Ryan Bode
1. You have been active nationally in the PHM Strategic Planning and Board Certification Committees and the movement towards becoming a board recognized specialty. What challenges do you think the field will face in the next 2-3 years and what are the key steps to overcoming these?
What an exciting time to be a Pediatric Hospitalist! To experience the progression of the discipline from initially being defined to now seeing it recognized as the next board certified specialty. I originally got involved as part of the Strategic Planning (“STP”) Committee put forth by the AAP SOHM, APA and SOHM. I volunteered to co-chair the “Residency Track” as one of the options for specific training or certification as we explored the various considerations for the future of our field (Maloney et al doi:10.1542/hpeds.2012-0048). I was then invited to continue on the PHM Board Certification Committee – I think because I wasn’t convinced board certification was the best option. As the debate ensued at one of the committee meetings in North Carolina, Dr. Erin Stucky Fisher framed the discussion with us focusing on two questions:
I have been fortunate to be a part of bringing a fellowship to my former institution, Phoenix Children’s Hospital, and now after relocating, we are starting our program at Nationwide Children's Hospital this coming July. We were excited to recently find out that we matched our first fellow to start in 2018. I was looking thru the National Resident Matching Program (NRMP) pediatric specialties fall match data – 72% of specialty fellowship programs and 83% of fellowship positions filled. How about pediatric hospital medicine? 94% of programs and 96% of our fellowship positions filled!! Only pediatric emergency medicine filled at a higher success rate. Yet, I still see this as our biggest potential challenge to watch closely as our number of programs and positions increases over the next 2-5 years. Will the number of graduating residents pursuing pediatric hospital medicine fellowship increase accordingly? Will the future of our field see the value in completing a fellowship? We define value in clinical medicine as quality/cost – I would use the same formula as we critically look at fellowship training and our future workforce and leaders. Not only are we advancing the care of hospitalized children, but are we advancing our fellows and each other – clinical expertise, teaching/quality improvement/research/leadership skills development, and mentorship? Are we successfully advocating for sustainable and balanced FTE definitions and subspecialty designee compensation? Graduating residents and future fellows will vote with their feet – and so far, the trend is promising.
2. Your research interest is in comparative effectiveness and the use of clinical pathways to improve outcomes and decrease care variation. What condition do you think currently has the most care variation? Are there any pediatric hospital medicine conditions that do not routinely have clinical pathways, but should?
There has been tremendous work in our field on advancing this knowledge. I think we have done a good job targeting high volume diagnoses demonstrating high variability in resource utilization and outcomes across (mainly) free standing children’s hospitals using the Pediatric Health Information System (PHIS) database. National collaborative projects such as the AAP Quality Improvement Innovation Networks (QuIIN) and Value in Inpatient Pediatrics (VIP) (https://www.aap.org/en-us/professional-resources/quality-improvement/Quality-Improvement-Innovation-Networks/Value-in-Inpatient-Pediatrics-Network/Pages/Value-in-Inpatient-Pediatrics-Network.aspx) have taken the next step in taking action on this variation and working across all types of hospitals that take care of children to improve quality and decrease cost. Emerging literature has demonstrated the impact of clinical pathways on decreasing length of stay and costs of these common conditions – particular those with clear evidence basis/national guidelines to guide the care (Lion et al doi: 10.1542/peds.2015-1202). Bronchiolitis, asthma, community acquired pneumonia, urinary tract infections – we may not have it 100% perfect but there has been significant progress and we are clearly headed the right direction.
Our next challenge is to create the evidence to enable additional clinical pathways. There is insufficient evidence and national guidelines on the management of hospitalized children with failure to thrive, constipation, headache/migraine, and pancreatitis – to name a few. As such, I would bet there is considerable variation in resource utilization and health care expenditure amongst these conditions. But before we can create pathways, we need better evidence.
3. You are a member of the PREP hospital medicine board that is tasked with writing questions to prepare all of us for the PHM boards. Tell us more about what that entails and what resources it will provide to those nervous about the exam.
Yes, thanks for asking – very exciting – “Written for pediatric hospitalists by pediatric hospitalists!” We got a bit ahead of ourselves as we formed the initial advisory board back in 2012 – took a few years hiatus as the timing was not quite right but have been full steam ahead over the past 18 months. In essence, each member of the board authors one question and critique per month. We get together every 6 months at the AAP headquarters in Chicago and for 2 days straight peer review the questions – I think we got thru over 60 questions and critiques at the last meeting. A true labor of love – it has been very rewarding getting to know such a talented and committed group of colleagues from across the country. I really hope people use the product and find it educational, relevant and dare I say fun (-ish).
Trial a few questions for free and then hopefully get your subscription today (https://shop.aap.org/2018-prep-hospital-medicine/)! The first set of 30 questions comes out this month. As an added benefit, access to PREP HM will be free for all of our fellows.
4. You were senior author on a Hospital Pediatrics article published in June 2017, entitled “Hospital-Level Variation in Practice Patterns and Patient Outcomes for Pediatric Patients Hospitalized With Functional Constipation.” The study looked at practice variation and patient outcomes for the hospital management of functional constipation in US children’s hospitals. Explain how this article should impact our practice and what the takeaway message should be.
Not surprisingly, our work showed that there is significant variation in hospitalization rates, therapies used, length of stay, and 90-day readmission rates for functional constipation. My real conclusion was “How is it possible that over 21,000 children over a 3 year period required hospitalization to a U.S. free standing children’s hospital for constipation!?” What I hope people take away is what we did in Phoenix – collected our own data, got thru the stages of “data grief” (denial, anger, bargaining, depression and acceptance) and then resolved to improve the care of these patients. We developed cohesive outpatient, ED and inpatient pathways with the primary goal being decreased hospitalizations in addition to standardization of care. We need to challenge ourselves to look beyond the walls of the hospital. This includes expanding clinical pathways across the continuum of care.
5. You joined Nationwide Children’s Hospital in October 2016 as the Chief of Hospital Pediatrics. What advice do you give to those individuals who change programs and start in a leadership position for smoothing out that transition?
Spend time developing relationships and getting to know your team – before introducing potential change. For someone with a clear vision, drive and a lot of impatience (like myself), that can be a real challenge. It has been an incredible growth experience for me professionally having completed my residency and entire faculty career at one place in Phoenix prior to the move to Columbus. Different culture, executive leadership team styles, historical and political contexts, and even clinical practice patterns. And a little less sun and warmth, but proximity to all of our family and the Ohio State Buckeyes! You can learn a lot about yourself by considering a change and even more by interviewing for a different institution. But be careful – you might end up actually following thru with it and finding yourself moving across the country!
6. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Ask the tough questions. Don’t be afraid to bring a little disruption to the status quo or conventional wisdom. A lot of innovation and quality improvement has come out of a questioning attitude.
What an exciting time to be a Pediatric Hospitalist! To experience the progression of the discipline from initially being defined to now seeing it recognized as the next board certified specialty. I originally got involved as part of the Strategic Planning (“STP”) Committee put forth by the AAP SOHM, APA and SOHM. I volunteered to co-chair the “Residency Track” as one of the options for specific training or certification as we explored the various considerations for the future of our field (Maloney et al doi:10.1542/hpeds.2012-0048). I was then invited to continue on the PHM Board Certification Committee – I think because I wasn’t convinced board certification was the best option. As the debate ensued at one of the committee meetings in North Carolina, Dr. Erin Stucky Fisher framed the discussion with us focusing on two questions:
- What is the best way to improve the care of hospitalized children?
- What is the best way to ensure the public trust?
I have been fortunate to be a part of bringing a fellowship to my former institution, Phoenix Children’s Hospital, and now after relocating, we are starting our program at Nationwide Children's Hospital this coming July. We were excited to recently find out that we matched our first fellow to start in 2018. I was looking thru the National Resident Matching Program (NRMP) pediatric specialties fall match data – 72% of specialty fellowship programs and 83% of fellowship positions filled. How about pediatric hospital medicine? 94% of programs and 96% of our fellowship positions filled!! Only pediatric emergency medicine filled at a higher success rate. Yet, I still see this as our biggest potential challenge to watch closely as our number of programs and positions increases over the next 2-5 years. Will the number of graduating residents pursuing pediatric hospital medicine fellowship increase accordingly? Will the future of our field see the value in completing a fellowship? We define value in clinical medicine as quality/cost – I would use the same formula as we critically look at fellowship training and our future workforce and leaders. Not only are we advancing the care of hospitalized children, but are we advancing our fellows and each other – clinical expertise, teaching/quality improvement/research/leadership skills development, and mentorship? Are we successfully advocating for sustainable and balanced FTE definitions and subspecialty designee compensation? Graduating residents and future fellows will vote with their feet – and so far, the trend is promising.
2. Your research interest is in comparative effectiveness and the use of clinical pathways to improve outcomes and decrease care variation. What condition do you think currently has the most care variation? Are there any pediatric hospital medicine conditions that do not routinely have clinical pathways, but should?
There has been tremendous work in our field on advancing this knowledge. I think we have done a good job targeting high volume diagnoses demonstrating high variability in resource utilization and outcomes across (mainly) free standing children’s hospitals using the Pediatric Health Information System (PHIS) database. National collaborative projects such as the AAP Quality Improvement Innovation Networks (QuIIN) and Value in Inpatient Pediatrics (VIP) (https://www.aap.org/en-us/professional-resources/quality-improvement/Quality-Improvement-Innovation-Networks/Value-in-Inpatient-Pediatrics-Network/Pages/Value-in-Inpatient-Pediatrics-Network.aspx) have taken the next step in taking action on this variation and working across all types of hospitals that take care of children to improve quality and decrease cost. Emerging literature has demonstrated the impact of clinical pathways on decreasing length of stay and costs of these common conditions – particular those with clear evidence basis/national guidelines to guide the care (Lion et al doi: 10.1542/peds.2015-1202). Bronchiolitis, asthma, community acquired pneumonia, urinary tract infections – we may not have it 100% perfect but there has been significant progress and we are clearly headed the right direction.
Our next challenge is to create the evidence to enable additional clinical pathways. There is insufficient evidence and national guidelines on the management of hospitalized children with failure to thrive, constipation, headache/migraine, and pancreatitis – to name a few. As such, I would bet there is considerable variation in resource utilization and health care expenditure amongst these conditions. But before we can create pathways, we need better evidence.
3. You are a member of the PREP hospital medicine board that is tasked with writing questions to prepare all of us for the PHM boards. Tell us more about what that entails and what resources it will provide to those nervous about the exam.
Yes, thanks for asking – very exciting – “Written for pediatric hospitalists by pediatric hospitalists!” We got a bit ahead of ourselves as we formed the initial advisory board back in 2012 – took a few years hiatus as the timing was not quite right but have been full steam ahead over the past 18 months. In essence, each member of the board authors one question and critique per month. We get together every 6 months at the AAP headquarters in Chicago and for 2 days straight peer review the questions – I think we got thru over 60 questions and critiques at the last meeting. A true labor of love – it has been very rewarding getting to know such a talented and committed group of colleagues from across the country. I really hope people use the product and find it educational, relevant and dare I say fun (-ish).
Trial a few questions for free and then hopefully get your subscription today (https://shop.aap.org/2018-prep-hospital-medicine/)! The first set of 30 questions comes out this month. As an added benefit, access to PREP HM will be free for all of our fellows.
4. You were senior author on a Hospital Pediatrics article published in June 2017, entitled “Hospital-Level Variation in Practice Patterns and Patient Outcomes for Pediatric Patients Hospitalized With Functional Constipation.” The study looked at practice variation and patient outcomes for the hospital management of functional constipation in US children’s hospitals. Explain how this article should impact our practice and what the takeaway message should be.
Not surprisingly, our work showed that there is significant variation in hospitalization rates, therapies used, length of stay, and 90-day readmission rates for functional constipation. My real conclusion was “How is it possible that over 21,000 children over a 3 year period required hospitalization to a U.S. free standing children’s hospital for constipation!?” What I hope people take away is what we did in Phoenix – collected our own data, got thru the stages of “data grief” (denial, anger, bargaining, depression and acceptance) and then resolved to improve the care of these patients. We developed cohesive outpatient, ED and inpatient pathways with the primary goal being decreased hospitalizations in addition to standardization of care. We need to challenge ourselves to look beyond the walls of the hospital. This includes expanding clinical pathways across the continuum of care.
5. You joined Nationwide Children’s Hospital in October 2016 as the Chief of Hospital Pediatrics. What advice do you give to those individuals who change programs and start in a leadership position for smoothing out that transition?
Spend time developing relationships and getting to know your team – before introducing potential change. For someone with a clear vision, drive and a lot of impatience (like myself), that can be a real challenge. It has been an incredible growth experience for me professionally having completed my residency and entire faculty career at one place in Phoenix prior to the move to Columbus. Different culture, executive leadership team styles, historical and political contexts, and even clinical practice patterns. And a little less sun and warmth, but proximity to all of our family and the Ohio State Buckeyes! You can learn a lot about yourself by considering a change and even more by interviewing for a different institution. But be careful – you might end up actually following thru with it and finding yourself moving across the country!
6. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Ask the tough questions. Don’t be afraid to bring a little disruption to the status quo or conventional wisdom. A lot of innovation and quality improvement has come out of a questioning attitude.