Mark Shen, MD

Clinical question: What is the incidence of apnea in infants hospitalized with respiratory syncytial virus (RSV) bronchiolitis?

Background: Apnea is a known and reported complication of RSV infection in infants. In clinical practice, this relationship could be the basis for admission despite a lack of symptoms that would otherwise necessitate hospitalization. The exact nature of this association remains unclear, specifically with respect to incidence and risk factors for apnea.

Study design: Systematic chart review.

Synopsis: A literature search was conducted using a combination of the terms “apnea” (or “apnoea”), “bronchiolitis,” “respiratory syncytial virus” and/or “lower respiratory tract infection.” Studies were included if they reported apnea rates for a consecutive cohort of hospitalized infants. Thirteen studies involving 5,575 patients were reviewed.

Rates of apnea ranged from 1.2% to 23.8%. Infants of younger, postconceptional age (≤44 weeks) and pre-term infants were at greater risk for apnea. Term infants without serious underlying illness appeared to have a <1% risk of apnea, based on the most recent studies.

A consistent finding of this review was the heterogeneity of the data in the included studies. Definitions of apnea varied, were broad, and included subjective criteria. Age stratification was infrequent. Inclusion and exclusion criteria were variable with respect to age cutoffs and relevant comorbidities. Future research will need to carefully delineate all of these potential confounding variables.

Bottom line: While rates of apnea in RSV bronchiolitis are difficult to quantify, there appears to be an association with younger, postconceptional age and pre-term birth.

Citation: Ralston S, Hill V. Incidence of apnea in infants hospitalized with respiratory syncytial virus bronchiolitis: a systematic review. J Pediatr. 2009;155(5):728-733.

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the incidence of apnea in infants hospitalized with respiratory syncytial virus (RSV) bronchiolitis?

Background: Apnea is a known and reported complication of RSV infection in infants. In clinical practice, this relationship could be the basis for admission despite a lack of symptoms that would otherwise necessitate hospitalization. The exact nature of this association remains unclear, specifically with respect to incidence and risk factors for apnea.

Study design: Systematic chart review.

Synopsis: A literature search was conducted using a combination of the terms “apnea” (or “apnoea”), “bronchiolitis,” “respiratory syncytial virus” and/or “lower respiratory tract infection.” Studies were included if they reported apnea rates for a consecutive cohort of hospitalized infants. Thirteen studies involving 5,575 patients were reviewed.

Rates of apnea ranged from 1.2% to 23.8%. Infants of younger, postconceptional age (≤44 weeks) and pre-term infants were at greater risk for apnea. Term infants without serious underlying illness appeared to have a <1% risk of apnea, based on the most recent studies.

A consistent finding of this review was the heterogeneity of the data in the included studies. Definitions of apnea varied, were broad, and included subjective criteria. Age stratification was infrequent. Inclusion and exclusion criteria were variable with respect to age cutoffs and relevant comorbidities. Future research will need to carefully delineate all of these potential confounding variables.

Bottom line: While rates of apnea in RSV bronchiolitis are difficult to quantify, there appears to be an association with younger, postconceptional age and pre-term birth.

Citation: Ralston S, Hill V. Incidence of apnea in infants hospitalized with respiratory syncytial virus bronchiolitis: a systematic review. J Pediatr. 2009;155(5):728-733.

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the incidence of apnea in infants hospitalized with respiratory syncytial virus (RSV) bronchiolitis?

Background: Apnea is a known and reported complication of RSV infection in infants. In clinical practice, this relationship could be the basis for admission despite a lack of symptoms that would otherwise necessitate hospitalization. The exact nature of this association remains unclear, specifically with respect to incidence and risk factors for apnea.

Study design: Systematic chart review.

Synopsis: A literature search was conducted using a combination of the terms “apnea” (or “apnoea”), “bronchiolitis,” “respiratory syncytial virus” and/or “lower respiratory tract infection.” Studies were included if they reported apnea rates for a consecutive cohort of hospitalized infants. Thirteen studies involving 5,575 patients were reviewed.

Rates of apnea ranged from 1.2% to 23.8%. Infants of younger, postconceptional age (≤44 weeks) and pre-term infants were at greater risk for apnea. Term infants without serious underlying illness appeared to have a <1% risk of apnea, based on the most recent studies.

A consistent finding of this review was the heterogeneity of the data in the included studies. Definitions of apnea varied, were broad, and included subjective criteria. Age stratification was infrequent. Inclusion and exclusion criteria were variable with respect to age cutoffs and relevant comorbidities. Future research will need to carefully delineate all of these potential confounding variables.

Bottom line: While rates of apnea in RSV bronchiolitis are difficult to quantify, there appears to be an association with younger, postconceptional age and pre-term birth.

Citation: Ralston S, Hill V. Incidence of apnea in infants hospitalized with respiratory syncytial virus bronchiolitis: a systematic review. J Pediatr. 2009;155(5):728-733.

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

The putrid smell of vomit wafted behind me, flowing in and out of my nostrils with each up and down of our boat. Two in our deep-sea-fishing party already had lost their breakfast; I was focused on keeping mine down. The ocean seemed fairly calm, but I didn’t feel very steady. In fact, I felt like I was on a bamboo raft that had been tied together with palm fronds.

In between thoughts of how I would have been ostracized as a seafaring Polynesian, I had one thought on my mind. “Keep your eyes on the horizon,” our captain had said as we boarded the boat. My eyes were not going anywhere else that day. The horizon, whether the coastline of Oahu or just the thin line between ocean blue and sky blue, provided an unwavering constant as the waves changed our position minute by minute.

Our daily work as hospitalists is filled with ups and downs—waves, if you will. At times they threaten to capsize us; at others, they provide a short boost of momentum. These waves come in many forms, whether a busy teaching service, an interaction with a consultant, or your personal schedule. And all too often, that constant cyclical motion becomes hypnotizing. All of us have encountered colleagues that get lost at sea; they seem to always focus on that constant sense of unsteadiness. We recognize this form of despair as whining, and it’s not far removed from motion sickness. The only difference is the specific sense that is assaulted when the victim can no longer handle the ride.

Chart a Course to Success

If the captain of our fishing charter had been a business instructor, the lesson for the day would have been strategic planning. If he had been a medical school professor—well, there probably is no suitable analogy, as the path to organizational success isn’t yet a part of our core curriculum. Strategic planning is the deceptively simple process by which you ensure that you are headed toward your ultimate vision; it’s how you, your group, or your field charts its course toward the horizon.

Medicine has been in the habit of learning from business lately. Toyota’s strategy is a prime example. Their core strategic plan is termed “Lean” production or practices. Continuous quality improvement, though an oversimplification, is a substitute phrase that all hospitalists should recognize. Amazingly, Toyota’s strategic plan extends 50 to 100 years into the future and is intertwined into each and every phase of the company. Although the Lean system is being carefully studied and applied by many in the healthcare industry, the true hidden curriculum lies not in the details of their practices, but rather in their choice and execution of strategy. Toyota’s impressive history of achievement contains a few valuable lessons applicable to your own future success.

At one time, Toyota was a newcomer to the established field of automobile manufacturing, not dissimilar to the current state of most pediatric hospitalists. Like us, they undoubtedly faced uphill battles surrounding established cultural barriers and rigid practice patterns. And despite giving up more than half a century to Ford and the concept of mass production, Toyota has become the leading manufacturer of automobiles in the world.

How did Toyota choose and execute a strategy that allowed it to thrive in the face of such obstacles? In the beginning, there probably were many strategic options. They could have decided to focus on creating a specific product, such as the “ultimate driving machine,” or cars that are boxy but safe. They could have opted to cater to a specific consumer class, perhaps building a strong fleet of affordable autos. Or they could have looked to improve their purchasing power and distribution methods (think Dell and Walmart).

Instead, they made a conscious decision to pursue excellence in reliability, quality, and value (sound familiar?), then followed through beautifully.

Strategy at Home

Despite differences in industry and scale, all of these same sorts of decisions are critical to the success of your career, your HM group, or even the field of pediatric HM. Are you aware of the specific strategies in place for your group’s success? Have you been involved in the process? Before this year, I was probably like most of you. I had some vague notion of success. It involved increasing relative value units, making everyone happy, and completing a big QI or research project.

In the past 12 months, however, I have taken part in three strategic planning sessions: one for a regional pediatric society, one for my hospital, and one for my hospitalist group. The importance of these processes crystallized for me. Apparently, the leaders in our field have had the same thoughts. They convened the Pediatric Hospital Medicine Roundtable, a strategic planning session for our field (see “All Grown Up,” p. 1). Clearly, 2009 is the year of the strategic plan.

Despite the unifying theme, the processes and products of all of these plans have been unique. Strategic plans must be developed organically, out of local context and environment, and can only be created by those who live and breathe the work. What works for group safety at the university hospital of quality focus might not work for group communication experts at suburban community hospitals. Differences in institutional, organizational, and cultural beliefs should affect the decision-making process. When a strategy has been devised, it should be carefully chosen and explicitly implemented.

Does your group’s strategy come to mind? Or are you just treading water, unable to see beyond the next looming wave? If you have a vision of what you want, whether it’s money, fame, or protected time, then this same line of reasoning should apply to the strategic plan for your individual career, as well as the future of pediatric HM.

The lesson here is simple: Success requires a plan. Strategic planning is how you set a vision for the future and chart that course. Unexpected political waves are sure to come, and not every victory will come with a prize catch. But if you can create that beautiful Impressionist painting on the horizon and maintain that course, you are less likely to lose your breakfast and go without lunch. TH

Dr. Shen is The Hospitalist’s pediatric editor.

The putrid smell of vomit wafted behind me, flowing in and out of my nostrils with each up and down of our boat. Two in our deep-sea-fishing party already had lost their breakfast; I was focused on keeping mine down. The ocean seemed fairly calm, but I didn’t feel very steady. In fact, I felt like I was on a bamboo raft that had been tied together with palm fronds.

In between thoughts of how I would have been ostracized as a seafaring Polynesian, I had one thought on my mind. “Keep your eyes on the horizon,” our captain had said as we boarded the boat. My eyes were not going anywhere else that day. The horizon, whether the coastline of Oahu or just the thin line between ocean blue and sky blue, provided an unwavering constant as the waves changed our position minute by minute.

Our daily work as hospitalists is filled with ups and downs—waves, if you will. At times they threaten to capsize us; at others, they provide a short boost of momentum. These waves come in many forms, whether a busy teaching service, an interaction with a consultant, or your personal schedule. And all too often, that constant cyclical motion becomes hypnotizing. All of us have encountered colleagues that get lost at sea; they seem to always focus on that constant sense of unsteadiness. We recognize this form of despair as whining, and it’s not far removed from motion sickness. The only difference is the specific sense that is assaulted when the victim can no longer handle the ride.

Chart a Course to Success

If the captain of our fishing charter had been a business instructor, the lesson for the day would have been strategic planning. If he had been a medical school professor—well, there probably is no suitable analogy, as the path to organizational success isn’t yet a part of our core curriculum. Strategic planning is the deceptively simple process by which you ensure that you are headed toward your ultimate vision; it’s how you, your group, or your field charts its course toward the horizon.

Medicine has been in the habit of learning from business lately. Toyota’s strategy is a prime example. Their core strategic plan is termed “Lean” production or practices. Continuous quality improvement, though an oversimplification, is a substitute phrase that all hospitalists should recognize. Amazingly, Toyota’s strategic plan extends 50 to 100 years into the future and is intertwined into each and every phase of the company. Although the Lean system is being carefully studied and applied by many in the healthcare industry, the true hidden curriculum lies not in the details of their practices, but rather in their choice and execution of strategy. Toyota’s impressive history of achievement contains a few valuable lessons applicable to your own future success.

At one time, Toyota was a newcomer to the established field of automobile manufacturing, not dissimilar to the current state of most pediatric hospitalists. Like us, they undoubtedly faced uphill battles surrounding established cultural barriers and rigid practice patterns. And despite giving up more than half a century to Ford and the concept of mass production, Toyota has become the leading manufacturer of automobiles in the world.

How did Toyota choose and execute a strategy that allowed it to thrive in the face of such obstacles? In the beginning, there probably were many strategic options. They could have decided to focus on creating a specific product, such as the “ultimate driving machine,” or cars that are boxy but safe. They could have opted to cater to a specific consumer class, perhaps building a strong fleet of affordable autos. Or they could have looked to improve their purchasing power and distribution methods (think Dell and Walmart).

Instead, they made a conscious decision to pursue excellence in reliability, quality, and value (sound familiar?), then followed through beautifully.

Strategy at Home

Despite differences in industry and scale, all of these same sorts of decisions are critical to the success of your career, your HM group, or even the field of pediatric HM. Are you aware of the specific strategies in place for your group’s success? Have you been involved in the process? Before this year, I was probably like most of you. I had some vague notion of success. It involved increasing relative value units, making everyone happy, and completing a big QI or research project.

In the past 12 months, however, I have taken part in three strategic planning sessions: one for a regional pediatric society, one for my hospital, and one for my hospitalist group. The importance of these processes crystallized for me. Apparently, the leaders in our field have had the same thoughts. They convened the Pediatric Hospital Medicine Roundtable, a strategic planning session for our field (see “All Grown Up,” p. 1). Clearly, 2009 is the year of the strategic plan.

Despite the unifying theme, the processes and products of all of these plans have been unique. Strategic plans must be developed organically, out of local context and environment, and can only be created by those who live and breathe the work. What works for group safety at the university hospital of quality focus might not work for group communication experts at suburban community hospitals. Differences in institutional, organizational, and cultural beliefs should affect the decision-making process. When a strategy has been devised, it should be carefully chosen and explicitly implemented.

Does your group’s strategy come to mind? Or are you just treading water, unable to see beyond the next looming wave? If you have a vision of what you want, whether it’s money, fame, or protected time, then this same line of reasoning should apply to the strategic plan for your individual career, as well as the future of pediatric HM.

The lesson here is simple: Success requires a plan. Strategic planning is how you set a vision for the future and chart that course. Unexpected political waves are sure to come, and not every victory will come with a prize catch. But if you can create that beautiful Impressionist painting on the horizon and maintain that course, you are less likely to lose your breakfast and go without lunch. TH

Dr. Shen is The Hospitalist’s pediatric editor.

The putrid smell of vomit wafted behind me, flowing in and out of my nostrils with each up and down of our boat. Two in our deep-sea-fishing party already had lost their breakfast; I was focused on keeping mine down. The ocean seemed fairly calm, but I didn’t feel very steady. In fact, I felt like I was on a bamboo raft that had been tied together with palm fronds.

In between thoughts of how I would have been ostracized as a seafaring Polynesian, I had one thought on my mind. “Keep your eyes on the horizon,” our captain had said as we boarded the boat. My eyes were not going anywhere else that day. The horizon, whether the coastline of Oahu or just the thin line between ocean blue and sky blue, provided an unwavering constant as the waves changed our position minute by minute.

Our daily work as hospitalists is filled with ups and downs—waves, if you will. At times they threaten to capsize us; at others, they provide a short boost of momentum. These waves come in many forms, whether a busy teaching service, an interaction with a consultant, or your personal schedule. And all too often, that constant cyclical motion becomes hypnotizing. All of us have encountered colleagues that get lost at sea; they seem to always focus on that constant sense of unsteadiness. We recognize this form of despair as whining, and it’s not far removed from motion sickness. The only difference is the specific sense that is assaulted when the victim can no longer handle the ride.

Chart a Course to Success

If the captain of our fishing charter had been a business instructor, the lesson for the day would have been strategic planning. If he had been a medical school professor—well, there probably is no suitable analogy, as the path to organizational success isn’t yet a part of our core curriculum. Strategic planning is the deceptively simple process by which you ensure that you are headed toward your ultimate vision; it’s how you, your group, or your field charts its course toward the horizon.

Medicine has been in the habit of learning from business lately. Toyota’s strategy is a prime example. Their core strategic plan is termed “Lean” production or practices. Continuous quality improvement, though an oversimplification, is a substitute phrase that all hospitalists should recognize. Amazingly, Toyota’s strategic plan extends 50 to 100 years into the future and is intertwined into each and every phase of the company. Although the Lean system is being carefully studied and applied by many in the healthcare industry, the true hidden curriculum lies not in the details of their practices, but rather in their choice and execution of strategy. Toyota’s impressive history of achievement contains a few valuable lessons applicable to your own future success.

At one time, Toyota was a newcomer to the established field of automobile manufacturing, not dissimilar to the current state of most pediatric hospitalists. Like us, they undoubtedly faced uphill battles surrounding established cultural barriers and rigid practice patterns. And despite giving up more than half a century to Ford and the concept of mass production, Toyota has become the leading manufacturer of automobiles in the world.

How did Toyota choose and execute a strategy that allowed it to thrive in the face of such obstacles? In the beginning, there probably were many strategic options. They could have decided to focus on creating a specific product, such as the “ultimate driving machine,” or cars that are boxy but safe. They could have opted to cater to a specific consumer class, perhaps building a strong fleet of affordable autos. Or they could have looked to improve their purchasing power and distribution methods (think Dell and Walmart).

Instead, they made a conscious decision to pursue excellence in reliability, quality, and value (sound familiar?), then followed through beautifully.

Strategy at Home

Despite differences in industry and scale, all of these same sorts of decisions are critical to the success of your career, your HM group, or even the field of pediatric HM. Are you aware of the specific strategies in place for your group’s success? Have you been involved in the process? Before this year, I was probably like most of you. I had some vague notion of success. It involved increasing relative value units, making everyone happy, and completing a big QI or research project.

In the past 12 months, however, I have taken part in three strategic planning sessions: one for a regional pediatric society, one for my hospital, and one for my hospitalist group. The importance of these processes crystallized for me. Apparently, the leaders in our field have had the same thoughts. They convened the Pediatric Hospital Medicine Roundtable, a strategic planning session for our field (see “All Grown Up,” p. 1). Clearly, 2009 is the year of the strategic plan.

Despite the unifying theme, the processes and products of all of these plans have been unique. Strategic plans must be developed organically, out of local context and environment, and can only be created by those who live and breathe the work. What works for group safety at the university hospital of quality focus might not work for group communication experts at suburban community hospitals. Differences in institutional, organizational, and cultural beliefs should affect the decision-making process. When a strategy has been devised, it should be carefully chosen and explicitly implemented.

Does your group’s strategy come to mind? Or are you just treading water, unable to see beyond the next looming wave? If you have a vision of what you want, whether it’s money, fame, or protected time, then this same line of reasoning should apply to the strategic plan for your individual career, as well as the future of pediatric HM.

The lesson here is simple: Success requires a plan. Strategic planning is how you set a vision for the future and chart that course. Unexpected political waves are sure to come, and not every victory will come with a prize catch. But if you can create that beautiful Impressionist painting on the horizon and maintain that course, you are less likely to lose your breakfast and go without lunch. TH

Dr. Shen is The Hospitalist’s pediatric editor.

More than 350 pediatric hospitalists convened in Tampa, Fla., last week for Pediatric Hospital Medicine (PHM) 2009, tri-sponsored by SHM, the Academic Pediatric Association (APA), and the American Academy of Pediatrics (AAP). More impressive than the continued growth of the field, however, was the palpable theme of development and maturation.

The theme was immediately evident as Patrick Conway, MD, MSc, took the stage to give the keynote address. Dr. Conway, a card-carrying pediatric hospitalist, has built upon his beginnings in health services research and a White House fellowship to become the chief medical officer in the Department of Health and Human Services (HHS) Office of the Secretary/Assistant Secretary for Planning and Evaluation. He also is the executive director of the Federal Coordinating Council for Comparative Effectiveness Research.

After providing an insider’s view of HHS, comparative effectiveness research, and healthcare reform and policy, he challenged pediatric hospitalists to demonstrate their value to the healthcare system.

Synergistically, this year’s meeting also provided an opportunity for the PHM Roundtable, a strategic planning session of pediatric hospitalist leaders, to fully share its vision for transforming the delivery of hospital care to children. As a manifestation of this vision, collaborative discussions and workgroup plans coalesced amid the enlightening mix of clinical, practice management, academic, and quality and patient safety workshops.

Growth and development are central concepts in pediatrics, and PHM 2009 highlighted the field’s energetic steps towards maturation.

Dr. Shen is pediatric editor of The Hospitalist and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas

More than 350 pediatric hospitalists convened in Tampa, Fla., last week for Pediatric Hospital Medicine (PHM) 2009, tri-sponsored by SHM, the Academic Pediatric Association (APA), and the American Academy of Pediatrics (AAP). More impressive than the continued growth of the field, however, was the palpable theme of development and maturation.

The theme was immediately evident as Patrick Conway, MD, MSc, took the stage to give the keynote address. Dr. Conway, a card-carrying pediatric hospitalist, has built upon his beginnings in health services research and a White House fellowship to become the chief medical officer in the Department of Health and Human Services (HHS) Office of the Secretary/Assistant Secretary for Planning and Evaluation. He also is the executive director of the Federal Coordinating Council for Comparative Effectiveness Research.

After providing an insider’s view of HHS, comparative effectiveness research, and healthcare reform and policy, he challenged pediatric hospitalists to demonstrate their value to the healthcare system.

Synergistically, this year’s meeting also provided an opportunity for the PHM Roundtable, a strategic planning session of pediatric hospitalist leaders, to fully share its vision for transforming the delivery of hospital care to children. As a manifestation of this vision, collaborative discussions and workgroup plans coalesced amid the enlightening mix of clinical, practice management, academic, and quality and patient safety workshops.

Growth and development are central concepts in pediatrics, and PHM 2009 highlighted the field’s energetic steps towards maturation.

Dr. Shen is pediatric editor of The Hospitalist and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas

More than 350 pediatric hospitalists convened in Tampa, Fla., last week for Pediatric Hospital Medicine (PHM) 2009, tri-sponsored by SHM, the Academic Pediatric Association (APA), and the American Academy of Pediatrics (AAP). More impressive than the continued growth of the field, however, was the palpable theme of development and maturation.

The theme was immediately evident as Patrick Conway, MD, MSc, took the stage to give the keynote address. Dr. Conway, a card-carrying pediatric hospitalist, has built upon his beginnings in health services research and a White House fellowship to become the chief medical officer in the Department of Health and Human Services (HHS) Office of the Secretary/Assistant Secretary for Planning and Evaluation. He also is the executive director of the Federal Coordinating Council for Comparative Effectiveness Research.

After providing an insider’s view of HHS, comparative effectiveness research, and healthcare reform and policy, he challenged pediatric hospitalists to demonstrate their value to the healthcare system.

Synergistically, this year’s meeting also provided an opportunity for the PHM Roundtable, a strategic planning session of pediatric hospitalist leaders, to fully share its vision for transforming the delivery of hospital care to children. As a manifestation of this vision, collaborative discussions and workgroup plans coalesced amid the enlightening mix of clinical, practice management, academic, and quality and patient safety workshops.

Growth and development are central concepts in pediatrics, and PHM 2009 highlighted the field’s energetic steps towards maturation.

Dr. Shen is pediatric editor of The Hospitalist and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas

I recently returned from a seminar where I sang “Kumbaya” (OK, maybe I hummed) and performed a skit in front of the 250 other participants. Having once been edited out of my own end-of-residency movie, you might think this was Acting 101 for the next Shen’s Anatomy. Rather, this was “Hospitals and Communities Moving Forward with Patient and Family-Centered Care.” Replete with experiential lessons in positive change, it transformed my vision of the future for patients, families, and our field.

Patient- and family-centered care (PFCC) is a movement rooted in the values at the core of our profession. As soon as the hunter-gatherers formed communities, a village healer emerged. Parents could turn to the healer for help when a child developed bronchiolitis. With similar amounts of hand-waving, these healers produced outcomes similar to current bronchiolitis care.

But what once was a simple relationship has become fractured through relentless de-evolutionary forces. Progressive specialization has exponentially increased the number of healers. The rapid, paternalistic injection of science and technology overwhelms even the most capable of Homo sapiens. The final product can be as cold and sterile as a modern-day operating room.

Amidst the labyrinthine tangle of providers, information, and facilities, there is a warm underglow of hope. Unless you’ve been hiding under the concrete foundation of the old part of your hospital, you’ve heard about family-centered rounds (FCR). It’s the new black, or the new steroids, of pediatric HM. And it carries with it the potential to be the bellwether of change.

A simplistic view entails moving teaching rounds from the conference room to the bedside. Throw in a multidisciplinary component and you have a theoretical therapeutic milieu from which all manner of positive education and patient outcomes might be measured.

But one must ask the question: Can creating patient- and family-centeredness really be this simple?

Work with Families

Let’s begin with definitions. At one end of the spectrum is system-centered care (SCC). In this system, family members are denied access to the recovery room because it’s easier for the post-operative staff to do their work. Children wake up terrified? Tough. SCC is what the system does to you.

The next step on the developmental continuum is patient- and family-focused care (PFFC). Providers work for the benefit of the patient and family. You transport your gaggle of learners to the bedside for each and every family. You do it for everyone because you believe it’s best for the patient. You do it … until Tyler, age 9, tells you that your intimidating team gives him ulcers, perhaps literally.

What I thought was PFCC really was PFF, at best. By imposing my form of rounds on each patient and family, I had left out a key tenet of PFCC: collaboration. PFCC is partnering with patients and families. A simple fix for rounds would be to ask each patient and family how they would like to be involved.

Then again, just as a family is not easily defined, FCR is not best viewed in light of its structural composition or mechanics, but in its ability to deliver what each individual patient and family desires. And given the alacrity with which research in our field has gravitated toward FCR as a clean, measurable intervention, the implications of an FCR-dominant agenda should be highlighted.

To date, we have focused on measuring the challenges and successes of FCR implementation in academic settings. The emphasis on traditional teaching rounds has been at the price of the exclusion of defining what is family-centered when consultants or nonteaching hospitalists provide care, let alone nonphysician staff and outpatient providers. The emphasis on measurable data has subdued the powerful voices of patient and family stories. We have, predictably, created a hospitalist-centered agenda.

PFCC’s broad umbrella involves working with families at every juncture, from the design of your unit to the format of rounds to the outcomes of your study. True PFCC is measured by culture change and is successful when patients and families are surrounded by continuous healing relationships. By focusing efforts squarely on the implementation of FCR, I fear we may lose sight of a tremendous opportunity.

Pediatric Calling

Adult HM has turned a focus on quality and safety into a building block for the growth and acceptance of the field. Pediatrics invented and advanced the medical home concept, now a core principle of healthcare reform. PFCC is a central yet underdeveloped component of both of these parent organization efforts. Meanwhile, federally mandated public reporting of patients’ and families’ experience of care is under way, and hospitals are at varying stages of funding relevant initiatives.

These winds of change have created a fertile climate from which pediatric HM should blossom and lead. We can build upon our strong start in FCR, but we also must expand our efforts to lead in all directions. We must align our goals with administrative leadership, extend our work laterally to all other physicians and healthcare personnel, and elevate patients and families from subjects to collaborators.

FCR becomes a speed bump only if it is seen as a distinct and removable piece of PFCC. FCR accelerates change when it is embedded in the continuum of PFCC. Translating this vision into the language of strategic planning, a mission statement for the future of pediatric HM might look something like this:

Our strategy is to demonstrate our value to healthcare by leveraging FCR knowledge and expertise to generate a strong leadership presence at the forefront of the PFCC movement.

• We will seek partnership with institutional, community, and national leaders to promote a unified and collective vision for change.
• We will continue to accumulate not only data, but also powerful stories with which to effect change.
• We will use our experience in interdisciplinary partnerships with families to engage early adopters from other domains of the healthcare system.
• We will maintain a central focus on relationships and communication to effectively model culture change. TH

Dr. Shen is pediatric editor of The Hospitalist and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas.

I recently returned from a seminar where I sang “Kumbaya” (OK, maybe I hummed) and performed a skit in front of the 250 other participants. Having once been edited out of my own end-of-residency movie, you might think this was Acting 101 for the next Shen’s Anatomy. Rather, this was “Hospitals and Communities Moving Forward with Patient and Family-Centered Care.” Replete with experiential lessons in positive change, it transformed my vision of the future for patients, families, and our field.

Patient- and family-centered care (PFCC) is a movement rooted in the values at the core of our profession. As soon as the hunter-gatherers formed communities, a village healer emerged. Parents could turn to the healer for help when a child developed bronchiolitis. With similar amounts of hand-waving, these healers produced outcomes similar to current bronchiolitis care.

But what once was a simple relationship has become fractured through relentless de-evolutionary forces. Progressive specialization has exponentially increased the number of healers. The rapid, paternalistic injection of science and technology overwhelms even the most capable of Homo sapiens. The final product can be as cold and sterile as a modern-day operating room.

Amidst the labyrinthine tangle of providers, information, and facilities, there is a warm underglow of hope. Unless you’ve been hiding under the concrete foundation of the old part of your hospital, you’ve heard about family-centered rounds (FCR). It’s the new black, or the new steroids, of pediatric HM. And it carries with it the potential to be the bellwether of change.

A simplistic view entails moving teaching rounds from the conference room to the bedside. Throw in a multidisciplinary component and you have a theoretical therapeutic milieu from which all manner of positive education and patient outcomes might be measured.

But one must ask the question: Can creating patient- and family-centeredness really be this simple?

Work with Families

Let’s begin with definitions. At one end of the spectrum is system-centered care (SCC). In this system, family members are denied access to the recovery room because it’s easier for the post-operative staff to do their work. Children wake up terrified? Tough. SCC is what the system does to you.

The next step on the developmental continuum is patient- and family-focused care (PFFC). Providers work for the benefit of the patient and family. You transport your gaggle of learners to the bedside for each and every family. You do it for everyone because you believe it’s best for the patient. You do it … until Tyler, age 9, tells you that your intimidating team gives him ulcers, perhaps literally.

What I thought was PFCC really was PFF, at best. By imposing my form of rounds on each patient and family, I had left out a key tenet of PFCC: collaboration. PFCC is partnering with patients and families. A simple fix for rounds would be to ask each patient and family how they would like to be involved.

Then again, just as a family is not easily defined, FCR is not best viewed in light of its structural composition or mechanics, but in its ability to deliver what each individual patient and family desires. And given the alacrity with which research in our field has gravitated toward FCR as a clean, measurable intervention, the implications of an FCR-dominant agenda should be highlighted.

To date, we have focused on measuring the challenges and successes of FCR implementation in academic settings. The emphasis on traditional teaching rounds has been at the price of the exclusion of defining what is family-centered when consultants or nonteaching hospitalists provide care, let alone nonphysician staff and outpatient providers. The emphasis on measurable data has subdued the powerful voices of patient and family stories. We have, predictably, created a hospitalist-centered agenda.

PFCC’s broad umbrella involves working with families at every juncture, from the design of your unit to the format of rounds to the outcomes of your study. True PFCC is measured by culture change and is successful when patients and families are surrounded by continuous healing relationships. By focusing efforts squarely on the implementation of FCR, I fear we may lose sight of a tremendous opportunity.

Pediatric Calling

Adult HM has turned a focus on quality and safety into a building block for the growth and acceptance of the field. Pediatrics invented and advanced the medical home concept, now a core principle of healthcare reform. PFCC is a central yet underdeveloped component of both of these parent organization efforts. Meanwhile, federally mandated public reporting of patients’ and families’ experience of care is under way, and hospitals are at varying stages of funding relevant initiatives.

These winds of change have created a fertile climate from which pediatric HM should blossom and lead. We can build upon our strong start in FCR, but we also must expand our efforts to lead in all directions. We must align our goals with administrative leadership, extend our work laterally to all other physicians and healthcare personnel, and elevate patients and families from subjects to collaborators.

FCR becomes a speed bump only if it is seen as a distinct and removable piece of PFCC. FCR accelerates change when it is embedded in the continuum of PFCC. Translating this vision into the language of strategic planning, a mission statement for the future of pediatric HM might look something like this:

Our strategy is to demonstrate our value to healthcare by leveraging FCR knowledge and expertise to generate a strong leadership presence at the forefront of the PFCC movement.

• We will seek partnership with institutional, community, and national leaders to promote a unified and collective vision for change.
• We will continue to accumulate not only data, but also powerful stories with which to effect change.
• We will use our experience in interdisciplinary partnerships with families to engage early adopters from other domains of the healthcare system.
• We will maintain a central focus on relationships and communication to effectively model culture change. TH

Dr. Shen is pediatric editor of The Hospitalist and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas.

I recently returned from a seminar where I sang “Kumbaya” (OK, maybe I hummed) and performed a skit in front of the 250 other participants. Having once been edited out of my own end-of-residency movie, you might think this was Acting 101 for the next Shen’s Anatomy. Rather, this was “Hospitals and Communities Moving Forward with Patient and Family-Centered Care.” Replete with experiential lessons in positive change, it transformed my vision of the future for patients, families, and our field.

Patient- and family-centered care (PFCC) is a movement rooted in the values at the core of our profession. As soon as the hunter-gatherers formed communities, a village healer emerged. Parents could turn to the healer for help when a child developed bronchiolitis. With similar amounts of hand-waving, these healers produced outcomes similar to current bronchiolitis care.

But what once was a simple relationship has become fractured through relentless de-evolutionary forces. Progressive specialization has exponentially increased the number of healers. The rapid, paternalistic injection of science and technology overwhelms even the most capable of Homo sapiens. The final product can be as cold and sterile as a modern-day operating room.

Amidst the labyrinthine tangle of providers, information, and facilities, there is a warm underglow of hope. Unless you’ve been hiding under the concrete foundation of the old part of your hospital, you’ve heard about family-centered rounds (FCR). It’s the new black, or the new steroids, of pediatric HM. And it carries with it the potential to be the bellwether of change.

A simplistic view entails moving teaching rounds from the conference room to the bedside. Throw in a multidisciplinary component and you have a theoretical therapeutic milieu from which all manner of positive education and patient outcomes might be measured.

But one must ask the question: Can creating patient- and family-centeredness really be this simple?

Work with Families

Let’s begin with definitions. At one end of the spectrum is system-centered care (SCC). In this system, family members are denied access to the recovery room because it’s easier for the post-operative staff to do their work. Children wake up terrified? Tough. SCC is what the system does to you.

The next step on the developmental continuum is patient- and family-focused care (PFFC). Providers work for the benefit of the patient and family. You transport your gaggle of learners to the bedside for each and every family. You do it for everyone because you believe it’s best for the patient. You do it … until Tyler, age 9, tells you that your intimidating team gives him ulcers, perhaps literally.

What I thought was PFCC really was PFF, at best. By imposing my form of rounds on each patient and family, I had left out a key tenet of PFCC: collaboration. PFCC is partnering with patients and families. A simple fix for rounds would be to ask each patient and family how they would like to be involved.

Then again, just as a family is not easily defined, FCR is not best viewed in light of its structural composition or mechanics, but in its ability to deliver what each individual patient and family desires. And given the alacrity with which research in our field has gravitated toward FCR as a clean, measurable intervention, the implications of an FCR-dominant agenda should be highlighted.

To date, we have focused on measuring the challenges and successes of FCR implementation in academic settings. The emphasis on traditional teaching rounds has been at the price of the exclusion of defining what is family-centered when consultants or nonteaching hospitalists provide care, let alone nonphysician staff and outpatient providers. The emphasis on measurable data has subdued the powerful voices of patient and family stories. We have, predictably, created a hospitalist-centered agenda.

PFCC’s broad umbrella involves working with families at every juncture, from the design of your unit to the format of rounds to the outcomes of your study. True PFCC is measured by culture change and is successful when patients and families are surrounded by continuous healing relationships. By focusing efforts squarely on the implementation of FCR, I fear we may lose sight of a tremendous opportunity.

Pediatric Calling

Adult HM has turned a focus on quality and safety into a building block for the growth and acceptance of the field. Pediatrics invented and advanced the medical home concept, now a core principle of healthcare reform. PFCC is a central yet underdeveloped component of both of these parent organization efforts. Meanwhile, federally mandated public reporting of patients’ and families’ experience of care is under way, and hospitals are at varying stages of funding relevant initiatives.

These winds of change have created a fertile climate from which pediatric HM should blossom and lead. We can build upon our strong start in FCR, but we also must expand our efforts to lead in all directions. We must align our goals with administrative leadership, extend our work laterally to all other physicians and healthcare personnel, and elevate patients and families from subjects to collaborators.

FCR becomes a speed bump only if it is seen as a distinct and removable piece of PFCC. FCR accelerates change when it is embedded in the continuum of PFCC. Translating this vision into the language of strategic planning, a mission statement for the future of pediatric HM might look something like this:

Our strategy is to demonstrate our value to healthcare by leveraging FCR knowledge and expertise to generate a strong leadership presence at the forefront of the PFCC movement.

• We will seek partnership with institutional, community, and national leaders to promote a unified and collective vision for change.
• We will continue to accumulate not only data, but also powerful stories with which to effect change.
• We will use our experience in interdisciplinary partnerships with families to engage early adopters from other domains of the healthcare system.
• We will maintain a central focus on relationships and communication to effectively model culture change. TH

Dr. Shen is pediatric editor of The Hospitalist and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas.