Oct 30, 2015

Essential Qualities of Healthcare Leaders: The Four T’s

Dr. Catherine DeAngelis was practicing clinical quality improvement much before it became a buzzword in healthcare. It was my pleasure to host a reception on behalf of the UC Davis Women in Medicine and Health Sciences Program for Dr. De (as she is usually called) during her recent visit to UC Davis.

Dr. De is a remarkable role model on many levels for healthcare improvers, especially those who fall into my specific demographic of women in academic pediatrics and public health. She has been a nurse and a pediatrician, whose first faculty position was at the Columbia College of Physicians in New York in the early 1970's. There, she worked on improving healthcare systems in Harlem and Manhattan utilizing physician-nurse practitioner teams. She felt that nurses were often underused, and that they had the ability and training to work with physicians as a team and contribute more substantially to healthcare.

When asked about the essential qualities of leaders, she spoke about four traits that served her well... the 4 T’s: Tenacious, Tough-minded, Thick-skinned, and Tenderhearted.

Tenacious: Dr. De described her childhood in a coal-mining town in Pennsylvania, where she noticed that the two most respected people in her small town were the doctor and the priest. Her childhood dream was to become a surgeon, and her idea of playing with dolls involved cutting and stitching them up. Medical school was financially not feasible for her family at the time, and she trained to become a nurse. She worked at Columbia Presbyterian Medical Center as a nurse for a year before going back to school - this time to the University of Pittsburgh school of medicine.

Tough-minded: She was JAMA’s first woman editor-in-chief in the journal’s 116-year history. Before she took on this position, she negotiated a governance plan with JAMA that allowed her complete editorial freedom and the ability to report to a journal oversight committee, as opposed to American Medical Association management. She also increased JAMA’s publication of research articles on women and children’s issues.

Thick-skinned: Dr. De spoke about the responsibility of journal editors to rigorously evaluate scientific manuscripts, and to stick to their guns under pressure from organizations or authors with conflicts of interest.  To quote The New York Times, “If Tony Soprano were seeing a pediatrician instead of a psychiatrist, it would be Dr. Catherine D. DeAngelis. And he would have been scared straight long ago”. She is widely-known for her role in advocating that results of clinical trials on humans be reported in a public registry, to enhance transparency in research and to prevent misrepresentation of research findings.

Tenderhearted: Dr. De spoke about her experience as a third year medical student, when a patient kept asking for his nurse and the ward staff was unable to figure out who he was referring to. It turns out that the “nurse” he was looking for was the then medical student Dr. De. The patient was puzzled that she was not his nurse, since she took the time to talk to him and to comfort him “like a nurse”. She mentioned how her experience as nurse influenced her to be more compassionate and to appreciate the team-based nature of healthcare. As she told me - “From the person who mops the floor to the one who brings the food tray - thank them for their work, because life would be terrible without them.”

Do you have a 4T story - either from your own experience as a leader, or from a healthcare leader you know?

- Ulfat Shaikh

Jun 22, 2015

My week as a country doctor

Just got done with a week as camp doctor at a resident camp for children in Central California. I started volunteering as camp doc last summer, not just so I could clandestinely keep an eye on my own kids and take their pictures on the sly - but as a personal dare to see if I could do one of the most challenging yet rewarding jobs in medicine, being a country doctor.

At camp, I focus on keeping children healthy, and provide basic medical care wherever campers and staff need it - at our infirmary, by the lake, at the ropes course, or at lunch tables. I triage who should go to the emergency room 40 minutes away, or who needs some extra TLC for homesickness. I work with a camp nurse who dispenses prescription and over-the-counter medications four times a day. The camp doctor has office hours twice a day at the infirmary for sick campers and staff.

Being out here in the foot hills of the Sierras with a tightly knit community of about 300 children and 150 counselors and staff reminds me of why I went into primary care pediatrics. I don’t have to deal with mounds of documentation, billing and coding, or prior authorizations from health insurance companies. Here, I just focus on keeping my little community healthy. So I thought that I should share some tips for others contemplating a stint as a camp doctor.

Ten tips from a camp doctor to future camp doctors:

1. Homesickness can manifest in startling ways: Homesickness may show up as all sorts of physical symptoms - headache, sleeplessness, poor appetite, bellyache, nausea, vomiting, diarrhea, dizziness, anxiety, or panic attacks. The wise Nurse Giggles helped me realize that sometimes my physician’s instincts may need to defer to my parental instincts. All children may need is your reassurance that they are okay. As much as you might want to help, remember to let your campers’ counselors handle homesickness. It is fine to give the child hugs at mealtimes if you like, but if the camper ends up bonding with the doctor or nurse more than their counselors or bunkmates, they will just want to hang out all day in the infirmary and participate even less in activities and making new friends.

2. Have a back-up plan for backups: Kids will revert to what their parents don’t want them to eat. The typical plate model they will follow at camp may consists of half a plate of corn dogs and half a plate of bread. You will find yourself surreptitiously looking at your campers’ plates at mealtimes and predicting which kids you will see next in the infirmary for stool softeners, a cup of chamomile tea, and a motivational interviewing session on eating their fruits and veggies.

3. Bees like juicy kids: Know where all the epinephrine auto-injectors are at camp. Children are stung by bees more often than adults. Perhaps because they tend to spend more time outdoors, or because they wear bright and patterned clothes, or because they like walking barefoot. Most bee stings are mild, but in about a fifth of stings you will see a large local reaction that can look astonishing scary. A whole forearm can swell up and turn red for days and can be mistaken for an infection. An ice pack, antihistamines, a painkiller, and corticosteroid cream usually do the trick. Just remember not to squeeze the stinger out or use tweezers. Just scrape the stinger out gently.

4. Prepare to provide full spectrum care: I had naively assumed before I went to camp that I would be working as a pediatrician - until counselors and staff starting walking/limping in. Generally not used to seeing many individuals over 5 feet tall in my practice, I had to quickly get used to 6 ½ foot tall Australian surfers towering over me as I took care of their lacerations and splinters.

5. Stay alert to issues that can spread like wildfire: The majority of your time will be spent taking care of strains, sprains, stings, swimmer's ear, conjunctivitis, cuts, allergies, and asthma. However, some issues need to be nipped in the bud so that they don’t get out of hand. Impetigo, gastroenteritis and head lice come to mind. Also, campers spreading the word among their bunk mates that the infirmary freezer stocks ice pops.

6. Enjoy the privilege of the time you get to spend with your campers: I work in a busy clinic during my regular life, where I frequently have limited time to spend with each patient. At camp I am fully able to learn about the whole child and appreciate what life is like for a child with a chronic condition 24/7. Campers teach me about their everyday challenges, from having to give themselves insulin shots to how they handle dietary restrictions and allergies.

7. Love your local EMS: Find out how to contact local emergency medical services, response times, training level of emergency service providers, and available services. Find out if there are dentists or orthodontists in the area willing to treat dental emergencies.

8. You will need to pick a camp name, and you may have this name for life: Perhaps the most challenging part of this job. I landed on Dr. Aqua after going through at least 15 names that were already taken by other counselors and staff, or that my family vetoed. The name worked well given my childhood by the sea. Chances are that you will end up keeping your camp name for a while, so choose it responsibly!

9. If this is not a medical home, then what is?: My campers have immediate access to high quality clinicians who like their jobs enough to actually take vacation to work. My campers get same-day appointments and house calls with a smile. In return, they write me sweet notes and give me high-fives and hugs when they see me out and about at camp. Take this opportunity to see how rewarding the life of a country doctor can be.

10. Have fun with your campers!: Clearing up my schedule to be a camp doctor for a week was not all work - it was a great deal of fun and a growth experience. Between infirmary office hours I took some time to enjoy camp activities – canoeing, basketball, horseback riding, and archery. Even the sidesplitting “BeyoncĂ© Tour” run by a high-energy counselor from England with the apt camp name of Nitro. 

I left camp with more than I arrived with. An enormous appreciation and respect for camp staff, a renewed interest in pediatrics, and some cool dance moves. All in all, a uniquely rewarding and energizing experience.

- Ulfat Shaikh

Nurse Honey Bear, Megatron and Dr. Aqua at the camp infirmary

Apr 26, 2015

Agents of change

Earlier this month, we held our 5th Annual UC Davis Quality Forum. In true pediatrician-style, as the Quality Forum turns five this year, let me reflect on some of our developmental milestones.

The Forum was conceived as a germ of an idea back in 2010 with the goal of enhancing the visibility of our local clinical quality improvement (QI) efforts. At that time, we thought it was a brilliant idea, of course. As 2011 grew closer, our nervousness as new parents grew and we realized that the risk of us falling flat on our faces was very real. I am glad to report that 25 whole abstracts were submitted that first year. About 60 committed people showed up. That was the year of many firsts. We started walking and talking, spreading the word to anyone who cared to listen. Learnt to follow directions from people across the health system, and understood the concept of “no”. 

The terrible twos turned out to be not so terrible after all. Now more confident toddlers, we were comfortable with exploring and showed more independence. We began to run. Brent James who leads

Feb 16, 2015

Personalized Medicine - Disney Style

As a pediatrician I make it part of my personal continuing education goals to keep up with the latest in children’s entertainment. Big Hero 6, Disney’s latest animated feature film, did not disappoint. It introduced me to Baymax, a potential future health care colleague I can look up to.

Baymax was inspired by a Big Hero 6 co-director’s visit to a Carnegie Mellon robotics lab that was exploring soft safe robots and developing inflatable arms to help feed, groom, and dress nursing home residents or the elderly.

Baymax, the lovable inflatable marshmallow-like robot is Hiro Hamada’s “personal health care companion”. Firmly committed to patient satisfaction, Baymax “cannot deactivate until you say you

Dec 11, 2014

Be Bold, Be Brief, Be Brilliant, Be Gone

"I didn't have the time to write a short letter, so I wrote a long one", said Mark Twain.

Marketing and communication experts know that well-crafted and memorable health communication messages are brief, high impact, and visual. Research shows that the average attention span is as little as eight seconds. Most information transmitted to the brain is visual, and images are processed several thousand times faster by the brain than text.

My medical training reinforced this concept and I was taught to let patients leave medical visits with no more than a couple of key messages, and to use visual aids to reinforce messages whenever possible.

Unfortunately this body of evidence has not translated into health professions education with much consistency. Slide presentations, too often, have too much information, minuscule fonts,