Building a Career in Pediatric Hospital Medicine

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Building a Career in Pediatric Hospital Medicine

• Jennifer Daru, MD, FAAP
• September 11, 2008

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(No Transcript)
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Disclosure

• I have no disclosures.

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Objectives

• To examine what a career in pediatric hospital
  medicine (PHM) might be like
• To understand why you should or shouldn't pursue
  a fellowship in PHM
• To appreciate what skill sets are required to be
  a successful hospitalist
• Darus Goal To give you a sense of the field,
  where its going, the language involved and how
  you can contribute to it as you progress through
  your career

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• The general pediatrician who specializes in
  inpatient practice rides the wave of the future.
• Menna VJ. Inpatient Care The General
  Pediatricians Future. Pediatr in Rev
  199012(6)165-6

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Resident Interest in PHM Increasing
Daru, JA et al, Pediatric Hospital Medicine as a
Career Trainee Perspective, PAS 2008
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Career Wanted Pediatric Hospitalist

• Do you like pediatric inpatient medicine?
• Not interested in doing another three years of
  training?
• Join us! (P.S. We have got lots of jobs, youll
  be paid by a hospital, your malpractice will be
  covered and you can do shift work!)
• P.P.S. Youll have to cover nights, weekends and
  holidays and respond to hospital administrators

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Hospital Medicine Past,Present and Your Future
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Hospitalists History and Definition

• 1996 Wachter coins term Hospitalist
• Physicians who spend at least 25 of their time
  serving as the physician of record for
  hospitalized patients who have been referred by
  primary care physicians and who are referred back
  to their primary care physicians at the time of
  discharge (Wachter, 1997)
• 1998 National Association of Inpatient
  Physicians holds first meeting (now the Society
  of Hospital Medicine)
• 2003 The tri-sponsored conference is born San
  Antonio, Texas

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History (continued)

• 2003 AAP Section on Hospital Care (now Hospital
  Medicine) Produces paper Guiding Principles of
  Pediatric Hospitalist Programs
• 2003 First textbook comes out
• 2005 Added to the dictionary
• 2006 The Journal of Hospital Medicine
• 2007 Ambulatory Pediatric Association becomes
  Academic Pediatric Association another textbook
• 2007 The first news journal for Pediatric
  Hospital Medicine is born Hospital Pediatrics

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Define yourself or be defined

• A hospitalist is a physician who specializes in
  treating hospitalized patients of other
  physicians in order to minimize the number of
  hospital visits by other physicians.
• (Miriam Webster 2005)
• Physicians whose primary professional focus is
  the general medical care of hospitalized
  patients. Their activities include patient care,
  teaching, research, and leadership related to
  hospital medicine.
• (SHM)

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Understand Hospitalist Mandates
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Your Personal Job Mandates

• Full-time vs. Part-time
• Academic vs. Non-Academic
• Purely clinical vs. Clinical Administrative
• Career-building Career-evolving vs. Career
  (Income) maintenance

Thanks to Doug Carlson
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Your Personal Life Mandates

• Commitments to
• Yourself (health, sleep, love)
• Family
• Friends
• Fun

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Take Your Mandates andFind Some Mentorship
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Top 10 Qualities of a Good Mentor

• 1. Willingness to share skills, knowledge, and
  expertise
• 2. Demonstrates a positive attitude and acts as
  a role model
• 3. Takes personal interest in the mentoring
  relationship
• 4. Exhibits enthusiasm in the field
• 5. Values ongoing learning and growth in the
  field

http//internships.about.com/od/internships101/tp/
MentQualities.htm Accessed9/7/08
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Top 10 Qualities of a Good Mentor

• 6. Provides guidance and constructive feedback
• 7. Respected by colleagues and employees in all
  levels of the organization
• 8. Sets and meets ongoing personal and
  professional goals
• 9. Values the opinions and initiatives of others
• 10. Motivates others by setting a good example

http//internships.about.com/od/internships101/tp/
MentQualities.htm Accessed9/7/08
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How to Find a Mentor

• Invite someone to lunch
• Known person
• Unknown person
• AAP SOHM developing individual mentorship list
• Or use the AAP Listserv
• Network at Conference

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Discussion Topics with Mentor

• Where do you want to work and what kind of job
  do you want?
• Rural vs. Suburban vs. Urban
• Community vs. academic
• Advantages and Disadvantages of fellowship
• Explore any opportunities carefully
• Call me (or others) to discuss

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Location and Your Vocation
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Smaller/Rural/Community Hospitals

• In general more ED or NICU based work
• Pediatric pts
• The ward may struggle to maintain a census
• Your role front-line diagnostician, specialist
  replacement, child advocate and educator
• Rapid Career advancement (CHAIR?) possible

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Large / Academic Centers

• You are a smaller player in a big machine
• Specialists support patients along with you
• More complex patients, but buck doesnt stop with
  you
• Opportunities for mentorship are increased
• You may participate in education of others
• Over time, hospitalists are playing larger
  administrative roles
• VPMA, CMO, Chair, Chief Quality Officer

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Is FellowshipRight For You?

• Know the options and goals

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Why Fellowships Exist

• AAP says
• Goal of subspecialty training is to advance the
  health of children by preparing graduates who are
  competent in clinical care, education, and
  research
• Academic Hospitalist Leaders feel
• Research is the key to driving the field of
  Hospital Medicine forward

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Learning Comes in Many Forms How Residents Want
to be Trained
Daru, JA et al, Pediatric Hospital Medicine as a
Career Trainee Perspective, PAS 2008
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Considering a Fellowship
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Pro-Fellowship Points

• Trains Physicians for Careers in Academia and
  beyond
• Will learn how to perform research and contribute
  to developing field of medicine that sorely needs
  it
• Clinical Advancement
• Participate in Medical Education
• Currently a Two Year commitment
• Specialty Boards coming soon? Then its 3!
• May also allow for Public Health Degree or MBA

Thanks to Rana Kronfol
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Fellowship List

• Children's Specialists San Diego (affiliated with
  UCSD)
• National Medical Center (Washington, DC)
• Baylor College of Medicine (affiliated withTexas
  Children's Hospital, Houston)
• Children's Hospital at Boston (affiliated with
  Harvard)
• University of South Florida
• Emory
• Sick Kids in Toronto
• Your local hospital?

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Con-Fellowship Points

• Residency training should be good enough to get
  you going
• Jobs too diverse for fellowship to prepare you
  appropriately
• Not everyone should or wants to do research
• Loan Deferment is too expensive
• Fellowship may not increase your take home

Thanks to David Rappaport
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The Future of the Field
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Board Certification vs. Recognition of Focused
Practice

• Defining a Subspecialty (Board-certified)
• Constitutes a body of knowledge or technique
  beyond that of the broad discipline
• Requires additional training and directly
  supervised performance of procedures /
  application of specific practice methods by
  experts in the field.
• Involves applying medicine AND
  specialized knowledge and procedures to a subset
  of patients.

(American Board of Internal Medicine Website)
http//www.abim.org/news/news/hospital-medicine-q
a.aspx
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Recognition of Focused Practice Favored in
Internal Medicine

• In contrast, hospital medicine is the practice of
  medicine for patients during
  hospitalization.
• Thus, the exploration of a Recognition of Focused
  Practice
• Received after practicing for some time, passing
  a test, etc.
• Pediatric Hospital Medicine likely to follow
  adult lead

(American Board of Internal Medicine Website)
http//www.abim.org/news/news/hospital-medicine-q
a.aspx
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Your Future Your Job
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Resources for a Job as a Hospitalist

• Your friendly neighborhood Hospitalist
• Call hospitals, ask for hospitalist or
  director/chair
• Jennifer Daru - daruj_at_sutterhealth.org
• AAP SOHM website
• Winter 2006 Publication PHM Career Wanted
• Pediatric Hospitalist Program of North America
  Database
• Join Listserv
• SHM website
• A White Paper on Hospitalist Career Satisfaction.
  SHM Career Satisfaction Task Force, December, 2006

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Selecting a Job

• Step 1 What areas does the team cover and what
  skill sets are expected vs. mentored?
• What does the job expect of you?
• Step 2 Is the job structured to make it
  sustainable for the long term?
• What do you expect of the job?

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Questions to Ask

• What is the goal of the Hospitalist team?
• How is the job structured?
• How long has the program been in place?
• What skills sets am I expected to have?
• How will I be mentored in these skill sets?
• How are schedules done (seniority, equality)?
• How does the organization support my personal
  goals (vacation, family, travel, volunteerism)?

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More Questions to Consider

• How do you support advancement of my career?
• What reward systems does the team have in place?
  (salary strategy, incentives)
• What is the relationship between administration
  and the program?
• What is the relationship between local doctors
  and the program?
• What is the age distribution of physicians on the
  team?
• What happens when the team is short staffed?
• Can I see the call room?

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Hospitalists Participate in Many Areas of Care
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Neonatal Critical Care Hospitalists Bring Needed
Skills

• Umbilical catheterization
• Endotracheal intubation
• Arterial and venous blood draws
• Percutaneous and central line placement
• Lumbar puncture
• Thoracentesis
• Exchange transfusion
• Suprapubic tap

Carlson D et al. Pediatric Hospitalists filled
varied roles in the care of newborns. Pediatric
Annals. 200332(12) 802-810.
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Pediatric Critical Care Hospitalists Bring
Needed Skills

• Bag-valve-mask ventilation
• Endotracheal intubation
• Femoral venous line placement
• PICC line placement
• Thoracentesis
• Thoracostomy tube placement
• Joint Aspiration
• Arterial line placement
• Paracentesis
• Intraosseous placement

Swift, J. Integrating Hospitalists into the
Pediatric Intensive Care Unit. Pediatric Annals.
2003 32(12)813-816.
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Ward Patient Care Hospitalists Bring Needed
Skills

• PALS certification and associated skill sets
• NRP certification and associated skill sets
• Chest tube placement
• Intravenous line placement
• Lumbar puncture
• Suprapubic tap
• Urinary catheterization
• Venous and arterial blood draw

From Gill J, Daru JA. Community Pediatricians
Collaborate with Hospitalists to Build a better
Ward Service. Pediatric Annals. 2003
32(3)791-796.
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Benefits Hospitalists Bring

• Achievement of Quality Measures
• Asthma
• Pediatric Rapid Response Teams
• Increase in patient safety
• Increase in patient satisfaction
• Increase in primary care provider satisfaction
• Added knowledge and experience to inpatient
  scenarios

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Good Characteristics for a Hospitalist

• Able to lead a team of caregivers
• Able to get the job done under pressure
• Pressure may be a difficult situation or a busy
  day
• Knows where to go for help
• During a code, diagnostic dilemma or career
  crisis
• Politically savvy
• Has a flexible family
• You may be home after school, but gone at night

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Avoid the Pitfalls

• Assess program for longevity
• Assess job structure for the support you need
• Avoid burnout

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Resident Perception of Longevity of Pediatric
Hospital Medicine Positions
Unsure 4
Long-term Career 26
Either Long-term or Short-term 49
Short-term Opportunity 21
Daru, JA et al, Resident Exposure to and
Perception of Pediatric Hospital Medicine, PAS
2008
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Framework for Career Satisfaction
A White Paper on Hospitalist Career Satisfaction.
SHM Career Satisfaction Task Force, December, 2006
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Job Fit

• Task Control control over when, how, and how
  quickly a task is done
• Decision/Organizational Control control over
  task assignment and policies
• Physical Environment Control control over the
  location, layout, and climate of where work is
  done
• Resource Control control over the availability
  of support staff, supplies, and materials

A White Paper on Hospitalist Career Satisfaction.
SHM Career Satisfaction Task Force, December, 2006
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Avoiding Burnout

• 1970 Maslach and Jackson invent construct of
  burnout
• Emotional exhaustion
• Depersonalization
• Reduced sense of personal accomplishment
• Hospitalists at high risk

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Growing Your Practice and Your Success

• Find where you fit in,
• Contribute to the field,
• Record everything!

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Get Basics Down, Know Goals

• Build your skill sets as a diagnostician and a
  proceduralist and then go beyond this
• Build a practice you will be proud of when you
  retire
• Decide where you want to go
• Happy where you are
• Want to become part of leadership locally or
  nationally
• Want to become part of administration
• Develop a Specialty (quality, abuse, pain)

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Want Advancement?

• Build Your CV/Portfolio
• Publish, Publish, Publish
• Get involved nationally
• Opportunities abound
• Consider an additional degree
• MBA, MPH

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Promotion Portfolio

• If you dont document it, youre not doing it
• Try to develop a theme or focus
• More than just publications and grants
• Clinical Contributions
• Educational Contributions
• Community Service Contributions
• Research Contributions (grants, scientific
  publications)
• References

With Thanks to Liza Zaoutis, Pediatric Hospital
Medicine Conference 2008
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Clinical Contributions

• Direct or supervisory patient care (service)
• Quantity shifts, weeks, blocks, months
• Busy-ness e.g., encounters/day
• Call in-hospital or from home
• Procedures
• New clinical programs that youve developed
• Clinical administrative responsibilities
• e.g., clinical director of area or program
• e.g., NP supervisor
• Participation in clinical trials

With Thanks to Liza Zaoutis, Pediatric Hospital
Medicine Conference 2008
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Clinical Contributions (contd)

• Clinical pathways or guidelines that youve
  developed or implemented
• Quality initiatives
• Member or leader
• Committee, working group, task force
• New policy or procedures
• Other innovations (e.g., new sign-out system,
  new rounding method, new communication
  techniques, billing updates)

With Thanks to Liza Zaoutis, Pediatric Hospital
Medicine Conference 2008
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Clinical Contributions (contd)

• Feedback you give
• To med students
• To residents/fellows
• To NPs or other staff
• Feedback you get
• From staff
• From trainees
• From families

With Thanks to Liza Zaoutis, Pediatric Hospital
Medicine Conference 2008
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Educational Contributions

• Didactic teaching session
• Everyone, every time
• Intra-institutional, regional, national,
  international
• Keep evaluations (if theyre good)
• Curriculum development (e.g., rotations,
  electives)
• New handouts, syllabi, reading lists
• Simulation models (e.g., mock codes)
• Assessment tool development (e.g., exam
  questions, OSCE)

With Thanks to Liza Zaoutis, Pediatric Hospital
Medicine Conference 2008
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Educational Contributions (contd)

• Mentorship
• Development of CME courses, workshops
• Education-related publications
• Case reports
• Book chapters
• Abstracts, articles
• Teaching awards

With Thanks to Liza Zaoutis, Pediatric Hospital
Medicine Conference 2008
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Community Service Contributions

• Institutional committees/activities
• Division, Department
• Hospital
• School of Medicine, University
• Extra-institutional committees/activities
• Local, regional, national
• Media (newspaper, radio, TV, website)

With Thanks to Liza Zaoutis, Pediatric Hospital
Medicine Conference 2008
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References

• Those you have taught
• Students (medical, nursing, etc)
• Residents, fellows
• Peers (CME, other colleagues)
• Colleagues
• Supervisors
• Administrators, nonclinical collaborators
• Patients and families
• Extramural consultants

With Thanks to Liza Zaoutis, Pediatric Hospital
Medicine Conference 2008
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Other Insider tips for Success

• Be able to describe what a Hospitalist is and
  know the name of your field (Hospital Medicine)
• Remember that you represent the hospital in all
  of your interactions as a physician
• Know this
• Do Hospitalists make their salaries?
• Keep an eye on the future of the field

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Know the Future of PHM

• Expanding Patient Care Realms
• Medically Complex Kids
• Transport
• Sedation
• Quality Improvement
• Practice guidelines
• Outcomes research
• Board Certification/Recognition of Focused
  Practice
• Similar to Intensivists, ED?
• Mentorship

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At the end of the day

• Be happy in your life
• Your job is one piece of this
• Build career you will be proud of when you retire
• This means building a pediatric hospital program
  that contributes to its community (large or
  small) by providing the care children need in a
  safe, family-focused environment regardless of
  resources available but in a sustainable way.

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Thank You!

• Jennifer Daru, MD, FAAP
• Chief, Division of Pediatric Hospital Medicine
• California Pacific Medical Center
• daruj_at_sutterhealth.org
• 415-600-0758