- Yemisi Jones
1. You are the co-director of the Liberty Simulation Education at Cincinnati Children’s. How do you think simulation can help pediatric hospitalists?
Simulation is a fantastic tool that as a new specialty we have yet to fully leverage. As with other aspects of acute care medicine, hospital medicine is late to the party, after critical care and emergency medicine, in truly incorporating simulation into the way we train and maintain competencies. At my institution we use simulation at our satellite hospital for training of our multidisciplinary resuscitation team, which is led by our hospitalist group. Another opportunity is in the sticky area of achieving, measuring, and maintaining procedural competence. These are both generally uncommon events that are ripe for performance decay over time, which make them excellent candidates for simulation education.
2. As a co-author of “Things We Do for No Reason: Systemic Corticosteroids for Wheezing in Preschool-Aged Children” in the Journal of Hospital Medicine in 2019, what is your approach to a colleague who is unnecessarily and frequently prescribing steroids to young children?
As we describe in the paper, this group of children is very heterogenous, but we do know the majority likely do not benefit from systemic steroids during a wheezing episode. I would encourage my colleague to try and categorize her wheezing preschoolers to the extent possible as “associated with viral infections only” or “multifactorial,” potentially using one of the screening tools we suggest: the Pediatric Asthma Risk Score (PARS) or Asthma Predictive Index (API). This can help guide the choice of systemic steroid therapy, as there is some evidence that children with multifactorial triggered wheezing are more likely to progress to a true asthma phenotype and may benefit from systemic steroids during episodes even early in life. However, the big caveat is that more study is needed to better answer this question, especially for those children with severe presentations.
3. Similarly, the “Things We Do for No Reason” series was inspired by the Choosing Wisely campaign. What would you add to either of these lists?
Well, after the review of the literature as I noted above, I think giving systemic steroids for all wheezing children under the age of 5 should be considered. I think we also have room to safely do less with the use of continuous pulse oximetry and oxygen therapies, including high-flow. The use of the term “wean” as it applies to how we discontinue oxygen certainly leads to children receiving it for longer than needed as opposed to trialing them off.
4. PHM20 was completely virtual this year due to the COVID-19 pandemic. You were a member of the planning committee--what did you think about the new format? How do you see the conference moving forward? Do you think there will be a virtual component even as we move back to in-person conferences in the next few years?
While the decision to transition PHM20 was a difficult and sudden one, in hindsight it clearly was the safest move. With the benefit of experience with the pandemic and the luxury of a longer planning period, the decision to move PHM21 virtually was equally difficulty although less sudden. Our field is now faced with the challenge of staying connected, up-to-date, and motivated in a new virtual space. The quick pivot for PHM20 meant limited technological capabilities, but I am proud of the fact that we were still able to offer a forum for the dissemination of scientific work, networking, discussion of hot topics, and clinical updates. With an extended planning period, I am confident that PHM21 will offer an even more robust experience for attendees.
While we have been forced by external circumstances to accelerate the incorporation of recorded and virtual components to our annual conferences, I feel sure these offerings will remain a fixture at our meetings even once we are able to convene again in person. Finding the right balance of in-person and virtual experiences will be the challenge and charge of future planning committees.
5. You recently co-authored “Leveraging the Outpatient Pharmacy to Reduce Medication Waste in Pediatric Asthma Hospitalizations” in the Journal of Hospital Medicine. What advice do you have for pediatric hospitalists that want to publish their QI projects?
The best advice I received on this topic is to approach the project planning with dissemination in mind. This means being systematic in your approach to solving the problem, documenting everything you did and when, and even reviewing the SQUIRE guidelines early on to ensure you will be able to produce a manuscript with high scholarly standards. Often, we are eager to get to testing solutions without clearly laying out the problem and theory behind the improvement plan. But, the benefit of learning from other quality improvement projects comes from putting the tests and results in the right context. Clearly laying this out will ensure the broader community is able to learn from and translate your work.
6. You’ve written about teaching high-value care in pediatrics. What are some strategies you have for bringing high-value care into your daily practice and into care discussions with patients and their families?
Well, this is a tough one. While we have made strides in bringing attention to high-value care within our field and even with trainees, I don’t think we yet know the best ways to approach families about this. I do think using language around “value” is better received than “cost,” but I’m not sure there is empirical evidence to support this. This is a great space for a creative hospitalist to contribute to the literature and help our understanding of this area.
I have had the benefit of training and working at multiple different hospitals during my career, which has given me the perspective that well-meaning and intelligent hospitalists can practice high-quality medicine in a variety of ways. This has shaped my thinking to question practices that are easy to take for granted. One of the most important things we can do in our daily practice is to continually ask, “why do we do this?” Oftentimes, the habit become dogma without clear evidence. And without the question being asked, we can continue to incorporate low-value practices into the care of our patients. As you brought it up above, I was a big fan of the first Choosing Wisely list, which is a great start to highlight clear low-value areas in PHM practice. So, I’m looking forward to seeing what the next list will include.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
My 2 cents are that it is an exciting time to be a hospitalist. With the addition of the first ABP diplomates in Pediatric Hospital Medicine, our field is poised to enter a new stage in our maturation, and the door is wide open for those who want to take part in moving us forward. So, don’t hesitate to get involved at the local, regional, and national levels to help define our field and contribute to our understanding of how to care for hospitalized children even better.
Simulation is a fantastic tool that as a new specialty we have yet to fully leverage. As with other aspects of acute care medicine, hospital medicine is late to the party, after critical care and emergency medicine, in truly incorporating simulation into the way we train and maintain competencies. At my institution we use simulation at our satellite hospital for training of our multidisciplinary resuscitation team, which is led by our hospitalist group. Another opportunity is in the sticky area of achieving, measuring, and maintaining procedural competence. These are both generally uncommon events that are ripe for performance decay over time, which make them excellent candidates for simulation education.
2. As a co-author of “Things We Do for No Reason: Systemic Corticosteroids for Wheezing in Preschool-Aged Children” in the Journal of Hospital Medicine in 2019, what is your approach to a colleague who is unnecessarily and frequently prescribing steroids to young children?
As we describe in the paper, this group of children is very heterogenous, but we do know the majority likely do not benefit from systemic steroids during a wheezing episode. I would encourage my colleague to try and categorize her wheezing preschoolers to the extent possible as “associated with viral infections only” or “multifactorial,” potentially using one of the screening tools we suggest: the Pediatric Asthma Risk Score (PARS) or Asthma Predictive Index (API). This can help guide the choice of systemic steroid therapy, as there is some evidence that children with multifactorial triggered wheezing are more likely to progress to a true asthma phenotype and may benefit from systemic steroids during episodes even early in life. However, the big caveat is that more study is needed to better answer this question, especially for those children with severe presentations.
3. Similarly, the “Things We Do for No Reason” series was inspired by the Choosing Wisely campaign. What would you add to either of these lists?
Well, after the review of the literature as I noted above, I think giving systemic steroids for all wheezing children under the age of 5 should be considered. I think we also have room to safely do less with the use of continuous pulse oximetry and oxygen therapies, including high-flow. The use of the term “wean” as it applies to how we discontinue oxygen certainly leads to children receiving it for longer than needed as opposed to trialing them off.
4. PHM20 was completely virtual this year due to the COVID-19 pandemic. You were a member of the planning committee--what did you think about the new format? How do you see the conference moving forward? Do you think there will be a virtual component even as we move back to in-person conferences in the next few years?
While the decision to transition PHM20 was a difficult and sudden one, in hindsight it clearly was the safest move. With the benefit of experience with the pandemic and the luxury of a longer planning period, the decision to move PHM21 virtually was equally difficulty although less sudden. Our field is now faced with the challenge of staying connected, up-to-date, and motivated in a new virtual space. The quick pivot for PHM20 meant limited technological capabilities, but I am proud of the fact that we were still able to offer a forum for the dissemination of scientific work, networking, discussion of hot topics, and clinical updates. With an extended planning period, I am confident that PHM21 will offer an even more robust experience for attendees.
While we have been forced by external circumstances to accelerate the incorporation of recorded and virtual components to our annual conferences, I feel sure these offerings will remain a fixture at our meetings even once we are able to convene again in person. Finding the right balance of in-person and virtual experiences will be the challenge and charge of future planning committees.
5. You recently co-authored “Leveraging the Outpatient Pharmacy to Reduce Medication Waste in Pediatric Asthma Hospitalizations” in the Journal of Hospital Medicine. What advice do you have for pediatric hospitalists that want to publish their QI projects?
The best advice I received on this topic is to approach the project planning with dissemination in mind. This means being systematic in your approach to solving the problem, documenting everything you did and when, and even reviewing the SQUIRE guidelines early on to ensure you will be able to produce a manuscript with high scholarly standards. Often, we are eager to get to testing solutions without clearly laying out the problem and theory behind the improvement plan. But, the benefit of learning from other quality improvement projects comes from putting the tests and results in the right context. Clearly laying this out will ensure the broader community is able to learn from and translate your work.
6. You’ve written about teaching high-value care in pediatrics. What are some strategies you have for bringing high-value care into your daily practice and into care discussions with patients and their families?
Well, this is a tough one. While we have made strides in bringing attention to high-value care within our field and even with trainees, I don’t think we yet know the best ways to approach families about this. I do think using language around “value” is better received than “cost,” but I’m not sure there is empirical evidence to support this. This is a great space for a creative hospitalist to contribute to the literature and help our understanding of this area.
I have had the benefit of training and working at multiple different hospitals during my career, which has given me the perspective that well-meaning and intelligent hospitalists can practice high-quality medicine in a variety of ways. This has shaped my thinking to question practices that are easy to take for granted. One of the most important things we can do in our daily practice is to continually ask, “why do we do this?” Oftentimes, the habit become dogma without clear evidence. And without the question being asked, we can continue to incorporate low-value practices into the care of our patients. As you brought it up above, I was a big fan of the first Choosing Wisely list, which is a great start to highlight clear low-value areas in PHM practice. So, I’m looking forward to seeing what the next list will include.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
My 2 cents are that it is an exciting time to be a hospitalist. With the addition of the first ABP diplomates in Pediatric Hospital Medicine, our field is poised to enter a new stage in our maturation, and the door is wide open for those who want to take part in moving us forward. So, don’t hesitate to get involved at the local, regional, and national levels to help define our field and contribute to our understanding of how to care for hospitalized children even better.