- Russell McCulloh
1. You are trained in internal medicine-pediatrics and infectious disease—how does that training help you in your day-to-day work?
I firmly believe Med-Peds training is some of the best training a hospitalist could get. Hospitalists as a profession were born in Internal Medicine and many of the principles that we apply in Pediatric Hospital Medicine were first learned in the adult arena. Additionally, with the ever-increasing complexity of children we care for in the inpatient setting being familiar with the issues of polypharmacy and multiple medical complex conditions in the same patient that you naturally get from internal medicine training translated well into PHM. As for ID training ...I joke with my colleagues that 80% of pediatrics in some way has something to do with infectious diseases, so the training gives me some beneficial content expertise. I also think the in-depth differential diagnosis and medical decision-making you have to do in ID fits really well in PHM. My hero in PHM as a resident was an ID doc as well, so I am biased (you'll never guess who she is but she is awesome).
2. Your commentary in Hospital Pediatrics titled “Extending Antimicrobial Stewardship to All Hospitalized Children: The Time is Now” (September 2017) stated that “up to half of [antibiotic prescriptions] are inappropriately prescribed or completely unnecessary.” How do you teach antibiotic stewardship? Any practical tips for pediatric hospitalists to practice better antibiotic stewardship?
This topic is on my mind a lot as we are currently running a Value in Inpatient Pediatrics project focused on antibiotic stewardship. One of the most fundamental things you can do as a hospitalist is to get familiar with your institution's antibiogram. Studies show that pediatricians make better antibiotic choices when they look at antibiograms, even in places where the antibiogram may not be pediatric-specific. The other big way is to get to know your antimicrobial stewardship team. In smaller places they will need you to provide the pediatric perspective to complement their ID and pharmacy training. In bigger places they need you to help make change happen. In both cases you can learn a ton just through the communication.
3. You published “Feasible Strategies for Sustaining Guideline Adherence: Cross-sectional Analysis of a National Collaborative” in Hospital Pediatrics in November 2019. One of your findings was that order sets were feasible long-term and use increased after a lag time for implementation. Many of us see the time delay in getting new order sets created and into the EMR—have you found any tricks for speeding up the process or other ways to improve guideline adherence?
Every place I've worked we have had at least one hospitalist who works part time with IT. I think it's a natural fit for a hospitalist to be a clinical champion with IT. That connection helps smooth the way for the hospitalist team to get order sets deployed quickly and can also help other specialties do the same thing. One of the most effective other ways to improve adherence is audit and feedback. Groups that examine their own practice learn from what they do and tend to standardize their practice more. Introspection can be key to improving adherence.
4. In Pediatric Hospital Medicine, we are always looking for a test that will predict if a febrile infant < 60 days has an invasive bacterial infection and which infants need a lumbar puncture. You have published multiple articles looking at infant sepsis evaluation and a prediction tool. What is your approach to an infant < 60 days who presents with a fever? What factors affect your decision to perform a lumbar puncture?
Febrile infants are a humbling challenge for pediatricians, and one that requires you to both assess and communicate risk in a way that is understandable and not too frightening to parents. I am really optimistic that with the new AAP guidelines coming out that hospitalists will have more tools in their toolbox to help assess risk. Newer risk stratification schemes like the PECARN rules may help further expand the proportion of infants who can be safely observed without undergoing lumbar puncture. Nonetheless, for infants under a month of age they least often read the book and generally I think they need to undergo LP. Older infants when you look at the data definitely can benefit from using a risk-based approach when they aren't ill appearing. For those kids I try to engage families in shared decision-making, keeping in mind that, even when we do our job at our best parents are often scared that their baby may be at risk of severe illness or even death.
5. You have studied intermittent vs. continuous pulse oximetry in bronchiolitis, and the AAP guidelines now discourage using continuous pulse oximetry. What is the next change in management of bronchiolitis that you would like to see?
Oh, so many changes! First off, I'd like to see heated high flow use refined and narrowed to those most likely to benefit. The other big question in my mind is how children who have non-RSV bronchiolitis may be different from those with bronchiolitis due to RSV. Every hospitalist can tell a story of how a treatment that we know generally doesn't work in bronchiolitis worked for this one kid. I think that's because we do a lot of lumping without knowing what these kids really have in terms of their infection and we don't know what common characteristics those few who benefit from bronchodilators or other treatments have that we need to recognize.
6. Dr. Mo Shukry presented at Grand Rounds at Children’s Hospital and Medical Center in Omaha in February 2020, and you tweeted “avoiding passion #burnout” and “as my wife says get a hobby!” What are some of your hobbies? What do you do to avoid burnout?
I love to hike with my kids. Even the four-year-old gets into it. Hiking also turns out to be a great pandemic activity and gets you out of the house. We've been going year round and have enjoyed every season this past year! I also love to bike, and, to my wife's dismay, I love video games too!
7. In the Journal of the American Medical Informatics Association (JAMIA) last year, you published an article, “Estimating the impact of deploying an electronic clinical decision support tool as part of a national practice improvement project.” Can you tell us more about the tool and your results?
We developed a stepwise decision aid that helped people decide what workup they wanted to do for febrile infant evaluations. The tool, entitled PedsGuide and still freely available for download, was deployed as part of the VIP Reducing Excessive Variation in the Infant Sepsis Evaluation (REVISE) project. PedsGuide and order sets were two of the tools people identified as still being used after project completion. For REVISE we learned that sites in regions that had more use of the tool had more desired change in project benchmarks. This meant that our tool was associated with providers making better treatment decisions, which really is the point. The nice thing is that the tool didn't rely on the electronic health record, so we could deploy it to all sorts of sites regardless of their IT resources.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
When I was a student I took half my core rotations in rural Missouri, one of the best experiences of my life. A private practice dermatologist there taught me something as a med student I tell learners all the time. As a physician you should do three things professionally: (1) teach others your craft; (2) be active in your professional society; and (3) contribute new knowledge to the care of your patients. I've always thought that if he could do that as a private doc in a rural town, then everyone can. My other two cents? We need to be good to our community hospitalist colleagues, especially those working in small sites and rural areas. They need our support, now more than ever.
I firmly believe Med-Peds training is some of the best training a hospitalist could get. Hospitalists as a profession were born in Internal Medicine and many of the principles that we apply in Pediatric Hospital Medicine were first learned in the adult arena. Additionally, with the ever-increasing complexity of children we care for in the inpatient setting being familiar with the issues of polypharmacy and multiple medical complex conditions in the same patient that you naturally get from internal medicine training translated well into PHM. As for ID training ...I joke with my colleagues that 80% of pediatrics in some way has something to do with infectious diseases, so the training gives me some beneficial content expertise. I also think the in-depth differential diagnosis and medical decision-making you have to do in ID fits really well in PHM. My hero in PHM as a resident was an ID doc as well, so I am biased (you'll never guess who she is but she is awesome).
2. Your commentary in Hospital Pediatrics titled “Extending Antimicrobial Stewardship to All Hospitalized Children: The Time is Now” (September 2017) stated that “up to half of [antibiotic prescriptions] are inappropriately prescribed or completely unnecessary.” How do you teach antibiotic stewardship? Any practical tips for pediatric hospitalists to practice better antibiotic stewardship?
This topic is on my mind a lot as we are currently running a Value in Inpatient Pediatrics project focused on antibiotic stewardship. One of the most fundamental things you can do as a hospitalist is to get familiar with your institution's antibiogram. Studies show that pediatricians make better antibiotic choices when they look at antibiograms, even in places where the antibiogram may not be pediatric-specific. The other big way is to get to know your antimicrobial stewardship team. In smaller places they will need you to provide the pediatric perspective to complement their ID and pharmacy training. In bigger places they need you to help make change happen. In both cases you can learn a ton just through the communication.
3. You published “Feasible Strategies for Sustaining Guideline Adherence: Cross-sectional Analysis of a National Collaborative” in Hospital Pediatrics in November 2019. One of your findings was that order sets were feasible long-term and use increased after a lag time for implementation. Many of us see the time delay in getting new order sets created and into the EMR—have you found any tricks for speeding up the process or other ways to improve guideline adherence?
Every place I've worked we have had at least one hospitalist who works part time with IT. I think it's a natural fit for a hospitalist to be a clinical champion with IT. That connection helps smooth the way for the hospitalist team to get order sets deployed quickly and can also help other specialties do the same thing. One of the most effective other ways to improve adherence is audit and feedback. Groups that examine their own practice learn from what they do and tend to standardize their practice more. Introspection can be key to improving adherence.
4. In Pediatric Hospital Medicine, we are always looking for a test that will predict if a febrile infant < 60 days has an invasive bacterial infection and which infants need a lumbar puncture. You have published multiple articles looking at infant sepsis evaluation and a prediction tool. What is your approach to an infant < 60 days who presents with a fever? What factors affect your decision to perform a lumbar puncture?
Febrile infants are a humbling challenge for pediatricians, and one that requires you to both assess and communicate risk in a way that is understandable and not too frightening to parents. I am really optimistic that with the new AAP guidelines coming out that hospitalists will have more tools in their toolbox to help assess risk. Newer risk stratification schemes like the PECARN rules may help further expand the proportion of infants who can be safely observed without undergoing lumbar puncture. Nonetheless, for infants under a month of age they least often read the book and generally I think they need to undergo LP. Older infants when you look at the data definitely can benefit from using a risk-based approach when they aren't ill appearing. For those kids I try to engage families in shared decision-making, keeping in mind that, even when we do our job at our best parents are often scared that their baby may be at risk of severe illness or even death.
5. You have studied intermittent vs. continuous pulse oximetry in bronchiolitis, and the AAP guidelines now discourage using continuous pulse oximetry. What is the next change in management of bronchiolitis that you would like to see?
Oh, so many changes! First off, I'd like to see heated high flow use refined and narrowed to those most likely to benefit. The other big question in my mind is how children who have non-RSV bronchiolitis may be different from those with bronchiolitis due to RSV. Every hospitalist can tell a story of how a treatment that we know generally doesn't work in bronchiolitis worked for this one kid. I think that's because we do a lot of lumping without knowing what these kids really have in terms of their infection and we don't know what common characteristics those few who benefit from bronchodilators or other treatments have that we need to recognize.
6. Dr. Mo Shukry presented at Grand Rounds at Children’s Hospital and Medical Center in Omaha in February 2020, and you tweeted “avoiding passion #burnout” and “as my wife says get a hobby!” What are some of your hobbies? What do you do to avoid burnout?
I love to hike with my kids. Even the four-year-old gets into it. Hiking also turns out to be a great pandemic activity and gets you out of the house. We've been going year round and have enjoyed every season this past year! I also love to bike, and, to my wife's dismay, I love video games too!
7. In the Journal of the American Medical Informatics Association (JAMIA) last year, you published an article, “Estimating the impact of deploying an electronic clinical decision support tool as part of a national practice improvement project.” Can you tell us more about the tool and your results?
We developed a stepwise decision aid that helped people decide what workup they wanted to do for febrile infant evaluations. The tool, entitled PedsGuide and still freely available for download, was deployed as part of the VIP Reducing Excessive Variation in the Infant Sepsis Evaluation (REVISE) project. PedsGuide and order sets were two of the tools people identified as still being used after project completion. For REVISE we learned that sites in regions that had more use of the tool had more desired change in project benchmarks. This meant that our tool was associated with providers making better treatment decisions, which really is the point. The nice thing is that the tool didn't rely on the electronic health record, so we could deploy it to all sorts of sites regardless of their IT resources.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
When I was a student I took half my core rotations in rural Missouri, one of the best experiences of my life. A private practice dermatologist there taught me something as a med student I tell learners all the time. As a physician you should do three things professionally: (1) teach others your craft; (2) be active in your professional society; and (3) contribute new knowledge to the care of your patients. I've always thought that if he could do that as a private doc in a rural town, then everyone can. My other two cents? We need to be good to our community hospitalist colleagues, especially those working in small sites and rural areas. They need our support, now more than ever.