Ricardo Quiñonez
1. You have an interest in “overdiagnosis” and this is reflected in your presentations and articles. What do you think is currently the most frustrating example of overdiagnosis in pediatric hospital medicine?
My primary interest is overuse, for which overdiagnosis plays an important role. Overuse can be loosely defined as the provision of health care in which a patient experiences no net benefit. Overuse is comprised of overtreatment and overdiagnosis. Overdiagnosis is when we accurately diagnose someone with a true illness/disease, but the patient experience no benefit from that diagnosis. The “net benefit” part is important because if a patient does not experience net benefit then one of two possible outcomes is possible: nothing happens or more likely the patient experiences net harm. The true expert in overdiagnosis is Eric Coon, he was the first author for our paper on this subject back in 2014 which you can find here.
One of the conditions we proposed as being overdiagnosed answers your question about what I find as the most frustrating example of overdiagnosis in PHM: hypoxia. It is shocking to me that since 1980 we hospitalize 300% more kids with bronchiolitis without there really being any change to the epidemiology of bronchiolitis. Kids are not sicker now then in 1980, bronchiolitis is not more prevalent, yet we hospitalize kids much more often. The more likely explanation for this is that we now diagnose more hypoxia. Since the 1980’s, the pulse oximeter has become much more ubiquitous and thus we are much more able to diagnose hypoxia. Yet we don’t really know what this means. Obviously, children with hypoxia who are also experiencing severe respiratory distress merit hospitalization. However, how many times do we hospitalize children with bronchiolitis simply because we find they are hypoxic? I would argue that in the setting of a child who is otherwise well (drinking well, minimal or no respiratory distress) a number on the pulse oximeter is meaningless on its own.
Once hospitalized, the pulse oximeter drives everything and we are stuck playing the game of going up and down on the oxygen until the patient is able to maintain a pulse oximeter reading at or above 90% for some unspecified, arbitrary amount of time. We know kids even managed as outpatients can be profoundly hypoxic. We know that pulse oximeter readings drive admissions and we know that once hospitalized pulse oximetry drives length of stay. And yet we have no evidence that this monumental shift in practice has let to any patient benefit. So, we have dubious patient benefit, accurate diagnosis and net harm, this equals overdiagnosis. Hypoxia in bronchiolitis is to me the most egregious and frustrating example of overdiagnosis in pediatric hospital medicine. I believe the AAP’s bronchiolitis guideline recommendation to limit or avoid continuous pulse oximetry may go a long way towards reversing this trend.
2. You recently took over as the head of PHM at Texas Children’s Baylor College of Medicine. How do all of the new national developments in pediatric hospital medicine in the last year change your direction for the section?
I was very fortunate to take over as the leader of a group of vibrant, collegial and incredibly talented group of hospitalists. The Section of Pediatric Hospital Medicine at Texas Children’s Hospital is already a large, well established and successful group, however we need to be prepared for subspecialty status designation for PHM. This I think will drive what we prioritize within my Section/Division in the coming years. What this mean for me is that we need to increase, by a significant degree, the scholarly output of not just my Section, but PHM in general. A scholarly approach to all our clinical, QI, education and research efforts is essential.
Our new subspecialty fellows will require more and more experienced mentorship. While plenty of this mentorship can occur outside our section, there needs to be enough expertise within PHM to be able to handle the increased demand. We are far from reaching a critical mass of expertise within PHM and this expertise is desperately needed. We need to be seen as the experts in the care of the hospitalized child. This means leading the conversation in the clinical care of our most common inpatient conditions. This means publishing and developing new knowledge for the hospitalized child with asthma, bronchiolitis, pneumonia, Kawasaki’s disease etc. This means successfully competing for limited research dollars to develop this new knowledge. In many cases, we will overlap and/or compete with our subspecialty colleagues. This is inevitable, we need to be prepared.
3. You coauthored an article in Hospital Pediatrics in 2014 entitled, “Institutions and Individuals: What Makes a Hospitalist ‘Academic?’” What was the motivation behind this article?
Ah, this was the brainchild of the ever wise Dr. Ken Roberts. This opinion piece was simply an effort to clarify that “academic” should be a word that is used not to differentiate practice sites, but to describe what we do. It is a clarification that scholarly output can and does occur everywhere both at university affiliated and non-affiliated hospitals, at free standing children’s hospitals or children’s hospitals within a larger general hospital. An “academic” or scholarly approach to work is all that is needed to describe your practice as academic. A testament to this is the work of the Value in Inpatient Pedatrics (VIP). Through a series of projects and publications, VIP has demonstrated that a scholarly approach to practice not only does occur at community sites but often change can be more streamlined and sustained at these sites than our typical “academic” tertiary or quaternary care sites. In the paraphrased words of Forrest Gump, “Academic is as academic does.”
4. For those of us keeping track on the listserve, you have been an avid supporter of oral antibiotics for osteomyelitis. Time to put your money where your mouth is: how long do you typically leave patients on IV antibiotics for osteomyelitis and what criteria do you use for transition. Are there any exceptions to this rule?
My criteria for discharge on oral antibiotics for any infection is simple: an improving patient. This can mean improving clinical or both clinical and laboratory criteria (such as inflammatory markers). I don’t have many exceptions to this rule with perhaps the only one being an inability to take or absorb oral medications.
Now that is my criteria, but the reality that we grapple with as hospitalists is that our lack of an outpatient presence means we often co-manage these patients with subspecialists such as our infectious disease or orthopedic colleagues, who may have different opinions or tolerance from ours. This is just a reality of our practice and negotiating on behalf of the patient is a skill that is of critical importance to an experienced hospitalist.
I think in light of recent better quality evidence, practice is changing significantly and even die-hard defenders of intravenous antibiotics for osteomyelitis are starting to see the light. I even see the day in which a select group of patients with osteomyelitis are sent home from the clinic or ER with oral antibiotics.
Imagine that!
5. You have been at 2 institutions with pediatric hospital medicine fellowships. There are still many skeptics out there about the need for fellowship. What are your thoughts on this?
Well now that PHM subspecialty status is a forgone conclusion, PHM fellowships are obviously here to stay. However, I actually don’t think that a fellowship is needed to be a good hospitalist or even a successful academician in hospital medicine. So it is not “needed” but it sure doesn’t hurt.
As the leader of now 2 pediatric hospital medicine groups I have seen many people start their career fresh out of residency, and in fact, I was one of them. What I know almost for sure is that it takes about 2 years for someone who is not fellowship trained to truly be completely comfortable with the clinical side of their work. It probably takes another 1 to 2 years after that for that same person to get going in the scholarly part of their work and even then extra training in quality, research or education is almost certainly needed. Fellowship simply accelerates this trajectory. Fellowship provides a “protected” environment to develop these skills and I have no doubt that a fellowship trained hospitalist is simply better prepared for the transition from trainee to practicing clinician.
Atul Gawande wrote in the New Yorker about the lack of “apprenticeship” model in medicine that is widely used in many other industries. He famously used the Cheese Cake Factory as an example of how physicians could benefit from this model. Even in the best possible scenario, it is impossible for someone fresh out of residency to have the level of scrutiny of their work that a fellow gets. In most jobs, someone fresh out of residency is expected to perform, in their very first day, just like a seasoned hospitalist. How crazy is that? Essentially fellowship provides a protected, mentored apprenticeship into hospital medicine. It is not for everyone, but it enhances both the individual and the program. There is no doubt in my mind that a hospitalist is made better by a fellowship and a fellowship program makes a hospitalists group better in return.
6. You participated in an entertaining debate on pediatric dogmas at PHM 2016. What is your favorite (or least favorite) dogma and why?
One of my favorite dogmas was presented at that same meeting by Dan Coghlin from Hasbro Children’s. His was one that we chose as the listserve-solicited dogma and it was about the dogma that hospitalists universally improve the care of hospitalized children. Dan showed evidence for and against this notion. Early literature on pediatric hospitalists showed that we improved length of stay for children, that we have better adherence to guidelines and that we are rated more favorably than other non-hospitalist models by trainees amongst other advantages. This early literature drove much of the growth and support for PHM. However, subsequent publications have actually contradicted or at least questioned just about all of these early assertions. So why on earth would I like this? Because it teaches us humility. The question of whether we improve the care of hospitalized children is still an open question and we need to be continuously striving to prove this and not simply rest on our laurels and assume we do. It is in the DNA of pediatric hospitalists to question things and questioning our own worth should not be an exemption. As I said during that conference: “What is more “hospitalist” than a hospitalist criticizing hospitalists at a hospitalist conference?”
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
My two cents are that we need to continuously re-examine our practice. There are no unquestionable practices in medicine. We should abolish the term “standard of care,” a term all too often abused in our field and simply call it “current practice.” The standard of care is often and all too frequently reversed and when we question it we are benefiting our discipline and our patients. Let’s remember that most of what we do on a daily basis is NOT strongly supported by evidence and there is nothing wrong with wondering if there is a better way.
My primary interest is overuse, for which overdiagnosis plays an important role. Overuse can be loosely defined as the provision of health care in which a patient experiences no net benefit. Overuse is comprised of overtreatment and overdiagnosis. Overdiagnosis is when we accurately diagnose someone with a true illness/disease, but the patient experience no benefit from that diagnosis. The “net benefit” part is important because if a patient does not experience net benefit then one of two possible outcomes is possible: nothing happens or more likely the patient experiences net harm. The true expert in overdiagnosis is Eric Coon, he was the first author for our paper on this subject back in 2014 which you can find here.
One of the conditions we proposed as being overdiagnosed answers your question about what I find as the most frustrating example of overdiagnosis in PHM: hypoxia. It is shocking to me that since 1980 we hospitalize 300% more kids with bronchiolitis without there really being any change to the epidemiology of bronchiolitis. Kids are not sicker now then in 1980, bronchiolitis is not more prevalent, yet we hospitalize kids much more often. The more likely explanation for this is that we now diagnose more hypoxia. Since the 1980’s, the pulse oximeter has become much more ubiquitous and thus we are much more able to diagnose hypoxia. Yet we don’t really know what this means. Obviously, children with hypoxia who are also experiencing severe respiratory distress merit hospitalization. However, how many times do we hospitalize children with bronchiolitis simply because we find they are hypoxic? I would argue that in the setting of a child who is otherwise well (drinking well, minimal or no respiratory distress) a number on the pulse oximeter is meaningless on its own.
Once hospitalized, the pulse oximeter drives everything and we are stuck playing the game of going up and down on the oxygen until the patient is able to maintain a pulse oximeter reading at or above 90% for some unspecified, arbitrary amount of time. We know kids even managed as outpatients can be profoundly hypoxic. We know that pulse oximeter readings drive admissions and we know that once hospitalized pulse oximetry drives length of stay. And yet we have no evidence that this monumental shift in practice has let to any patient benefit. So, we have dubious patient benefit, accurate diagnosis and net harm, this equals overdiagnosis. Hypoxia in bronchiolitis is to me the most egregious and frustrating example of overdiagnosis in pediatric hospital medicine. I believe the AAP’s bronchiolitis guideline recommendation to limit or avoid continuous pulse oximetry may go a long way towards reversing this trend.
2. You recently took over as the head of PHM at Texas Children’s Baylor College of Medicine. How do all of the new national developments in pediatric hospital medicine in the last year change your direction for the section?
I was very fortunate to take over as the leader of a group of vibrant, collegial and incredibly talented group of hospitalists. The Section of Pediatric Hospital Medicine at Texas Children’s Hospital is already a large, well established and successful group, however we need to be prepared for subspecialty status designation for PHM. This I think will drive what we prioritize within my Section/Division in the coming years. What this mean for me is that we need to increase, by a significant degree, the scholarly output of not just my Section, but PHM in general. A scholarly approach to all our clinical, QI, education and research efforts is essential.
Our new subspecialty fellows will require more and more experienced mentorship. While plenty of this mentorship can occur outside our section, there needs to be enough expertise within PHM to be able to handle the increased demand. We are far from reaching a critical mass of expertise within PHM and this expertise is desperately needed. We need to be seen as the experts in the care of the hospitalized child. This means leading the conversation in the clinical care of our most common inpatient conditions. This means publishing and developing new knowledge for the hospitalized child with asthma, bronchiolitis, pneumonia, Kawasaki’s disease etc. This means successfully competing for limited research dollars to develop this new knowledge. In many cases, we will overlap and/or compete with our subspecialty colleagues. This is inevitable, we need to be prepared.
3. You coauthored an article in Hospital Pediatrics in 2014 entitled, “Institutions and Individuals: What Makes a Hospitalist ‘Academic?’” What was the motivation behind this article?
Ah, this was the brainchild of the ever wise Dr. Ken Roberts. This opinion piece was simply an effort to clarify that “academic” should be a word that is used not to differentiate practice sites, but to describe what we do. It is a clarification that scholarly output can and does occur everywhere both at university affiliated and non-affiliated hospitals, at free standing children’s hospitals or children’s hospitals within a larger general hospital. An “academic” or scholarly approach to work is all that is needed to describe your practice as academic. A testament to this is the work of the Value in Inpatient Pedatrics (VIP). Through a series of projects and publications, VIP has demonstrated that a scholarly approach to practice not only does occur at community sites but often change can be more streamlined and sustained at these sites than our typical “academic” tertiary or quaternary care sites. In the paraphrased words of Forrest Gump, “Academic is as academic does.”
4. For those of us keeping track on the listserve, you have been an avid supporter of oral antibiotics for osteomyelitis. Time to put your money where your mouth is: how long do you typically leave patients on IV antibiotics for osteomyelitis and what criteria do you use for transition. Are there any exceptions to this rule?
My criteria for discharge on oral antibiotics for any infection is simple: an improving patient. This can mean improving clinical or both clinical and laboratory criteria (such as inflammatory markers). I don’t have many exceptions to this rule with perhaps the only one being an inability to take or absorb oral medications.
Now that is my criteria, but the reality that we grapple with as hospitalists is that our lack of an outpatient presence means we often co-manage these patients with subspecialists such as our infectious disease or orthopedic colleagues, who may have different opinions or tolerance from ours. This is just a reality of our practice and negotiating on behalf of the patient is a skill that is of critical importance to an experienced hospitalist.
I think in light of recent better quality evidence, practice is changing significantly and even die-hard defenders of intravenous antibiotics for osteomyelitis are starting to see the light. I even see the day in which a select group of patients with osteomyelitis are sent home from the clinic or ER with oral antibiotics.
Imagine that!
5. You have been at 2 institutions with pediatric hospital medicine fellowships. There are still many skeptics out there about the need for fellowship. What are your thoughts on this?
Well now that PHM subspecialty status is a forgone conclusion, PHM fellowships are obviously here to stay. However, I actually don’t think that a fellowship is needed to be a good hospitalist or even a successful academician in hospital medicine. So it is not “needed” but it sure doesn’t hurt.
As the leader of now 2 pediatric hospital medicine groups I have seen many people start their career fresh out of residency, and in fact, I was one of them. What I know almost for sure is that it takes about 2 years for someone who is not fellowship trained to truly be completely comfortable with the clinical side of their work. It probably takes another 1 to 2 years after that for that same person to get going in the scholarly part of their work and even then extra training in quality, research or education is almost certainly needed. Fellowship simply accelerates this trajectory. Fellowship provides a “protected” environment to develop these skills and I have no doubt that a fellowship trained hospitalist is simply better prepared for the transition from trainee to practicing clinician.
Atul Gawande wrote in the New Yorker about the lack of “apprenticeship” model in medicine that is widely used in many other industries. He famously used the Cheese Cake Factory as an example of how physicians could benefit from this model. Even in the best possible scenario, it is impossible for someone fresh out of residency to have the level of scrutiny of their work that a fellow gets. In most jobs, someone fresh out of residency is expected to perform, in their very first day, just like a seasoned hospitalist. How crazy is that? Essentially fellowship provides a protected, mentored apprenticeship into hospital medicine. It is not for everyone, but it enhances both the individual and the program. There is no doubt in my mind that a hospitalist is made better by a fellowship and a fellowship program makes a hospitalists group better in return.
6. You participated in an entertaining debate on pediatric dogmas at PHM 2016. What is your favorite (or least favorite) dogma and why?
One of my favorite dogmas was presented at that same meeting by Dan Coghlin from Hasbro Children’s. His was one that we chose as the listserve-solicited dogma and it was about the dogma that hospitalists universally improve the care of hospitalized children. Dan showed evidence for and against this notion. Early literature on pediatric hospitalists showed that we improved length of stay for children, that we have better adherence to guidelines and that we are rated more favorably than other non-hospitalist models by trainees amongst other advantages. This early literature drove much of the growth and support for PHM. However, subsequent publications have actually contradicted or at least questioned just about all of these early assertions. So why on earth would I like this? Because it teaches us humility. The question of whether we improve the care of hospitalized children is still an open question and we need to be continuously striving to prove this and not simply rest on our laurels and assume we do. It is in the DNA of pediatric hospitalists to question things and questioning our own worth should not be an exemption. As I said during that conference: “What is more “hospitalist” than a hospitalist criticizing hospitalists at a hospitalist conference?”
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
My two cents are that we need to continuously re-examine our practice. There are no unquestionable practices in medicine. We should abolish the term “standard of care,” a term all too often abused in our field and simply call it “current practice.” The standard of care is often and all too frequently reversed and when we question it we are benefiting our discipline and our patients. Let’s remember that most of what we do on a daily basis is NOT strongly supported by evidence and there is nothing wrong with wondering if there is a better way.