Weijen Chang
1. As a board-certified physician in both Internal Medicine and Pediatrics, you have a unique perspective that other hospitalists do not. In what leadership, QI, or research positions do you see other Med-Peds graduates serving and why? What unique challenges do you see med-peds hospitalists facing that the rest of us may not be aware of?
In the pediatric hospitalist world, Med-Peds graduates are blessed with having a global view of challenges facing a hospital system that others may not, such as patient flow, readmissions reduction, and quality measures. They are also exposed to burgeoning research and QI being developed by their colleagues in both Medicine and Pediatrics – double the fun! Leadership opportunities present themselves on both sides of the age divide as well – double the chances! As such, Med-Peds hospitalists are well-positioned to take advantage and excel in all leadership, QI and/or research positions. The main question is, what is your passion?
The challenge many Med-Peds hospitalists face is being unable to say no. Med-Peds “peeps” can find any challenge in any niche worthy of their attention, and are generally both helpful and workaholic – a bad combination. Saying “yes” to too many projects can lead to lack of a true focus in their careers (I am guilty of that). A meandering career can be personally fulfilling, but may not be the best for academic or professional advancement. But it also depends on your circumstance – in a community hospital, many Med-Peds hospitalists excel in their role as the go-to problem solvers. Leveraging that role into leadership versus being just the “fixer” requires walking a fine line and showing your worth.
2. In 2018, you wrote “Practical Pearl: Bronchiolitis” with a set of guidelines for Baystate. How do you deal with the persistence of chest-Xrays, albuterol, and other non-evidenced based management, especially when it is initiated by other institutions or divisions (ie Emergency Department)?
First of all, I’m surprised you saw that practical pearl – at least someone is reading it. Approaching variation in clinical practice is a multilayered, never-ending challenge, at least in a teaching hospital. Every year you feel like you’ve gotten through to all the stakeholders and learners, then July rolls around… You start by being consistent in your own group’s practices, and making sure your group is philosophically consistent. It’s also important to approach variation with a growth mindset as opposed to a punitive one. We have to recognize that at the end of the day, we are all trying to get these kids better, but we have different rewards and consequences for favorable/unfavorable outcomes. Begin by making sure that both groups (ED, hospitalists, nursing, RTs) understand the risk/reward each faces. What is driving non-evidenced based practice? Does everyone know and understand (and believe) the underlying evidence? This is a long, continuous process, and is much more difficult than just posting a guideline and/or instituting an order set.
Making sure your EMR’s ordering system is driving evidence-based practice, however, is integral. But are you tracking whether people are using your EMR? Are you tracking the use of non-evidence based practices when people are using work-arounds? Fully taking advantage of these resources and answering these questions regularly requires IT and quality resources that not everyone has access to (myself included), but tracking just one quality measure regularly is better than tracking none. As long as it’s the right quality measure… But one thing that anyone can do is to just get the groups together to have lunch and chat, perhaps over combined journal club. An us vs them atmosphere is probably the worst thing that can happen.
3. Your article in the Journal of Hospital Medicine in May 2018 was entitled, “Things We Do for No Reason – The “48 Hour Rule-out” for Well-Appearing Febrile Infants” (J. Hosp. Med. 2018 May;13(5):343-346). What other things do you think might earn the title of “Things We Do for No Reason” in the future?
Ahhh, my favorite recurring feature in JHM. Phototherapy for neonates that don’t meet threshold. Follow up blood cultures for well-appearing infants brought back to the ED for blood cultures growing contaminants (stop the madness!!!). Intravenous corticosteroids for asthmatics who can take oral. Cohorting by virus. Sign me up for another Lenny!
4. As the editor of The Hospitalist (https://urldefense.proofpoint.com/v2/url?u=https-3A__www.the-2Dhospitalist.org_hospitalist&d=DwIGaQ&c=BLF1codk7grETTA02F6JwR5DiXMTPyNdcZpbXT_1iEc&r=XpY7pjrV8hFI82-FEs1tHtV1SFRDiYHdv3L3gMXJ8fHPA9-mwpEDiWGk9AwCBsAA&m=fqjw9gr_QtFXcFdI2xfOPaJGhnjwuWJvslujkUmG5S8&s=VvpEcdouyFojwfYWshZgnvBoRnVnP9wmL6tmzlmUHns&e=) since 2012, you review the critical publications in our field. What recommendations do you have for young pediatric hospitalists looking to publish their research? Do you expect any changes in the nature of research as we move forward as a field?
First of all, with Samir Shah at the helm of JHM, I expect to see a lot more PHM research reaching publication. A couple of other trends I would expect:
1. Newborn care: As hospitalists begin to take over newborn care, more hospitalist research focuses on the “routine” care of newborns, which is becoming less routine as we begin to see “acuity creep” in the newborn nursery. Also, hospitalist research begins to address improving the delivery of newborn care, much as other hospitalist literature addresses healthcare delivery.
2. Value: The issue of unnecessary and excessively costly care is already a hot topic, but this becomes more prominent as pediatric inpatient units/hospitals try to maintain quality but at lower costs, and avoid potentially harmful practices.
3. Transitions and linkages to outpatient care: As the field matures, despite PHM certification, hospitalists discover they are not an island, and improving the care of our patients depends on maintain a continuum of care for our patients. This is most exciting to me, as it gets me back to my roots in community based primary care.
5. What’s the best piece of career advice that you have ever been given?
One of my mentors in adult hospital medicine, Greg Maynard, use to say, “don’t sell yourself short.” What does that mean? For hospitalists, we view our continuous problem solving for our employers as part of the job, but each QI project, scheduling challenge solved, educational shortcoming addressed should be catalogued and celebrated. More importantly, at your review (individual or program), you shouldn’t shy away from highlighting these achievements and asking for protected time for these activities. You may not get it, but at least you have planted the flag. Once an employer gets you to do something for free for very long, it becomes hard not to make this an “expected” part of your job.
6. You are the Vice Chair for Clinical Affairs for the Department of Pediatrics at the University of Massachusetts Medical School-Baystate. What does this role entail and how might other hospitalists branch out to roles like this?
I like to say that this job is whatever the Chair wants it to be. Luckily for me, my chair, Charlotte Boney, while trained as an endocrinologist, secretly wishes she had become a hospitalist, so I love the role she has put me in. In all seriousness, my role encompasses helping her to operationalize clinical initiatives, reach out to the medical and lay community, address/solve personnel challenges, and be a sounding board for strategic planning. Of course, this falls right into the wheelhouse of what hospitalists love to do. In fact, I’m surprised that not all clinical vice-chairs are hospitalists, as we are so well suited to having both the operational acumen and strategic vision to take on this role. If you are interested in such a role, make sure your problem solving doesn’t just address the micro-challenges, but address system and strategic challenges. Then don’t shy away from supporting your chair on the big stages (think meetings with C-suite people). But to aspire to a vice-chair type of role, it’s most important to remember that it’s not just about protecting/promoting your HM division/group, it’s about supporting everyone around you to achieve department goals.
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 forget the North Star of everything we do – improving the long-term health of our patients and communities. Whatever difficult situation you find yourself in, making this your priority will always lead to the right decision.
In the pediatric hospitalist world, Med-Peds graduates are blessed with having a global view of challenges facing a hospital system that others may not, such as patient flow, readmissions reduction, and quality measures. They are also exposed to burgeoning research and QI being developed by their colleagues in both Medicine and Pediatrics – double the fun! Leadership opportunities present themselves on both sides of the age divide as well – double the chances! As such, Med-Peds hospitalists are well-positioned to take advantage and excel in all leadership, QI and/or research positions. The main question is, what is your passion?
The challenge many Med-Peds hospitalists face is being unable to say no. Med-Peds “peeps” can find any challenge in any niche worthy of their attention, and are generally both helpful and workaholic – a bad combination. Saying “yes” to too many projects can lead to lack of a true focus in their careers (I am guilty of that). A meandering career can be personally fulfilling, but may not be the best for academic or professional advancement. But it also depends on your circumstance – in a community hospital, many Med-Peds hospitalists excel in their role as the go-to problem solvers. Leveraging that role into leadership versus being just the “fixer” requires walking a fine line and showing your worth.
2. In 2018, you wrote “Practical Pearl: Bronchiolitis” with a set of guidelines for Baystate. How do you deal with the persistence of chest-Xrays, albuterol, and other non-evidenced based management, especially when it is initiated by other institutions or divisions (ie Emergency Department)?
First of all, I’m surprised you saw that practical pearl – at least someone is reading it. Approaching variation in clinical practice is a multilayered, never-ending challenge, at least in a teaching hospital. Every year you feel like you’ve gotten through to all the stakeholders and learners, then July rolls around… You start by being consistent in your own group’s practices, and making sure your group is philosophically consistent. It’s also important to approach variation with a growth mindset as opposed to a punitive one. We have to recognize that at the end of the day, we are all trying to get these kids better, but we have different rewards and consequences for favorable/unfavorable outcomes. Begin by making sure that both groups (ED, hospitalists, nursing, RTs) understand the risk/reward each faces. What is driving non-evidenced based practice? Does everyone know and understand (and believe) the underlying evidence? This is a long, continuous process, and is much more difficult than just posting a guideline and/or instituting an order set.
Making sure your EMR’s ordering system is driving evidence-based practice, however, is integral. But are you tracking whether people are using your EMR? Are you tracking the use of non-evidence based practices when people are using work-arounds? Fully taking advantage of these resources and answering these questions regularly requires IT and quality resources that not everyone has access to (myself included), but tracking just one quality measure regularly is better than tracking none. As long as it’s the right quality measure… But one thing that anyone can do is to just get the groups together to have lunch and chat, perhaps over combined journal club. An us vs them atmosphere is probably the worst thing that can happen.
3. Your article in the Journal of Hospital Medicine in May 2018 was entitled, “Things We Do for No Reason – The “48 Hour Rule-out” for Well-Appearing Febrile Infants” (J. Hosp. Med. 2018 May;13(5):343-346). What other things do you think might earn the title of “Things We Do for No Reason” in the future?
Ahhh, my favorite recurring feature in JHM. Phototherapy for neonates that don’t meet threshold. Follow up blood cultures for well-appearing infants brought back to the ED for blood cultures growing contaminants (stop the madness!!!). Intravenous corticosteroids for asthmatics who can take oral. Cohorting by virus. Sign me up for another Lenny!
4. As the editor of The Hospitalist (https://urldefense.proofpoint.com/v2/url?u=https-3A__www.the-2Dhospitalist.org_hospitalist&d=DwIGaQ&c=BLF1codk7grETTA02F6JwR5DiXMTPyNdcZpbXT_1iEc&r=XpY7pjrV8hFI82-FEs1tHtV1SFRDiYHdv3L3gMXJ8fHPA9-mwpEDiWGk9AwCBsAA&m=fqjw9gr_QtFXcFdI2xfOPaJGhnjwuWJvslujkUmG5S8&s=VvpEcdouyFojwfYWshZgnvBoRnVnP9wmL6tmzlmUHns&e=) since 2012, you review the critical publications in our field. What recommendations do you have for young pediatric hospitalists looking to publish their research? Do you expect any changes in the nature of research as we move forward as a field?
First of all, with Samir Shah at the helm of JHM, I expect to see a lot more PHM research reaching publication. A couple of other trends I would expect:
1. Newborn care: As hospitalists begin to take over newborn care, more hospitalist research focuses on the “routine” care of newborns, which is becoming less routine as we begin to see “acuity creep” in the newborn nursery. Also, hospitalist research begins to address improving the delivery of newborn care, much as other hospitalist literature addresses healthcare delivery.
2. Value: The issue of unnecessary and excessively costly care is already a hot topic, but this becomes more prominent as pediatric inpatient units/hospitals try to maintain quality but at lower costs, and avoid potentially harmful practices.
3. Transitions and linkages to outpatient care: As the field matures, despite PHM certification, hospitalists discover they are not an island, and improving the care of our patients depends on maintain a continuum of care for our patients. This is most exciting to me, as it gets me back to my roots in community based primary care.
5. What’s the best piece of career advice that you have ever been given?
One of my mentors in adult hospital medicine, Greg Maynard, use to say, “don’t sell yourself short.” What does that mean? For hospitalists, we view our continuous problem solving for our employers as part of the job, but each QI project, scheduling challenge solved, educational shortcoming addressed should be catalogued and celebrated. More importantly, at your review (individual or program), you shouldn’t shy away from highlighting these achievements and asking for protected time for these activities. You may not get it, but at least you have planted the flag. Once an employer gets you to do something for free for very long, it becomes hard not to make this an “expected” part of your job.
6. You are the Vice Chair for Clinical Affairs for the Department of Pediatrics at the University of Massachusetts Medical School-Baystate. What does this role entail and how might other hospitalists branch out to roles like this?
I like to say that this job is whatever the Chair wants it to be. Luckily for me, my chair, Charlotte Boney, while trained as an endocrinologist, secretly wishes she had become a hospitalist, so I love the role she has put me in. In all seriousness, my role encompasses helping her to operationalize clinical initiatives, reach out to the medical and lay community, address/solve personnel challenges, and be a sounding board for strategic planning. Of course, this falls right into the wheelhouse of what hospitalists love to do. In fact, I’m surprised that not all clinical vice-chairs are hospitalists, as we are so well suited to having both the operational acumen and strategic vision to take on this role. If you are interested in such a role, make sure your problem solving doesn’t just address the micro-challenges, but address system and strategic challenges. Then don’t shy away from supporting your chair on the big stages (think meetings with C-suite people). But to aspire to a vice-chair type of role, it’s most important to remember that it’s not just about protecting/promoting your HM division/group, it’s about supporting everyone around you to achieve department goals.
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 forget the North Star of everything we do – improving the long-term health of our patients and communities. Whatever difficult situation you find yourself in, making this your priority will always lead to the right decision.