- Zoey Goore
1. You spent 11 years in outpatient medicine before becoming a pediatric hospitalist. What do you think the best way to communicate with the PCP is at discharge? Any other insights from working on “the other side” before coming to inpatient medicine?
I have the significant advantage of working in an integrated delivery network, the majority of my inpatients are linked to a pediatrician within our same system. Those pediatricians get notification that the child is or has been in the hospital or emergency room. They can be following along as I am managing the patient.
On occasion I've even reached out to the physician WHILE the patient was in house to gain the support of the physician. Our hospitalized patients have a special relationship with their pediatrician - it is a trusted relationship often that has lasted several years. The pediatrician can provide reassurance to the parents that we too can be trusted to provide the best care for their child - I do this especially if I see that the family has been emailing the physician about the child's problem WHILE they are hospitalized.
If I want the pediatrician to simply know what happened the encounter will be routed automatically, so unless I am specifically worried about the pediatrician not reading the portion of my note that lists follow up needs, I do not specifically route the chart to them as I know it creates additional inbox work for them. We also have the benefit of a secure texting app on our work phones, so if there is something specific, I will text and ask to speak to the pediatrician. For patients who are not part of our system, I will do one of two things, print my discharge summary and give it to the patient to provide to his/her/their doctor and circle the relevant follow up needs, or call the physician's office and ask to speak with the physician directly if I am fearful that the discharge summary might not make it there or the parent may not follow up with the physician. This is a bit of work but important.
2. The Sacramento Reverse Food Truck was co-founded by you in 2014. Can you tell us more about it?
When I was elected vice president of the chapter, AAP was starting to move social determinants of health onto the 'pizza' boxes of priorities. Nationally we were talking about food scarcity and the effects of poverty on health outcomes (I know it feels like we have always had this as a priority, but we haven't). My outpatient practice was in an affluent area and I didn't know if we had a problem in my community. I started to ask around. Long story short (very long story) we did. Almost 30% of our children in Sacramento were/are living in poverty. I was part of a community collaborative aimed at addressing food scarcity. I was coming home after my discovery adventures and this problem became dinner table conversation. My husband heard a story on NPR about a bar that was community mission driven and as an advertising gimmick, they rehabbed a food truck and collected nonperishable items at the bar to give to the community. Their slogan for the truck was 'we don't make food we take food'. My husband thought we should try to do something similar here - we reached out to the bar, and they gave us all their graphics and said - copy away! We thought that since we live in one of the biggest produce producing communities in the world, AND we knew that millions of pounds of produce rot on the ground in our community each year that we would collect fresh produce and delivery it to the food banks or local schools for the children and their families. The idea was to go to farmer's markets and ask people to buy extra food from the farmers and donate it to the truck (win for the farmers because they would sell more and win for the community because we could donate the produce). We collected thousands and thousands of pounds of food while we had the truck. I'll never forget one of the student's eyes when she saw the peaches we brought. She asked timidly as she was helping me carry food in if she could have one - I said they are for you, your friends and family, of course have as many as you'd like. She immediately grabbed one and started eating it. She told me that stone fruit were really expensive, and they never had it at home. Such a wonderful thing to be able to provide health, nutritious food to families.
Unfortunately, the people who own the farmer's market locally didn't really appreciate the concept and wanted to staff where we parked the truck for another vendor. We tried to have food drives in more affluent areas, but we really hadn't planned well for how we would promote or staff (and it was just my husband and I running it and relying on friends and volunteers to support). We ended up giving the truck to a local nonprofit who was pooling resources to provide meals to needy recipients and needed a truck with refrigeration. Still trying to decide what to do for our next project...
3. As the assistant physician in chief (APIC) at North Valley with the Permanente Medical Group, please tell us about your role and what your day-to-day is like.
Gosh. Well right now it is crazy because my leadership gave me the additional role of APIC of COVID Vaccine distribution for our Sacramento Service area. Yup that means I am the physician overseeing how we are going to deliver vaccine to well, everybody. Today we'll be continuing discussions with CalExpo on how to set up a clinic there. We are learning as we go; for example, we heard that HCW not affiliated with one of the major medical centers did not have access to vaccine so we opened up vaccines to health care workers who are not our employees. Not sure why we underestimated what the demand would be, but part of my role was to book appointments (not quite a leadership role but it needs to be done so we can get people in).
My other assignments in this role are APIC of our Women's and Children's center, APIC of Equity Inclusion and Diversity, and APIC of outpatient CQC measures. I think the short version of what I do day to day is help people solve problems. I facilitate QI projects, help people make connections with others with whom they can collaborate. I challenge people and create expectations for people to look for ways (and deliver) to provide better, safer care for our patients. I advocate and try to protect my docs and staff. I try to make sure they are taking care of themselves (oxygen mask model - you can't help others if you don't take care of yourself).
Of late I've been also trying to talk to people about tolerance in my role as APIC of Equity Inclusion and Diversity. With such polarized views we are trying to be mindful of what it means to be tolerant and respect diversity of opinion. Turns out this is pretty challenging...
4. You are a member of the Society of Hospital Medicine (SOHM) executive committee. How did you get involved, and where do you see SOHM in the next 5 years?
I had been on the Committee for Continuing Medical Education and loved that experience. I was looking for another way to be involved in AAP and this position came up. I love to learn how others are doing things - this seemed like a great opportunity to do that.
My hospital is sort of a mix. We are a hospital within a hospital, but we see extremely complex patients and are a tertiary referral center for our 90 mile catchment area. But we still refer patients out to a higher level of care as we do not have all services (transplant, ecmo, CV surgery) nor do we have a Pediatric Training program. Participation in the committee could only help our program grow.
5. Can you tell us more about Solutions for Patient Safety Pediatrics for which you are a physician lead? Providers are sometimes hesitant to report safety concerns due to negative repercussions—what do you tell people with these hesitations?
I actually just stepped away from this (too much on my plate). But to address the hesitation. We need to keep our children safe. We cannot have patients come into the hospital and be harmed.
No one comes to work wanting to make mistakes or wanting to hurt people. With rare exception safety events happen because the system was not set up for success. We need to report every problem and every near miss so we can prevent and address the holes in our system. Our reporting is largely anonymous, and we circle back to give follow up to the group on problems submitted and what we did to address. Again, the problems aren't about people; they are about processes, so we do our best to provide a safe place to talk about errors. We also are continuing to develop 2nd victim programs to support the emotional toll that making an error takes on our physicians and staff.
6. You have been very involved with medical education—you are the Chief of Medical Education and oversee education for 1700 physicians in the Sacramento Valley and previously served on the AAP National Committee on Medical Education. How do you see medical education changing in the next 5-10 years? Does the COVID-19 pandemic affect this?
I'm no longer CME chief, but I hope medical education continues to evolve into more active, engaging learning. This will be even harder in the virtual environment, but we have to get there to change behavior. The goals of CME are to change knowledge, competence, and behavior. The adage of see one, do one, teach one although obviously not meant for the way to develop expertise (that takes time and practice), but does hit on adult learning. Adults learn by being engaged. If you know you are doing the next one or teaching the next one, you pay attention in a different way, and you solidify your knowledge by doing. Even if the doing is repeating the fact or methodology that you learned. When I was helping faculty design educational activities, I asked them to consider what is it you want the learner to do at the end of the activity? That also requires really finding out where the learner is now and figuring out a way to help the learner get to where you want them to be. MANY times, that involves helping physicians to know HOW to do something not WHAT to do.
This is where I think more QI will come in and more and more be part of CME. I'm sure there will always be a role for knowledge-based education, but the key is always how do we get the knowledge into practice? I may know the right antibiotic to use for CAP, but why don't I use it?
This is also why I applied to be APIC. I wanted to foster more change of competence and performance. Many institutions are still stuck in 'butts in chairs' education (meaning how many butts can I get in chairs not necessarily how can I change behavior?) I wanted to have a greater impact on the population. Little did I know they would ask me to head CQC and COVID vaccines!! Careful what you wish for, huh?
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Respect the General Pediatrician. They are subspecialists in their own right and should be considered as such. Most general practices are insanely busy and the work continues well beyond clinic hours with the demands of the EMR. When we have a difficult family, we get to send them back to the PCP. When they have a difficult family, they have to continue to work with them until the child transitions to adult medicine.....And they are keeping more and more patients out of our hospitals managing increasingly complex issues as outpatients. They deserve the recognition as hard working experts in their field of outpatient pediatric medicine.
I have the significant advantage of working in an integrated delivery network, the majority of my inpatients are linked to a pediatrician within our same system. Those pediatricians get notification that the child is or has been in the hospital or emergency room. They can be following along as I am managing the patient.
On occasion I've even reached out to the physician WHILE the patient was in house to gain the support of the physician. Our hospitalized patients have a special relationship with their pediatrician - it is a trusted relationship often that has lasted several years. The pediatrician can provide reassurance to the parents that we too can be trusted to provide the best care for their child - I do this especially if I see that the family has been emailing the physician about the child's problem WHILE they are hospitalized.
If I want the pediatrician to simply know what happened the encounter will be routed automatically, so unless I am specifically worried about the pediatrician not reading the portion of my note that lists follow up needs, I do not specifically route the chart to them as I know it creates additional inbox work for them. We also have the benefit of a secure texting app on our work phones, so if there is something specific, I will text and ask to speak to the pediatrician. For patients who are not part of our system, I will do one of two things, print my discharge summary and give it to the patient to provide to his/her/their doctor and circle the relevant follow up needs, or call the physician's office and ask to speak with the physician directly if I am fearful that the discharge summary might not make it there or the parent may not follow up with the physician. This is a bit of work but important.
2. The Sacramento Reverse Food Truck was co-founded by you in 2014. Can you tell us more about it?
When I was elected vice president of the chapter, AAP was starting to move social determinants of health onto the 'pizza' boxes of priorities. Nationally we were talking about food scarcity and the effects of poverty on health outcomes (I know it feels like we have always had this as a priority, but we haven't). My outpatient practice was in an affluent area and I didn't know if we had a problem in my community. I started to ask around. Long story short (very long story) we did. Almost 30% of our children in Sacramento were/are living in poverty. I was part of a community collaborative aimed at addressing food scarcity. I was coming home after my discovery adventures and this problem became dinner table conversation. My husband heard a story on NPR about a bar that was community mission driven and as an advertising gimmick, they rehabbed a food truck and collected nonperishable items at the bar to give to the community. Their slogan for the truck was 'we don't make food we take food'. My husband thought we should try to do something similar here - we reached out to the bar, and they gave us all their graphics and said - copy away! We thought that since we live in one of the biggest produce producing communities in the world, AND we knew that millions of pounds of produce rot on the ground in our community each year that we would collect fresh produce and delivery it to the food banks or local schools for the children and their families. The idea was to go to farmer's markets and ask people to buy extra food from the farmers and donate it to the truck (win for the farmers because they would sell more and win for the community because we could donate the produce). We collected thousands and thousands of pounds of food while we had the truck. I'll never forget one of the student's eyes when she saw the peaches we brought. She asked timidly as she was helping me carry food in if she could have one - I said they are for you, your friends and family, of course have as many as you'd like. She immediately grabbed one and started eating it. She told me that stone fruit were really expensive, and they never had it at home. Such a wonderful thing to be able to provide health, nutritious food to families.
Unfortunately, the people who own the farmer's market locally didn't really appreciate the concept and wanted to staff where we parked the truck for another vendor. We tried to have food drives in more affluent areas, but we really hadn't planned well for how we would promote or staff (and it was just my husband and I running it and relying on friends and volunteers to support). We ended up giving the truck to a local nonprofit who was pooling resources to provide meals to needy recipients and needed a truck with refrigeration. Still trying to decide what to do for our next project...
3. As the assistant physician in chief (APIC) at North Valley with the Permanente Medical Group, please tell us about your role and what your day-to-day is like.
Gosh. Well right now it is crazy because my leadership gave me the additional role of APIC of COVID Vaccine distribution for our Sacramento Service area. Yup that means I am the physician overseeing how we are going to deliver vaccine to well, everybody. Today we'll be continuing discussions with CalExpo on how to set up a clinic there. We are learning as we go; for example, we heard that HCW not affiliated with one of the major medical centers did not have access to vaccine so we opened up vaccines to health care workers who are not our employees. Not sure why we underestimated what the demand would be, but part of my role was to book appointments (not quite a leadership role but it needs to be done so we can get people in).
My other assignments in this role are APIC of our Women's and Children's center, APIC of Equity Inclusion and Diversity, and APIC of outpatient CQC measures. I think the short version of what I do day to day is help people solve problems. I facilitate QI projects, help people make connections with others with whom they can collaborate. I challenge people and create expectations for people to look for ways (and deliver) to provide better, safer care for our patients. I advocate and try to protect my docs and staff. I try to make sure they are taking care of themselves (oxygen mask model - you can't help others if you don't take care of yourself).
Of late I've been also trying to talk to people about tolerance in my role as APIC of Equity Inclusion and Diversity. With such polarized views we are trying to be mindful of what it means to be tolerant and respect diversity of opinion. Turns out this is pretty challenging...
4. You are a member of the Society of Hospital Medicine (SOHM) executive committee. How did you get involved, and where do you see SOHM in the next 5 years?
I had been on the Committee for Continuing Medical Education and loved that experience. I was looking for another way to be involved in AAP and this position came up. I love to learn how others are doing things - this seemed like a great opportunity to do that.
My hospital is sort of a mix. We are a hospital within a hospital, but we see extremely complex patients and are a tertiary referral center for our 90 mile catchment area. But we still refer patients out to a higher level of care as we do not have all services (transplant, ecmo, CV surgery) nor do we have a Pediatric Training program. Participation in the committee could only help our program grow.
5. Can you tell us more about Solutions for Patient Safety Pediatrics for which you are a physician lead? Providers are sometimes hesitant to report safety concerns due to negative repercussions—what do you tell people with these hesitations?
I actually just stepped away from this (too much on my plate). But to address the hesitation. We need to keep our children safe. We cannot have patients come into the hospital and be harmed.
No one comes to work wanting to make mistakes or wanting to hurt people. With rare exception safety events happen because the system was not set up for success. We need to report every problem and every near miss so we can prevent and address the holes in our system. Our reporting is largely anonymous, and we circle back to give follow up to the group on problems submitted and what we did to address. Again, the problems aren't about people; they are about processes, so we do our best to provide a safe place to talk about errors. We also are continuing to develop 2nd victim programs to support the emotional toll that making an error takes on our physicians and staff.
6. You have been very involved with medical education—you are the Chief of Medical Education and oversee education for 1700 physicians in the Sacramento Valley and previously served on the AAP National Committee on Medical Education. How do you see medical education changing in the next 5-10 years? Does the COVID-19 pandemic affect this?
I'm no longer CME chief, but I hope medical education continues to evolve into more active, engaging learning. This will be even harder in the virtual environment, but we have to get there to change behavior. The goals of CME are to change knowledge, competence, and behavior. The adage of see one, do one, teach one although obviously not meant for the way to develop expertise (that takes time and practice), but does hit on adult learning. Adults learn by being engaged. If you know you are doing the next one or teaching the next one, you pay attention in a different way, and you solidify your knowledge by doing. Even if the doing is repeating the fact or methodology that you learned. When I was helping faculty design educational activities, I asked them to consider what is it you want the learner to do at the end of the activity? That also requires really finding out where the learner is now and figuring out a way to help the learner get to where you want them to be. MANY times, that involves helping physicians to know HOW to do something not WHAT to do.
This is where I think more QI will come in and more and more be part of CME. I'm sure there will always be a role for knowledge-based education, but the key is always how do we get the knowledge into practice? I may know the right antibiotic to use for CAP, but why don't I use it?
This is also why I applied to be APIC. I wanted to foster more change of competence and performance. Many institutions are still stuck in 'butts in chairs' education (meaning how many butts can I get in chairs not necessarily how can I change behavior?) I wanted to have a greater impact on the population. Little did I know they would ask me to head CQC and COVID vaccines!! Careful what you wish for, huh?
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Respect the General Pediatrician. They are subspecialists in their own right and should be considered as such. Most general practices are insanely busy and the work continues well beyond clinic hours with the demands of the EMR. When we have a difficult family, we get to send them back to the PCP. When they have a difficult family, they have to continue to work with them until the child transitions to adult medicine.....And they are keeping more and more patients out of our hospitals managing increasingly complex issues as outpatients. They deserve the recognition as hard working experts in their field of outpatient pediatric medicine.