Vineeta Mittal
1. You founded the APA Family-Centered Care Special Interest Group (SIG) in 2008 and have published numerous papers on family centered rounds. In today’s world of patient throughput, large rounding teams, and large patient volumes, how do you keep your rounding family-centered? What tips or tricks do you have for managing these common pitfalls?
Healthcare is about “patient and family-centered” care. We as hospitalists are the leaders of complex multidisciplinary teams and are constantly working/negotiating/advocating with medical and surgical sub-specialists and other services in caring for our patients. Therefore, I believe that it is our duty and responsibility to communicate directly with our patients and families, and a family-centered rounding model fits in naturally with our workflow. The logistics are challenging at times and for that we have to be innovative, open-minded and humane. I believe that we can partner with our patients and trainees in some situations. A few styles that have worked for me include:
1. Using a conversation style presentation instead of a long standardized H&P format
2. On long-term patients, starting with a one line assessment and plan and then leaving time for questions from the families
3. On weekends, I’ve done “discovery FCRs” where the team reviews all vitals, notes, and labs beforehand and then we go room-to-room and see patients together (discovering their current status). One person talks and another person examines the patient.
There is no right or wrong way to do FCRs, we have to try new ideas to accommodate our workflow and our patients.
2. You are involved in bronchiolitis research for the Pediatric Research in Inpatient Setting (PRIS), CHAT (Children’s Hospitals Across Texas), and Pediatric Health Information System (PHIS). Where is the newest research in bronchiolitis heading?
I see two emerging aspects of research in bronchiolitis. One that involves implementing practice guidelines based on what is already discovered, this is the basis of the QI models developed by many PHM programs including ours at UTSW, where we are trying to streamline care based on reducing over-utilization. The other aspect involves finding new knowledge as we find gaps in the current literature. For example: 1) oxygen delivery devices and the role of high flow nasal cannula; 2) how to differentiate bronchiolitis population from those who have reactive airway disease; 3) management of bronchiolitis in children with co-morbid conditions. Lastly, as we move to value-based model, cost effective models might evolve.
3. With an interest in both bronchiolitis and asthma, I’d like to pose an age-old question: How do you determine when to use albuterol in a sick, hospitalized, respiratory patient, knowing that the bronchiolitis guidelines do not support it? Do you base it on age alone or are there other criteria that you use?
In my humble opinion, in a wheezing child, this is a tough question. We still haven’t mastered the art of differentiating between children who have bronchiolitis and children who have reactive airway disease clinically. Therefore, in our local guidelines, we recommend that those with wheezing, history of eczema, food allergies, hay fever, and/or family history of asthma and smokers-may benefit from a trial of bronchodilator. We document response to bronchodilator by the modified RDAI score as it is validated for response to therapy. So those would be my criteria to use albuterol. If there were no response to albuterol, I wouldn’t continue. If, however, they do respond, I use it. I’ve seen kids admitted as bronchiolitics on HHFNC at 6 liters and with increased FiO2, be completely clear on auscultation after albuterol, get off HHFNC, and go home the same day. So I decide case-by-case.
4. One of your passions is faculty development. What are some steps that newer and evolving hospitalist programs can take to promote and improve faculty development at their own institutions?
Our field is very young and so are our faculty, therefore faculty development is crucial for all of us to grow. Being a young field, we have both challenges and opportunities. The newer and evolving programs can start with peer mentoring (within your division). There is wealth of talent in every group and coming together and starting with case discussions on current patients can lead to improved practice and also lead to case reports and evidence-based guidelines. Reach out to leaders/established faculty in your pediatrics department who can mentor and sponsor, explore and use local available resources, and take advantage of the PHM’s national resources.
The resources available within PHM like; 1) the robust AAP Listserves, 2) our annual PHM conference, and 3) the presence of PHM Committees/Special Interest Groups within the three national Societies (American Academy of Pediatrics, Academic Pediatric Association, and Society for Hospital Medicine) are great resources for faculty development, networking, and forming mentoring teams. Each of these societies has their annual conference where PHM is well represented. So new and evolving programs can divide and conquer and have their faculties attend different conferences and share ideas locally. I have been very fortunate to meet many wonderful mentors through the annual PHM conference. In fact, over time, PHM conference has become my second home and I go back every year to meet people who have shaped my professional career and also to give back to the field. So the cycle continues.
5. Congratulations on your recent election to the Section Executive Committee for SOHM. What are your goals for this position? What do you see as the biggest challenge facing pediatric hospital medicine in the next 5 years and why?
Thank you. I am honored and humbled to be elected and my goal is to continue to advance our field further. The mental health crisis and medical and surgical co-management are the biggest challenges that we will face in the next 5 years.
As we know, the current mental health crisis is concerning. 1 in 5 children in US are affected by mental health related disorders. Moreover, with national shortage of trained psychiatrist and lack of community resources/facilities, we will have to embrace children hospitalized with mental health conditions (and also help ED boarder situation). Similarly, the complexity of population of hospitalized children is changing. Majority of complex children have 2,3 or 4 systems affected and no single organ specialist can manage them independently. Therefore, we will be the natural fit to care for these children and coordinate their care with multiple medical and surgical specialists.
So, developing and expanding our knowledge base and skill sets to care for the broad population that now represents the hospitalized children, in the setting of a young and developing field, will be the biggest challenge we will face in the next 5 years.
6. Recently you were elected as the President of the medical and dental staff at Children’s Medical Center Dallas. Why do you think it’s important for hospitalists to apply for leadership roles among their institution and what biases have you encountered as a pediatric hospitalist in a leadership position and how do you overcome these?
As hospitalists, we lead multidisciplinary teams on daily basis and work with medical/surgical specialists, and ancillary services. By nature of our work we provide 24/7 coverage, are very hands-on, know most service lines and their workflow, and therefore we have a lot of knowledge, insight and experience about the working of the hospital. We understand what works and what doesn’t. This knowledge and experience is crucial for the hospital to develop successful programs, implement quality and operational initiatives. Therefore, we should lead local committees and take on senior leadership roles, including the Medical and Dental Staff leadership, so we can partner with hospital and make our systems more efficient to provide high quality care. Moreover, being in the leadership position also helps with professional/leadership development, visibility (for self and division), recognition of crucial role hospitalists play in a hospital/health system and helps with resource allocation. I don’t notice any specific biases, except that leaders acknowledge and trust our opinion because they understand that we as hospitalists know the pulse of a hospital.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” what are your two cents?
Don’t sweat the small stuff…and it is all small stuff. Being a hospitalist is hard, make peace with imperfection, work hard, and play harder.
Healthcare is about “patient and family-centered” care. We as hospitalists are the leaders of complex multidisciplinary teams and are constantly working/negotiating/advocating with medical and surgical sub-specialists and other services in caring for our patients. Therefore, I believe that it is our duty and responsibility to communicate directly with our patients and families, and a family-centered rounding model fits in naturally with our workflow. The logistics are challenging at times and for that we have to be innovative, open-minded and humane. I believe that we can partner with our patients and trainees in some situations. A few styles that have worked for me include:
1. Using a conversation style presentation instead of a long standardized H&P format
2. On long-term patients, starting with a one line assessment and plan and then leaving time for questions from the families
3. On weekends, I’ve done “discovery FCRs” where the team reviews all vitals, notes, and labs beforehand and then we go room-to-room and see patients together (discovering their current status). One person talks and another person examines the patient.
There is no right or wrong way to do FCRs, we have to try new ideas to accommodate our workflow and our patients.
2. You are involved in bronchiolitis research for the Pediatric Research in Inpatient Setting (PRIS), CHAT (Children’s Hospitals Across Texas), and Pediatric Health Information System (PHIS). Where is the newest research in bronchiolitis heading?
I see two emerging aspects of research in bronchiolitis. One that involves implementing practice guidelines based on what is already discovered, this is the basis of the QI models developed by many PHM programs including ours at UTSW, where we are trying to streamline care based on reducing over-utilization. The other aspect involves finding new knowledge as we find gaps in the current literature. For example: 1) oxygen delivery devices and the role of high flow nasal cannula; 2) how to differentiate bronchiolitis population from those who have reactive airway disease; 3) management of bronchiolitis in children with co-morbid conditions. Lastly, as we move to value-based model, cost effective models might evolve.
3. With an interest in both bronchiolitis and asthma, I’d like to pose an age-old question: How do you determine when to use albuterol in a sick, hospitalized, respiratory patient, knowing that the bronchiolitis guidelines do not support it? Do you base it on age alone or are there other criteria that you use?
In my humble opinion, in a wheezing child, this is a tough question. We still haven’t mastered the art of differentiating between children who have bronchiolitis and children who have reactive airway disease clinically. Therefore, in our local guidelines, we recommend that those with wheezing, history of eczema, food allergies, hay fever, and/or family history of asthma and smokers-may benefit from a trial of bronchodilator. We document response to bronchodilator by the modified RDAI score as it is validated for response to therapy. So those would be my criteria to use albuterol. If there were no response to albuterol, I wouldn’t continue. If, however, they do respond, I use it. I’ve seen kids admitted as bronchiolitics on HHFNC at 6 liters and with increased FiO2, be completely clear on auscultation after albuterol, get off HHFNC, and go home the same day. So I decide case-by-case.
4. One of your passions is faculty development. What are some steps that newer and evolving hospitalist programs can take to promote and improve faculty development at their own institutions?
Our field is very young and so are our faculty, therefore faculty development is crucial for all of us to grow. Being a young field, we have both challenges and opportunities. The newer and evolving programs can start with peer mentoring (within your division). There is wealth of talent in every group and coming together and starting with case discussions on current patients can lead to improved practice and also lead to case reports and evidence-based guidelines. Reach out to leaders/established faculty in your pediatrics department who can mentor and sponsor, explore and use local available resources, and take advantage of the PHM’s national resources.
The resources available within PHM like; 1) the robust AAP Listserves, 2) our annual PHM conference, and 3) the presence of PHM Committees/Special Interest Groups within the three national Societies (American Academy of Pediatrics, Academic Pediatric Association, and Society for Hospital Medicine) are great resources for faculty development, networking, and forming mentoring teams. Each of these societies has their annual conference where PHM is well represented. So new and evolving programs can divide and conquer and have their faculties attend different conferences and share ideas locally. I have been very fortunate to meet many wonderful mentors through the annual PHM conference. In fact, over time, PHM conference has become my second home and I go back every year to meet people who have shaped my professional career and also to give back to the field. So the cycle continues.
5. Congratulations on your recent election to the Section Executive Committee for SOHM. What are your goals for this position? What do you see as the biggest challenge facing pediatric hospital medicine in the next 5 years and why?
Thank you. I am honored and humbled to be elected and my goal is to continue to advance our field further. The mental health crisis and medical and surgical co-management are the biggest challenges that we will face in the next 5 years.
As we know, the current mental health crisis is concerning. 1 in 5 children in US are affected by mental health related disorders. Moreover, with national shortage of trained psychiatrist and lack of community resources/facilities, we will have to embrace children hospitalized with mental health conditions (and also help ED boarder situation). Similarly, the complexity of population of hospitalized children is changing. Majority of complex children have 2,3 or 4 systems affected and no single organ specialist can manage them independently. Therefore, we will be the natural fit to care for these children and coordinate their care with multiple medical and surgical specialists.
So, developing and expanding our knowledge base and skill sets to care for the broad population that now represents the hospitalized children, in the setting of a young and developing field, will be the biggest challenge we will face in the next 5 years.
6. Recently you were elected as the President of the medical and dental staff at Children’s Medical Center Dallas. Why do you think it’s important for hospitalists to apply for leadership roles among their institution and what biases have you encountered as a pediatric hospitalist in a leadership position and how do you overcome these?
As hospitalists, we lead multidisciplinary teams on daily basis and work with medical/surgical specialists, and ancillary services. By nature of our work we provide 24/7 coverage, are very hands-on, know most service lines and their workflow, and therefore we have a lot of knowledge, insight and experience about the working of the hospital. We understand what works and what doesn’t. This knowledge and experience is crucial for the hospital to develop successful programs, implement quality and operational initiatives. Therefore, we should lead local committees and take on senior leadership roles, including the Medical and Dental Staff leadership, so we can partner with hospital and make our systems more efficient to provide high quality care. Moreover, being in the leadership position also helps with professional/leadership development, visibility (for self and division), recognition of crucial role hospitalists play in a hospital/health system and helps with resource allocation. I don’t notice any specific biases, except that leaders acknowledge and trust our opinion because they understand that we as hospitalists know the pulse of a hospital.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” what are your two cents?
Don’t sweat the small stuff…and it is all small stuff. Being a hospitalist is hard, make peace with imperfection, work hard, and play harder.