Dr. Sunitha Kaiser
1. You have a master's degree in clinical epidemiology and health care research from the University of Toronto. How has this degree helped you in your career? For those looking to become more involved in epidemiology and health care research, can you suggest ways for young hospitalists to get their feet wet?
I was able to get my master’s during my PHM fellowship, and this training helped advance my career in a number of ways. I developed skills in designing and conducting different types of studies, learned how to excel as a physician scientist from talented mentors at Sick Kids Hospital in Toronto, and formulated plans for my future application for a career development award. So, this training laid the foundation for my current career as a health services researcher. One way for young hospitalists to explore this path is to search for others (preferably in their institutions) doing research projects and find an interesting one to collaborate on.
2. Congratulations on your 2019 PHM award for Quality and Patient Safety! What advice do you have for those at smaller institutions/hospitals without dedicated time or money to put towards quality improvement measures? How can individuals improve sustainability in quality improvement? How do hospitalists affect change outside of their division/section - especially for measures affected by other services (emergency room, ICU), such as reduction of chest X-ray utilization in asthma or ceftriaxone use in pneumonia?
I would suggest as an early step, engaging with divisional, departmental, and hospital leaders about your QI ideas. This engagement will help assure your goals align with larger institutional goals, alert you to resources you may or may not be aware of that can help you, and create opportunities to advocate for the resources you need to be successful (such as IT support). Integrating QI measures into the electronic record, using tools like order sets and quality dashboards, is likely critical to sustainability. Having hospital leaders on board with your project can also give you more momentum to affect care in other services, such as the ED.
3. You have done a lot of research interest is in comparative effectiveness and the use of clinical pathways to improve outcomes and decrease care variation. In fact, you published “Using Quality Improvement to Tackle Unwarranted Practice Variation” in Hospital Pediatrics in 2018. 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?
We know that there is inappropriate variation in care for almost every condition we examine, in both children and adults. This is due to the many barriers clinicians face in adopting evidence-based practices, such as lack of knowledge of new guidelines and reluctance to change old habits. Several children’s hospitals (e.g., Seattle, CHOP) have developed a wide array of clinical pathways that can be accessed freely online. These resources are a great starting point for any hospital seeking to improve quality of care.
4. Many of your publications focus on improving asthma care, particularly standardizing care. If you got to wave a magic wand and change one thing about asthma care across North America, what would it be and why?
Social risk factors play a much larger role in health than healthcare delivery. If I got to wave a magic wand and change something about asthma care, it would be our collective ability to screen for social risk factors (such as unstable housing), better connect families to community agencies/resources, and better support the community agencies that ultimately address these risks.
5. I was quite surprised by your article in Pediatrics in 2014: “National patterns of codeine prescriptions for children in the emergency department.” In the article, you show that even after national guidelines came out recommending against the use of codeine, there was a relatively small decline, and use of codeine for cough or URI did not decline. Why do you think codeine is still being prescribed? As inpatient hospitalists, how can we help to create this change?
Codeine is likely still being prescribed for the same reasons that drive all practice variation- inadequate knowledge of the risks, reluctance to change old habits, and lack of self-efficacy/confidence among clinicians in their ability to develop and convince families of a better treatment plan. Inpatient physicians can help create this change by educating colleagues and families that there are safer, more effective options for treating the symptoms codeine products are used for (e.g., honey for cough, ibuprofen for fracture pain).
6. A lot of hospitalists struggle with distinguishing asthma and CAP and avoiding the dreaded “asthmonia” label. Many of us also struggle with younger children (12-24 months) with wheezing with acute infection, and when to call wheezing “asthma.” What is your take on these asthma conundrums: is there such a thing as “asthmonia?” Do you ever treat those <2 years of age as asthmatics and what factors would cause you to do so? In that same population, do you ever officially diagnose them with asthma?
We know viruses frequently infect young children, and we know viruses are the primary driver of both bronchospasm/wheezing and pneumonia in this age group. Consequently, we commonly see cases of young children with both wheezing and viral pneumonia. My practice is to determine how well the child’s history and presentation fits with asthma (e.g., prior episodes of wheezing, family or personal history of atopy, responsiveness to bronchodilators). If these factors are present, I treat the child as an asthmatic and counsel parents that the child has asthma. I tell them that the child’s asthma symptoms will likely improve or resolve as they get older, but it is important for them to use this language/“asthma” label with all caretakers, so all caretakers know that bronchodilators may help the child during future episodes of respiratory distress.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
I work with lots of PHM fellows and young faculty around the country, and I always push the importance of devoting/blocking out time to: 1) explore what different career paths and professional roles look like, 2) sit down to soul search and map out your career vision, 3) align your daily work and time with that vision, and 4) periodically refine that vision and recheck that your daily work aligns with it. We have an incredible community of enthusiastic and talented mentors in PHM that can help guide younger folks in this process, and really committing to these steps can support more successful, resilient, happy careers and lives.
I was able to get my master’s during my PHM fellowship, and this training helped advance my career in a number of ways. I developed skills in designing and conducting different types of studies, learned how to excel as a physician scientist from talented mentors at Sick Kids Hospital in Toronto, and formulated plans for my future application for a career development award. So, this training laid the foundation for my current career as a health services researcher. One way for young hospitalists to explore this path is to search for others (preferably in their institutions) doing research projects and find an interesting one to collaborate on.
2. Congratulations on your 2019 PHM award for Quality and Patient Safety! What advice do you have for those at smaller institutions/hospitals without dedicated time or money to put towards quality improvement measures? How can individuals improve sustainability in quality improvement? How do hospitalists affect change outside of their division/section - especially for measures affected by other services (emergency room, ICU), such as reduction of chest X-ray utilization in asthma or ceftriaxone use in pneumonia?
I would suggest as an early step, engaging with divisional, departmental, and hospital leaders about your QI ideas. This engagement will help assure your goals align with larger institutional goals, alert you to resources you may or may not be aware of that can help you, and create opportunities to advocate for the resources you need to be successful (such as IT support). Integrating QI measures into the electronic record, using tools like order sets and quality dashboards, is likely critical to sustainability. Having hospital leaders on board with your project can also give you more momentum to affect care in other services, such as the ED.
3. You have done a lot of research interest is in comparative effectiveness and the use of clinical pathways to improve outcomes and decrease care variation. In fact, you published “Using Quality Improvement to Tackle Unwarranted Practice Variation” in Hospital Pediatrics in 2018. 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?
We know that there is inappropriate variation in care for almost every condition we examine, in both children and adults. This is due to the many barriers clinicians face in adopting evidence-based practices, such as lack of knowledge of new guidelines and reluctance to change old habits. Several children’s hospitals (e.g., Seattle, CHOP) have developed a wide array of clinical pathways that can be accessed freely online. These resources are a great starting point for any hospital seeking to improve quality of care.
4. Many of your publications focus on improving asthma care, particularly standardizing care. If you got to wave a magic wand and change one thing about asthma care across North America, what would it be and why?
Social risk factors play a much larger role in health than healthcare delivery. If I got to wave a magic wand and change something about asthma care, it would be our collective ability to screen for social risk factors (such as unstable housing), better connect families to community agencies/resources, and better support the community agencies that ultimately address these risks.
5. I was quite surprised by your article in Pediatrics in 2014: “National patterns of codeine prescriptions for children in the emergency department.” In the article, you show that even after national guidelines came out recommending against the use of codeine, there was a relatively small decline, and use of codeine for cough or URI did not decline. Why do you think codeine is still being prescribed? As inpatient hospitalists, how can we help to create this change?
Codeine is likely still being prescribed for the same reasons that drive all practice variation- inadequate knowledge of the risks, reluctance to change old habits, and lack of self-efficacy/confidence among clinicians in their ability to develop and convince families of a better treatment plan. Inpatient physicians can help create this change by educating colleagues and families that there are safer, more effective options for treating the symptoms codeine products are used for (e.g., honey for cough, ibuprofen for fracture pain).
6. A lot of hospitalists struggle with distinguishing asthma and CAP and avoiding the dreaded “asthmonia” label. Many of us also struggle with younger children (12-24 months) with wheezing with acute infection, and when to call wheezing “asthma.” What is your take on these asthma conundrums: is there such a thing as “asthmonia?” Do you ever treat those <2 years of age as asthmatics and what factors would cause you to do so? In that same population, do you ever officially diagnose them with asthma?
We know viruses frequently infect young children, and we know viruses are the primary driver of both bronchospasm/wheezing and pneumonia in this age group. Consequently, we commonly see cases of young children with both wheezing and viral pneumonia. My practice is to determine how well the child’s history and presentation fits with asthma (e.g., prior episodes of wheezing, family or personal history of atopy, responsiveness to bronchodilators). If these factors are present, I treat the child as an asthmatic and counsel parents that the child has asthma. I tell them that the child’s asthma symptoms will likely improve or resolve as they get older, but it is important for them to use this language/“asthma” label with all caretakers, so all caretakers know that bronchodilators may help the child during future episodes of respiratory distress.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
I work with lots of PHM fellows and young faculty around the country, and I always push the importance of devoting/blocking out time to: 1) explore what different career paths and professional roles look like, 2) sit down to soul search and map out your career vision, 3) align your daily work and time with that vision, and 4) periodically refine that vision and recheck that your daily work aligns with it. We have an incredible community of enthusiastic and talented mentors in PHM that can help guide younger folks in this process, and really committing to these steps can support more successful, resilient, happy careers and lives.