- Mary Ottolini
1. One of your areas of interest is family centered rounds (FCRs) and in one of your publications in Hospital Pediatrics in 2013, you conducted a time-motion study and showed that most rounds occurred outside of the room, especially when patients were on infectious isolation. How do you approach FCRs in this situation? Has it changed in the time of COVID-19?
When COVID first emerged in the Spring of 2020 we had a regression in our typical FCR structure with a bedside presentation and patient exam with the interprofessional team in the patient room to rounding first in a conference room and then independently going to the bedside to examine the patient. I strongly feel that this contributed to at least one adverse event because team members did not have a shared mental model of the patient’s acuity. We are now back to doing bedside FCR, albeit with a smaller number of team members. To allow for social distancing we have to limit how many students and residents can be in the room at once. Similar to what others around the country have reported, we are using technology to allow learners who are outside the room to virtually experience aspects of the physical exam, such as using a digital broadcasting stethoscope for heart and lung sounds. We are using an iPAD to allow learners to see other findings as well as to listen to the patient discussion. I think that colleagues at The University of Chicago, Comer Children’s Hospital are further ahead doing this than we are- but it is great to collaborate with other PHM groups. We hope to continue using the technology after COVID is over to allow parents as well as other members of the healthcare team like social work and nutrition to join rounds virtually as needs arise.
2. A study in the Journal of Women’s Health studied Grand Rounds introductions at academic hospitals and showed that females introduce male colleagues with the title of “doctor” 95% of the time, but males only did the same for their female colleagues 49% of the time. As a female and leader in PHM, have you encountered any gender bias and how do you handle those situations?
I always introduce speakers by their formal titles as a matter of respect.
I have encountered gender bias throughout my career, beginning in medical school. My 1983 medical school enrollment class had the largest percentage of women at 22%. On surgical rotations the surgeons’ lounge was accessed through the men’s locker room. I was able to obtain scrubs by asking my male colleagues to get them from the surgeon’s lounge and using the nurses’ locker room. Things weren’t particularly interprofessional in those days and the nurses did not particularly like having medical students in their space. This arrangement automatically gave the male trainees an advantage in establishing working relationships with attendings and residents, who were all male and made female students feel like we did not belong. I found however, that by being well prepared and working as long or longer hours than male colleagues I could earn respect from attendings and residents.
Frequently gender bias is subtle. At another institution that a colleague and I worked at repeatedly referred to as the “Marys”. This would never have happened to senior male leaders who would have been introduced individually as Dr _________. We were both full professors and had national reputations in our fields. I made a point of addressing the senior male leader who persistently referred to us this way by using his first name repeatedly while referring to my colleague as Dr. _____ and eventually he got the message. This is an example of the subtle undermining that occurs in institutional leadership meetings. In these circumstances I find I need to balance between being pleasant while being firm and direct in my response.
Other “boys club” references such as “You eat what you kill…” can also be forms of gender bias or micro aggressions in my opinion. Once a senior leader who was frustrated about a space issue said he would begin “Lifting my leg to mark my territory…”. I think it is important to address these remarks with senior leaders after meetings so that they start to recognize that this type of language represents a way of marginalizing women leaders.
3. From May 2016 to 2017, you served as president of the APA. To some, the choice of membership in various organizations (APA, SHM and/or AAP Section of Hospital Medicine) can be overwhelming and new graduates might not understand the reasons for joining. What would you say to pediatric hospitalists about this?
I wish that Pediatric Hospitalists could have a discounted bundled membership to join all three organizations, because they all bring strengths to the specialty and to individuals. I think most are members of the AAP, but not aware of the advantages of joining SHM and the APA. Although SHM is predominantly an adult-oriented organization, with a very large Internal Medicine membership, they have terrific resources for practice management and quality improvement. The APA offers great resources and networking to promote career satisfaction and success in an academic environment- whether at a tertiary care children’s hospital or community setting. There are a number of Special Interest Groups to promote networking and involvement in topics of interest to Pediatric Hospitalists. New hospitalists are most familiar with the AAP from educational resources such as PREP and advocacy involvement during residency. The AAP has a terrific listserv and Section on Hospital Medicine that has opportunities for involvement in subgroups to advance educational, QI and advocacy efforts.
4. You were the senior author on a paper in Academic Pediatrics in 2015, talking about entrustable professional activities (EPAs) related to consultation and referral. For hospitalists in programs where they spend only 1-2 days at a time with learners, how can entrustment progress despite constantly changing faculty supervisors?
I don’t think it is ideal to have less than a contiguous week with a learner unless you are able to work with them episodically in a longitudinal fashion to see progress over time. If the hospitalist has only 1-2 days with a learner it is really important to observe the learner during patient interactions using validated assessment tools to evaluate their clinical skills eliciting data, performing procedures, making decisions and communicating with patients and families. Each hospitalist can provide data points from their observations along with a learner’s patient/procedure log to generate entrustment assessments. It takes commitment by the PHM division to meet regularly, provide specific examples and give feedback to learners.
5. You clearly have a passion for medical education as well as pediatric hospital medicine. How do you see these two fields intersecting as PHM is now an American Board of Pediatrics (ABP) subspecialty?
PHM providers are ideally positioned to be successful clinician-educators. We have a flexible clinical schedule that permits us to observe learners in all facets of clinical care. Family Centered Rounds provides an ideal opportunity to assess clinical skills and teach at the bedside. I think it is important to emphasize to learners that learning during rounds will focus on clinical reasoning, interpreting the physical exam and communication skills so that they realize they are learning during rounds. Programs such as APEX provide hospitalists with advanced teaching skills to enhance their teaching effectiveness in the busy clinical setting. Clinical teaching challenges at the bedside include teaching to multiple levels of learners, promoting leadership skills by senior residents and keeping all team members engaged in learning while keeping the rounding process efficient.
To be academically successful however, pediatric hospitalists need to produce scholarship in addition to being excellent teachers. This basically means we need to be rigorous in our approach to problem solving. There is great temptation to develop innovative educational methods to address learner gaps in knowledge or skill because that is the creative, fun part. In order to generate a useful curriculum that others can use, it is important to do a good needs assessment of learners and determine what has already been tried before developing your own curriculum or teaching strategy. It is also critical to ground your intervention in a theoretical or conceptual framework so that it is more likely to be successful. Finally you need to plan how you will evaluate the success of your program and measure changes in your learners. Today many hospitalists are pursing additional training by enrolling in Masters Degree grant granting programs in Medical Education or in tailored programs such as the APA Educational Scholars Program or the Harvard Macy Program to gain greater capacity to successfully produce scholarship.
6. You recently made the move from Children’s National Medical Center in Washington D.C. after 26 years to the Barbara Bush Children’s Hospital and the MaineHealth pediatric service line. What has the transition been like?
The transition has been very interesting and rewarding for the most part. I like to explore a new challenge every 8-10 years. Although I am not sure I would have made the move to Maine if I knew Covid was looming, I am glad I did!
In 1994 I had the opportunity to pilot the first PHM program in the Mid-Atlantic area at Holy Cross, a community hospital academically affiliated with Children's National and then broaden that pilot to develop multiple PHM inpatient services at Children’s National while staffing several other community hospitals and a specialty transitional care- rehab hospital. I then transitioned from the PHM Division Chief to Vice Chair for Medical Education, overseeing about 1500 UME and GME trainees annually. There were not opportunities for further career advancement at Children’s National- as I perceived at that time there was a literal glass ceiling for women physicians in key leadership positions.
The challenges here in Maine are in many ways familiar. Poverty and other social determinants of health are prevalent among children in Maine, but the setting is more often rural than urban. The rural setting poses different challenges in dealing with adverse childhood experiences and trauma. As in other states, mental health support for children and families is a challenge. Although demographically, Maine is technically the oldest state in the country I have found the entire population (about 1.4 million) to be amazingly supportive of helping children lead healthier lives.
MaineHealth’s Barbara Bush Children’s Health Service Line with ten rural institutions provides not only medical care but promotes population health initiatives across Maine. We have outreach programs to address food insecurity, mental health screening, literacy, obesity, immunization hesitancy, ACES, and childhood trauma in urban communities with recent immigrants and rural communities across the state. It is amazing how well pediatric specialists and primary care pediatricians as well as family medicine providers work together to learn from each other and build capacity within their practices to address the needs of their patients. Covid has brought greater acceptance of telemedicine and eConsults to help decrease geographic isolation and travel for patients.
Rural outreach extends beyond primary care for The Barbara Bush Children’s Hospital. Like many rural states Maine struggles to maintain adequate access to high quality obstetrical and delivery room services. We found health disparities in neonatal outcomes related to rural hospital birth, in part related to lack of delivery room team resuscitation experience. Many hospitals have less than one baby born per day. To address limited opportunities for daily “practice” we implemented a simulation outreach program (Project MOOSE- Maine Ongoing Outreach Simulation Experience). The program consists of an intense on-site interprofessional team training and assessment, followed by a telesimulation monthly refresher. We are in the process of developing an augmented reality version of the telesimulation to provide a more authentic, less expensive alternative to the current high fidelity mannikin.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
My 2 cents is not to settle…
-Don’t settle for children’s health issues being less important than adult issues because they represent a smaller piece of the health economic pie. Pediatricians can innovate to pilot solutions to mitigate larger adult health problems that start in childhood at a fraction of the cost. The issue is what is valued in healthcare systems and society. We should value our future!
-Don’t settle for a focus just on inpatient pediatric health. As pediatric hospitalists we often see the tip of the iceberg. Many children end up hospitalized with ambulatory sensitive conditions like gastroenteritis or asthma that are preventable and disproportionately occur in minority populations or children living in poverty. Hospitalization rates, especially for problems with comorbid mental health problems reflect disparities in knowledge and access to care in their community.
- Don’t settle for reasons why you can’t do something. Use appreciative inquiry to discover underlying concerns and communicate your vision for a successful outcome. We can’t afford the time or wasted energy to be in conflict with one another about trying to do good things for kids.
When COVID first emerged in the Spring of 2020 we had a regression in our typical FCR structure with a bedside presentation and patient exam with the interprofessional team in the patient room to rounding first in a conference room and then independently going to the bedside to examine the patient. I strongly feel that this contributed to at least one adverse event because team members did not have a shared mental model of the patient’s acuity. We are now back to doing bedside FCR, albeit with a smaller number of team members. To allow for social distancing we have to limit how many students and residents can be in the room at once. Similar to what others around the country have reported, we are using technology to allow learners who are outside the room to virtually experience aspects of the physical exam, such as using a digital broadcasting stethoscope for heart and lung sounds. We are using an iPAD to allow learners to see other findings as well as to listen to the patient discussion. I think that colleagues at The University of Chicago, Comer Children’s Hospital are further ahead doing this than we are- but it is great to collaborate with other PHM groups. We hope to continue using the technology after COVID is over to allow parents as well as other members of the healthcare team like social work and nutrition to join rounds virtually as needs arise.
2. A study in the Journal of Women’s Health studied Grand Rounds introductions at academic hospitals and showed that females introduce male colleagues with the title of “doctor” 95% of the time, but males only did the same for their female colleagues 49% of the time. As a female and leader in PHM, have you encountered any gender bias and how do you handle those situations?
I always introduce speakers by their formal titles as a matter of respect.
I have encountered gender bias throughout my career, beginning in medical school. My 1983 medical school enrollment class had the largest percentage of women at 22%. On surgical rotations the surgeons’ lounge was accessed through the men’s locker room. I was able to obtain scrubs by asking my male colleagues to get them from the surgeon’s lounge and using the nurses’ locker room. Things weren’t particularly interprofessional in those days and the nurses did not particularly like having medical students in their space. This arrangement automatically gave the male trainees an advantage in establishing working relationships with attendings and residents, who were all male and made female students feel like we did not belong. I found however, that by being well prepared and working as long or longer hours than male colleagues I could earn respect from attendings and residents.
Frequently gender bias is subtle. At another institution that a colleague and I worked at repeatedly referred to as the “Marys”. This would never have happened to senior male leaders who would have been introduced individually as Dr _________. We were both full professors and had national reputations in our fields. I made a point of addressing the senior male leader who persistently referred to us this way by using his first name repeatedly while referring to my colleague as Dr. _____ and eventually he got the message. This is an example of the subtle undermining that occurs in institutional leadership meetings. In these circumstances I find I need to balance between being pleasant while being firm and direct in my response.
Other “boys club” references such as “You eat what you kill…” can also be forms of gender bias or micro aggressions in my opinion. Once a senior leader who was frustrated about a space issue said he would begin “Lifting my leg to mark my territory…”. I think it is important to address these remarks with senior leaders after meetings so that they start to recognize that this type of language represents a way of marginalizing women leaders.
3. From May 2016 to 2017, you served as president of the APA. To some, the choice of membership in various organizations (APA, SHM and/or AAP Section of Hospital Medicine) can be overwhelming and new graduates might not understand the reasons for joining. What would you say to pediatric hospitalists about this?
I wish that Pediatric Hospitalists could have a discounted bundled membership to join all three organizations, because they all bring strengths to the specialty and to individuals. I think most are members of the AAP, but not aware of the advantages of joining SHM and the APA. Although SHM is predominantly an adult-oriented organization, with a very large Internal Medicine membership, they have terrific resources for practice management and quality improvement. The APA offers great resources and networking to promote career satisfaction and success in an academic environment- whether at a tertiary care children’s hospital or community setting. There are a number of Special Interest Groups to promote networking and involvement in topics of interest to Pediatric Hospitalists. New hospitalists are most familiar with the AAP from educational resources such as PREP and advocacy involvement during residency. The AAP has a terrific listserv and Section on Hospital Medicine that has opportunities for involvement in subgroups to advance educational, QI and advocacy efforts.
4. You were the senior author on a paper in Academic Pediatrics in 2015, talking about entrustable professional activities (EPAs) related to consultation and referral. For hospitalists in programs where they spend only 1-2 days at a time with learners, how can entrustment progress despite constantly changing faculty supervisors?
I don’t think it is ideal to have less than a contiguous week with a learner unless you are able to work with them episodically in a longitudinal fashion to see progress over time. If the hospitalist has only 1-2 days with a learner it is really important to observe the learner during patient interactions using validated assessment tools to evaluate their clinical skills eliciting data, performing procedures, making decisions and communicating with patients and families. Each hospitalist can provide data points from their observations along with a learner’s patient/procedure log to generate entrustment assessments. It takes commitment by the PHM division to meet regularly, provide specific examples and give feedback to learners.
5. You clearly have a passion for medical education as well as pediatric hospital medicine. How do you see these two fields intersecting as PHM is now an American Board of Pediatrics (ABP) subspecialty?
PHM providers are ideally positioned to be successful clinician-educators. We have a flexible clinical schedule that permits us to observe learners in all facets of clinical care. Family Centered Rounds provides an ideal opportunity to assess clinical skills and teach at the bedside. I think it is important to emphasize to learners that learning during rounds will focus on clinical reasoning, interpreting the physical exam and communication skills so that they realize they are learning during rounds. Programs such as APEX provide hospitalists with advanced teaching skills to enhance their teaching effectiveness in the busy clinical setting. Clinical teaching challenges at the bedside include teaching to multiple levels of learners, promoting leadership skills by senior residents and keeping all team members engaged in learning while keeping the rounding process efficient.
To be academically successful however, pediatric hospitalists need to produce scholarship in addition to being excellent teachers. This basically means we need to be rigorous in our approach to problem solving. There is great temptation to develop innovative educational methods to address learner gaps in knowledge or skill because that is the creative, fun part. In order to generate a useful curriculum that others can use, it is important to do a good needs assessment of learners and determine what has already been tried before developing your own curriculum or teaching strategy. It is also critical to ground your intervention in a theoretical or conceptual framework so that it is more likely to be successful. Finally you need to plan how you will evaluate the success of your program and measure changes in your learners. Today many hospitalists are pursing additional training by enrolling in Masters Degree grant granting programs in Medical Education or in tailored programs such as the APA Educational Scholars Program or the Harvard Macy Program to gain greater capacity to successfully produce scholarship.
6. You recently made the move from Children’s National Medical Center in Washington D.C. after 26 years to the Barbara Bush Children’s Hospital and the MaineHealth pediatric service line. What has the transition been like?
The transition has been very interesting and rewarding for the most part. I like to explore a new challenge every 8-10 years. Although I am not sure I would have made the move to Maine if I knew Covid was looming, I am glad I did!
In 1994 I had the opportunity to pilot the first PHM program in the Mid-Atlantic area at Holy Cross, a community hospital academically affiliated with Children's National and then broaden that pilot to develop multiple PHM inpatient services at Children’s National while staffing several other community hospitals and a specialty transitional care- rehab hospital. I then transitioned from the PHM Division Chief to Vice Chair for Medical Education, overseeing about 1500 UME and GME trainees annually. There were not opportunities for further career advancement at Children’s National- as I perceived at that time there was a literal glass ceiling for women physicians in key leadership positions.
The challenges here in Maine are in many ways familiar. Poverty and other social determinants of health are prevalent among children in Maine, but the setting is more often rural than urban. The rural setting poses different challenges in dealing with adverse childhood experiences and trauma. As in other states, mental health support for children and families is a challenge. Although demographically, Maine is technically the oldest state in the country I have found the entire population (about 1.4 million) to be amazingly supportive of helping children lead healthier lives.
MaineHealth’s Barbara Bush Children’s Health Service Line with ten rural institutions provides not only medical care but promotes population health initiatives across Maine. We have outreach programs to address food insecurity, mental health screening, literacy, obesity, immunization hesitancy, ACES, and childhood trauma in urban communities with recent immigrants and rural communities across the state. It is amazing how well pediatric specialists and primary care pediatricians as well as family medicine providers work together to learn from each other and build capacity within their practices to address the needs of their patients. Covid has brought greater acceptance of telemedicine and eConsults to help decrease geographic isolation and travel for patients.
Rural outreach extends beyond primary care for The Barbara Bush Children’s Hospital. Like many rural states Maine struggles to maintain adequate access to high quality obstetrical and delivery room services. We found health disparities in neonatal outcomes related to rural hospital birth, in part related to lack of delivery room team resuscitation experience. Many hospitals have less than one baby born per day. To address limited opportunities for daily “practice” we implemented a simulation outreach program (Project MOOSE- Maine Ongoing Outreach Simulation Experience). The program consists of an intense on-site interprofessional team training and assessment, followed by a telesimulation monthly refresher. We are in the process of developing an augmented reality version of the telesimulation to provide a more authentic, less expensive alternative to the current high fidelity mannikin.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
My 2 cents is not to settle…
-Don’t settle for children’s health issues being less important than adult issues because they represent a smaller piece of the health economic pie. Pediatricians can innovate to pilot solutions to mitigate larger adult health problems that start in childhood at a fraction of the cost. The issue is what is valued in healthcare systems and society. We should value our future!
-Don’t settle for a focus just on inpatient pediatric health. As pediatric hospitalists we often see the tip of the iceberg. Many children end up hospitalized with ambulatory sensitive conditions like gastroenteritis or asthma that are preventable and disproportionately occur in minority populations or children living in poverty. Hospitalization rates, especially for problems with comorbid mental health problems reflect disparities in knowledge and access to care in their community.
- Don’t settle for reasons why you can’t do something. Use appreciative inquiry to discover underlying concerns and communicate your vision for a successful outcome. We can’t afford the time or wasted energy to be in conflict with one another about trying to do good things for kids.