Shawn Ralston
1. Bronchiolitis – you have dedicated a lot of thought and research towards this topic. If you got to wave a magic wand and change one thing about bronchiolitis care across North America, what would it be?
Hands down, it would be our use of pulse oximetry. Certainly, pulse oximetry is a really cool technology and has improved health care in many tangible ways…..just not for bronchiolitis. I feel like hospitalists and ED physicians have become prisoners to the pulse oximeter. We let that one little number drive our clinical behavior in a frighteningly exclusive fashion. We know that we are hospitalizing many, many more patients with bronchiolitis over the past few decades. In looking for reasons for the increased hospitalization rates, people have speculated about increased survival of children with significant prematurity and medical complexity as drivers. While the “sicker kids” phenomenon is incontrovertible at this point, I do not think that it can possibly explain the magnitude of the change, and personally I have little doubt that a major driver of the volume of admissions is the pulse oximeter. Mortality has remained the same or decreased, LOS has decreased dramatically and morbidity has mostly decreased, and all without any effective therapies having emerged…..so, the evidence supports the idea that we are probably hospitalizing less sick children at higher rates, along with the known increase in medically complex children. And, finally, the recent literature supports the idea that the pulse oximeter is driving our behavior as well (particularly Suzanne Schuh’s brilliant ED study, which may be my all-time favorite piece of clinical research). So, in honor of that study, I would use my magic wand to surreptitiously make the pulse oximeter read a few points higher than reality in bronchiolitis.
2. You have an interest in reducing unnecessary care and this is reflected in your presentations and articles. What do you think is currently the most frustrating example of unnecessary care in pediatric hospital medicine?
This is a tough one, because I don’t think I can narrow the issue to a single disease example. I think the chief problem with unnecessary care is actually measuring it. Most of the care that might be characterized as unnecessary is almost completely invisible in our current quality measurement framework. So much of medicine is discretionary, meaning that a reasonable individual might choose one of several courses. Almost nothing is binary, e.g. always right or always wrong. Yet, very few would argue that everything we do is truly necessary? Personally, I’m willing to give you half of what I do as unnecessary on most days. What concerns me most is care that is potentially unnecessary AND that harms the patient, and the fact that we don’t really consider such events preventable in the same ways as, say, CLABSIs. Let me try to give you an example. I recently came on service and one of the patients was a child at the end of a long hospital stay where she’d received what I considered to be an overly prolonged and overly broad spectrum course of intravenous antibiotics for complicated pneumonia. The patient had already suffered a PICC line associated clot as well as C. diff colitis by the time I met her and my contribution was to spend several days arguing with an insurer over specialty pharmacy benefits for home anticoagulation before I could finally allow this exhausted and stir-crazy family to leave the hospital. There is essentially no literature to support the absolute necessity of the clinical management that led to those complications (though plenty of expert opinion) and a good amount of comparative effectiveness research to suggest other management strategies are reasonable, if not preferable. Yet, the harm the patient experienced is simply chalked up as a known side effect of a “necessary” therapy. I find that state of affairs to be completely unacceptable and I actually see it as a form of tragedy that neither complication was examined as potentially preventable. Too bad she didn’t have a catheter associated UTI or a fall, then it might have attracted some attention.
3. As the editor of Hospital Pediatrics, you have your finger on the pulse of publications in our field. What recommendations do you have for young pediatric hospitalists looking to publish their research? What articles do you find most exciting?
Ok, I am terrible at giving advice. I spent too much time as a graduate student in the humanities, so I can talk myself into and out of an idea in a matter of 5 minutes. Plus, I never took any of the good advice given to me and though I may regret that fact, I am not sure how it could have gone any other way. Like a lot of people, I learn the most enduring lessons by getting things wrong. So, I guess, my advice is this: when you make mistakes, don’t regret them too much. Academic life contains a lot of mistakes and rejection - so cultivate resiliency. Frankly, I haven’t the slightest idea what I mean by “cultivate resiliency.” Maybe learn the words to “Let It Go.”
What articles do I find most exciting? I like most everything pediatric hospitalists are doing right now, but there is simply no substitute for randomization. The things that excites me most are hospitalist-led clinical trials. Pardon me for making everything about bronchiolitis, but the hypertonic saline trials headed up by Susan Wu and Alyssa Silver are great examples of hospitalist RCTs. Sure, these were enormous undertakings, but they were also enormous contributions to our clinical knowledge base.
4. In your JAMA Pediatrics article “Doing More vs Doing Good,” you talk about the idea of parsimonious care, defined as “care that utilizes the most efficient means to effectively diagnose a condition and treat a patient.” For those of us with a small vocabulary, can you expand/explain what you mean by this?
You’ve asked me about one of my favorite ideas, so thank you. I took the word from the American College of Physicians ethics manual because it defines parsimony as the ethical stance in medicine and I was just very excited by that idea. In this case, parsimony is the idea that if you can get there in fewer steps than me, then you are better at the job. Parsimonious care is the opposite of wasteful (I was going to say profligate but it felt like too many “p”s ). Parsimony has intellectual, ethical and financial implications all rolled up in the word and the reason I care so much about it is that I think it is part of what makes a person a good doctor. I believe there is something inherently true in the assertion that a good doctor is one who arrives at the diagnosis using fewer steps or fewer resources.
5. At a prior PHM meeting, you gave a talk aimed at women and discussed the gender bias in medicine. A recent study shows male physicians are introduced by the title of “doctor” 95% of the time compared to 49% of female physicians. As a female and leader in PHM, how do you handle those situations and what advice do you have for female colleagues?
When this happens to me, and quite frankly I am still sometimes mistaken for the nurse while my intern is addressed as “doctor” because he happens to be the only guy in the group (especially if he happens to be tall), I try to remember one thing: don’t take it personally. I absolutely believe that women have to work harder for the same results, and I am committed to doing anything I might be able to do to mitigate that fact; however, I also think it’s fairly rare for people to be actively intending to express bias in their behavior. Many, if not most, biases are unconscious. That fact does not excuse bias at all, but it does inform how I respond to it on an interprersonal basis. My natural tendency in most uncomfortable situations is to rip the band-aid off quickly. So when I am greeted as the nurse, I might say, “nope, I’m the doctor and the boss of this large team gathered here, including this very tall young man who is my intern….” I often use the word “boss” very intentionally in such a situation to make a clear point that I am comfortable in a position of authority. Honestly, I started doing this at a point when the word “boss” actually did make me a little uncomfortable. Bias throws us off because it disturbs our sense that we belong, so what works for me is to try to establish that I am in my comfort zone (or faking it well). And, lest anybody interpret what I just said as me implying that the onus in handling gender bias should fall on women, that is not at all what I intend. I am sharing what works for me in a purely practical sense, which is very different than what I might suggest as a global solution to the societal problem of gender bias. Frankly, that would be equal pay for equal work. My own solution to that systemic problem is to knock off an hour and a half early every day since women are paid 20% less than men at the same rank in medicine.
6. On the listserv and at PHM presentations, you have described yourself as “vocal” and “outspoken.” What advice do you have for other extroverts on when to speak up and when to stay quiet?
Oh my, what a great question. I really should shut up more, but I tend to care a lot about certain things and I simply can’t control my general enthusiasm for a good argument. If I am engaged in the discussion it is simply because I really do care about the topic. I don’t mind disagreements because I believe that if we were all compelled to politely agree about everything all the time, we would settle on the lowest common denominator. So, honestly, I’m not sure there is much point in fighting your inherent tendencies, though you do have to learn to live with the consequences of those tendencies which may not include universal public approval.
Oh, and by the way, I am a total introvert. I took the Myers-Briggs as a medical student and I scored as a solid introvert. Though, now, I have to say that the Myers-Briggs is a completely made-up load of hooey, and so I’m probably not an introvert after all.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Hmmm, I’ve gotten this far without any mention of skepticism, another favorite topic, so let’s do that. I think we get away with misattributions of causality all the time in medicine. Its our faulty wiring causing us to believe we make things happen. And so, I am continually skeptical of the layers and layers of activity that we are adding to our hospital systems in the name of quality or patient safety. It can’t be true that everything we do works. I think we have taken a very deterministic approach to most problems and that our systems are actually complex and outcomes are not easily predicted. Sometimes you can add extra layers to a process, and though each layer can have a logical association with “safer” or “better” care, when taken together in the chaos of daily practice they change the system in unanticipated ways that can make care worse. I see this happen on a regular basis in my clinical practice and I worry that our current approach to problem solving is so focused on adding layers and steps that we often lose sight of what we might strip away to make care better. Finally, I also think we’ve failed to process just how important statistics are in combatting the natural human tendency to misattribute causality, or to remember the last disaster. I am reminded of Jay Berry’s absolutely brilliant paper on quality measurement from Pediatrics in August 2015 which pointed out that most pediatric facilities don’t have the volume to detect a real difference in many of the outcomes we are reporting. I think of that paper every month when I get the patient safety report and we are celebrating the success of our VAP or CLABSI interventions without anywhere near enough points in the denominator of ventilator or line days to determine true change. I realize that what I am saying is that our successes may not be true successes, and our failures may be random events, and that such an assertion is difficult to embrace…..but it might not be wrong. And - I am not suggesting that we stop working on quality or patient safety. I am just hoping that the next era of work on our practical problems in the hospital is both more nuanced and more skeptical.
Hands down, it would be our use of pulse oximetry. Certainly, pulse oximetry is a really cool technology and has improved health care in many tangible ways…..just not for bronchiolitis. I feel like hospitalists and ED physicians have become prisoners to the pulse oximeter. We let that one little number drive our clinical behavior in a frighteningly exclusive fashion. We know that we are hospitalizing many, many more patients with bronchiolitis over the past few decades. In looking for reasons for the increased hospitalization rates, people have speculated about increased survival of children with significant prematurity and medical complexity as drivers. While the “sicker kids” phenomenon is incontrovertible at this point, I do not think that it can possibly explain the magnitude of the change, and personally I have little doubt that a major driver of the volume of admissions is the pulse oximeter. Mortality has remained the same or decreased, LOS has decreased dramatically and morbidity has mostly decreased, and all without any effective therapies having emerged…..so, the evidence supports the idea that we are probably hospitalizing less sick children at higher rates, along with the known increase in medically complex children. And, finally, the recent literature supports the idea that the pulse oximeter is driving our behavior as well (particularly Suzanne Schuh’s brilliant ED study, which may be my all-time favorite piece of clinical research). So, in honor of that study, I would use my magic wand to surreptitiously make the pulse oximeter read a few points higher than reality in bronchiolitis.
2. You have an interest in reducing unnecessary care and this is reflected in your presentations and articles. What do you think is currently the most frustrating example of unnecessary care in pediatric hospital medicine?
This is a tough one, because I don’t think I can narrow the issue to a single disease example. I think the chief problem with unnecessary care is actually measuring it. Most of the care that might be characterized as unnecessary is almost completely invisible in our current quality measurement framework. So much of medicine is discretionary, meaning that a reasonable individual might choose one of several courses. Almost nothing is binary, e.g. always right or always wrong. Yet, very few would argue that everything we do is truly necessary? Personally, I’m willing to give you half of what I do as unnecessary on most days. What concerns me most is care that is potentially unnecessary AND that harms the patient, and the fact that we don’t really consider such events preventable in the same ways as, say, CLABSIs. Let me try to give you an example. I recently came on service and one of the patients was a child at the end of a long hospital stay where she’d received what I considered to be an overly prolonged and overly broad spectrum course of intravenous antibiotics for complicated pneumonia. The patient had already suffered a PICC line associated clot as well as C. diff colitis by the time I met her and my contribution was to spend several days arguing with an insurer over specialty pharmacy benefits for home anticoagulation before I could finally allow this exhausted and stir-crazy family to leave the hospital. There is essentially no literature to support the absolute necessity of the clinical management that led to those complications (though plenty of expert opinion) and a good amount of comparative effectiveness research to suggest other management strategies are reasonable, if not preferable. Yet, the harm the patient experienced is simply chalked up as a known side effect of a “necessary” therapy. I find that state of affairs to be completely unacceptable and I actually see it as a form of tragedy that neither complication was examined as potentially preventable. Too bad she didn’t have a catheter associated UTI or a fall, then it might have attracted some attention.
3. As the editor of Hospital Pediatrics, you have your finger on the pulse of publications in our field. What recommendations do you have for young pediatric hospitalists looking to publish their research? What articles do you find most exciting?
Ok, I am terrible at giving advice. I spent too much time as a graduate student in the humanities, so I can talk myself into and out of an idea in a matter of 5 minutes. Plus, I never took any of the good advice given to me and though I may regret that fact, I am not sure how it could have gone any other way. Like a lot of people, I learn the most enduring lessons by getting things wrong. So, I guess, my advice is this: when you make mistakes, don’t regret them too much. Academic life contains a lot of mistakes and rejection - so cultivate resiliency. Frankly, I haven’t the slightest idea what I mean by “cultivate resiliency.” Maybe learn the words to “Let It Go.”
What articles do I find most exciting? I like most everything pediatric hospitalists are doing right now, but there is simply no substitute for randomization. The things that excites me most are hospitalist-led clinical trials. Pardon me for making everything about bronchiolitis, but the hypertonic saline trials headed up by Susan Wu and Alyssa Silver are great examples of hospitalist RCTs. Sure, these were enormous undertakings, but they were also enormous contributions to our clinical knowledge base.
4. In your JAMA Pediatrics article “Doing More vs Doing Good,” you talk about the idea of parsimonious care, defined as “care that utilizes the most efficient means to effectively diagnose a condition and treat a patient.” For those of us with a small vocabulary, can you expand/explain what you mean by this?
You’ve asked me about one of my favorite ideas, so thank you. I took the word from the American College of Physicians ethics manual because it defines parsimony as the ethical stance in medicine and I was just very excited by that idea. In this case, parsimony is the idea that if you can get there in fewer steps than me, then you are better at the job. Parsimonious care is the opposite of wasteful (I was going to say profligate but it felt like too many “p”s ). Parsimony has intellectual, ethical and financial implications all rolled up in the word and the reason I care so much about it is that I think it is part of what makes a person a good doctor. I believe there is something inherently true in the assertion that a good doctor is one who arrives at the diagnosis using fewer steps or fewer resources.
5. At a prior PHM meeting, you gave a talk aimed at women and discussed the gender bias in medicine. A recent study shows male physicians are introduced by the title of “doctor” 95% of the time compared to 49% of female physicians. As a female and leader in PHM, how do you handle those situations and what advice do you have for female colleagues?
When this happens to me, and quite frankly I am still sometimes mistaken for the nurse while my intern is addressed as “doctor” because he happens to be the only guy in the group (especially if he happens to be tall), I try to remember one thing: don’t take it personally. I absolutely believe that women have to work harder for the same results, and I am committed to doing anything I might be able to do to mitigate that fact; however, I also think it’s fairly rare for people to be actively intending to express bias in their behavior. Many, if not most, biases are unconscious. That fact does not excuse bias at all, but it does inform how I respond to it on an interprersonal basis. My natural tendency in most uncomfortable situations is to rip the band-aid off quickly. So when I am greeted as the nurse, I might say, “nope, I’m the doctor and the boss of this large team gathered here, including this very tall young man who is my intern….” I often use the word “boss” very intentionally in such a situation to make a clear point that I am comfortable in a position of authority. Honestly, I started doing this at a point when the word “boss” actually did make me a little uncomfortable. Bias throws us off because it disturbs our sense that we belong, so what works for me is to try to establish that I am in my comfort zone (or faking it well). And, lest anybody interpret what I just said as me implying that the onus in handling gender bias should fall on women, that is not at all what I intend. I am sharing what works for me in a purely practical sense, which is very different than what I might suggest as a global solution to the societal problem of gender bias. Frankly, that would be equal pay for equal work. My own solution to that systemic problem is to knock off an hour and a half early every day since women are paid 20% less than men at the same rank in medicine.
6. On the listserv and at PHM presentations, you have described yourself as “vocal” and “outspoken.” What advice do you have for other extroverts on when to speak up and when to stay quiet?
Oh my, what a great question. I really should shut up more, but I tend to care a lot about certain things and I simply can’t control my general enthusiasm for a good argument. If I am engaged in the discussion it is simply because I really do care about the topic. I don’t mind disagreements because I believe that if we were all compelled to politely agree about everything all the time, we would settle on the lowest common denominator. So, honestly, I’m not sure there is much point in fighting your inherent tendencies, though you do have to learn to live with the consequences of those tendencies which may not include universal public approval.
Oh, and by the way, I am a total introvert. I took the Myers-Briggs as a medical student and I scored as a solid introvert. Though, now, I have to say that the Myers-Briggs is a completely made-up load of hooey, and so I’m probably not an introvert after all.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Hmmm, I’ve gotten this far without any mention of skepticism, another favorite topic, so let’s do that. I think we get away with misattributions of causality all the time in medicine. Its our faulty wiring causing us to believe we make things happen. And so, I am continually skeptical of the layers and layers of activity that we are adding to our hospital systems in the name of quality or patient safety. It can’t be true that everything we do works. I think we have taken a very deterministic approach to most problems and that our systems are actually complex and outcomes are not easily predicted. Sometimes you can add extra layers to a process, and though each layer can have a logical association with “safer” or “better” care, when taken together in the chaos of daily practice they change the system in unanticipated ways that can make care worse. I see this happen on a regular basis in my clinical practice and I worry that our current approach to problem solving is so focused on adding layers and steps that we often lose sight of what we might strip away to make care better. Finally, I also think we’ve failed to process just how important statistics are in combatting the natural human tendency to misattribute causality, or to remember the last disaster. I am reminded of Jay Berry’s absolutely brilliant paper on quality measurement from Pediatrics in August 2015 which pointed out that most pediatric facilities don’t have the volume to detect a real difference in many of the outcomes we are reporting. I think of that paper every month when I get the patient safety report and we are celebrating the success of our VAP or CLABSI interventions without anywhere near enough points in the denominator of ventilator or line days to determine true change. I realize that what I am saying is that our successes may not be true successes, and our failures may be random events, and that such an assertion is difficult to embrace…..but it might not be wrong. And - I am not suggesting that we stop working on quality or patient safety. I am just hoping that the next era of work on our practical problems in the hospital is both more nuanced and more skeptical.