Some questions pediatric hospitalists still need to consider: Can you fill a void? Is there sufficient novel material for creating a certifying exam? Are there enough people who would take this exam? How will physicians view maintenance of certification? Where will the naysayers come from? What will be the response from primary care general pediatricians? What will be the response from academic generalists/pediatricians? What will be the subspecialist response?
Dr. Ludwig expressed one concern succinctly: “You might ultimately decrease the number of practitioners willing to make the commitment.”
Dr. Wellikson concurred. “Those of you who are group leaders are constantly in a recruiting mode,” he said. “You need something to help you determine who is good and who is not, but adding three years may drive those who would have been great pediatric hospitalists to become great pediatric anesthesiologists.”
In the end, the group could not agree on an answer. “You have an amazing amount of excitement,” said Dr. Ludwig. “Temper your excitement with focus. You need to decide whether becoming another subspecialty is what you want.”
SOMETHING FOR EVERYONE
The conference offered a broad range of learning opportunities.
Those interested in research heard about opportunities to collaborate and learned how to share resources and develop research projects.
Educators—and aren’t all hospitalists involved in education at some level?—learned “Seven Simple Secrets to Successful Supervision” from Vinny Chiang, MD, chief of inpatient services at Children’s Hospital, Boston. He says the single most powerful question you can ask as an educator is, “What do you think?”
“The med student may say, ‘I think the kid is sick.’ The intern may say, ‘I think it’s rejection.’ The resident may say, ‘We need to distinguish between infection and rejection,’” said Dr. Chiang. By asking this question, he said, “You make that trainee an active participant.”
Evidence-based medicine and the use of pathways were also on the agenda. The discussions started with the basics, defining terms. According to Dr. Chiang, evidence-based medicine is, “the conscientious, explicit, and judicious use of current best evidence in making a clinical decision.” (See also “Evidence-Based Medicine for the Hospitalist,” p. 22.)
Pathways, developed from that best evidence, are tools that guide clinical care. “It’s the same as with calculators and PDAs,” said Stephen E. Muething, MD, associate director of clinical services at Cincinnati Children’s Hospital. “A pathway is a tool that allows a resident to spend their time identifying the 20% who shouldn’t be on the pathway and figuring out what to do for them.”
“Medicine can be systematized,” said Dr. Wellikson. “You can have best practices.”
Attendees expressed concerns that pathways may not leave room for a hospitalist’s judgment.
“There is no pathway that addresses 100% of patients,” said Dr. Muething. “A pathway should be defined as a guideline not a standard of care. From a medicallegal standpoint, you need to document why you deviated from a pathway. You still need to use clinical judgment. Don’t forget to think.”
One reason to use pathways, according to Dr. Muething, is that you can more rapidly identify what works and what doesn’t. “If everyone is doing it the same way,” he said, “then even if everyone is doing it wrong, you’ll be able to identify the problem and resolve it more quickly, improving outcome.”
Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.
—Erin Stiucky, MD