just as health disparities must regularly enter our consciousness in order to be effectively addressed, so too must overuse be in the spotlight if we are to meaningfully scale our efforts. (If you look carefully at the origins of the attention to overuse, you will notice healthy tenets of a social movement at its core)
3. Recently, an article was published in Pediatrics about the possible connection between phototherapy and cancer risk (Wickremasinghe AC, Kuzniewicz MW, Grimes BA, et al. Neonatal Phototherapy and Infantile Cancer. Pediatrics. 2016;137(6): ). What are your thoughts on this article and does it change your practice habits?
I should disclose that I am on the AAP committee that is working on updating the 2004 Guidelines for the Management of Hyperbilirubinemia. We are just about to dive into the thousands of articles from the literature review and it will be very interesting to review recent reports on the risks of phototherapy. However, we have to keep in mind that ultimately, the decision to start phototherapy is and has always been a complex balance of risks vs. benefits, mostly at the population level. I am excited about that kind of discussion. At any given bedside, it’s really hard to translate this kind of work to a recommendation without a discussion of why we use phototherapy in the first place. Arguably, that is the more important discussion; it just happens to be at the other end of the balance, or scale.
4. You’ve given a lecture entitled, “View from the C Suite” about your transition from resident to hospitalist to president of a hospital (Dell Children’s in Austin, Texas). Tell about briefly about that transition and what made it possible for you.
From the perspective of a pediatric hospitalist, I would call that an accidental transition. Right or wrong, up until that time I had always been someone who wanted to dissociate the business of medicine from clinical decision-making. It was ironic then that I got involved in strategic planning for Dell Children’s Medical Center 5 years ago and then, perhaps after voicing a few too many opinions on the future of healthcare, ended up in the role of President after a sudden vacancy in the position. So this was not a planned career move but in reflecting on the transition, it is clear to me that for a long time, I have wanted to help heal our healthcare system and that continues to drive my current path. You don’t have to do much more than compare the aspirations in a medical student’s personal statement with the cynicism of a mid-career hospitalist to see how much healthcare is struggling.
But if healthcare is ailing, I have always felt that hospitalists are stem cells, perfectly positioned to differentiate into a myriad of healthcare leadership roles. I won’t recap all of the different kinds of leadership roles in which hospitalists have taken but my guess is that if there were a metric that looked at breadth and depth of healthcare leadership by specialty (balanced by age of the specialty), hospital medicine would come out on top. This is where I would also discourage a focus on titles and ask everyone to instead think through, what are contextual factors in the hospital medicine movement that have given us all a platform to be successful?
My own career continues to evolve as I am in the process of leaving the hospital-centric position to a broader systems role. As in many pediatric systems, we have to manage many things outside of the hospital, everything from insurance products to outpatient clinics to partnerships and alliances. These ventures are variably owned, managed or invested in by our larger (adult) system and are not just distinct business entities. They must be clinically and strategically integrated to provide a seamless continuum of care for patients and families who look to us as the pediatric experts in our community. Although the hospital may be the center of the universe for hospitalists, on a macro level, it is not the center of a more efficient and effective healthcare system.
5. You worked hand in hand with Deb Brown, who is an RN, BSN, and the COO and CNO of Dell Children’s. What was that like and how do you think that we as hospitalists could better interface with nursing or other staff?
Deb and I were a dyad. We complemented each other in our daily work. Specific to nursing and operations, she was the expert but we always worked together to make sure that there was alignment in the clinical and business missions of the hospital. We did not spend a lot of time on the hospitalist-nurse/staff interface and I think that is because we have great hospitalist leaders and nursing leaders at Dell Children’s. We have long had an emphasis on interdisciplinary leadership and communication such that administration didn’t need to be involved in improving those relationships. In fact, I think it would be dangerous to have administrators try to bridge that divide. But the basic model remains – this is a team sport.
From the perspective of a hospitalist who has now been intimately involved in hospital operations, I would say that hospitalists need to spend time trying to understand the basics of hospital operations (and administrative leaders could do a better job of educating and sharing those basics). Managing nurse scheduling to maximize efficient coverage on a given unit is no different conceptually from creating a hospitalist shift schedule – not that easy to make everyone happy. It can be very difficult for a full-time practicing physician to understand the difficult decisions that hospitals must make to remain viable as businesses, particularly when things like nursing shortages and drug price inflation throw your budget for a loop. But at a time as dynamic as this in healthcare, if hospitalists do not work towards at least a basic understanding of the system, then it becomes difficult to have rational conversations about how to improve the system.
6. What’s the best piece of career advice that you have ever been given?
Remember your passion. I was reminded of this when I watched La La Land recently – no, not the Oscar snafu, the actual movie. If you focus too much on any one job, or title, or career path, you can quickly lose sight of who you are because you will feel like you’re constantly auditioning for imperfect roles or not being true to your inner music. Hospitalists are blessed to have so many opportunities for differentiation in their careers. I have been blessed to be able to focus on clinical medicine, education, quality improvement and now healthcare systems improvement. If I had spent too much time mapping out my job-position-career path, I would have ended up somewhere that would definitely have been less fulfilling than where I am now. So remember your passion and stay true to it. That’s my advice.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Take advantage of the vibrant pediatric hospital medicine community. Nothing is more gratifying to me than being around other pediatric hospitalists because there are so many interests, so many great ideas and best of all, passionate people. I don’t mean to sound like a lecherous Matthew McConaughey in the movie Dazed and Confused, but it really is pretty cool to be able to hang out on the listserv and see a diagnostic dilemma get a litany of responses within minutes, or to be at a conference and get career advice from any number of folks at different stages of very different careers.