The Outside Hospitalist: Inside Out

Dr. Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the Kid Experts, where the complex is our every day. Each episode, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge, and perhaps change, how you care for kids.

Welcome to Talking Pediatrics. I’m your host, Dr. Kade Goepferd. Did you know that the majority of pediatric healthcare happens outside the tertiary hospital setting? On today’s episode, the outside hospitalist host, Dr. Gabi Hester, discusses providing healthcare when you’re limited to what’s in the overhead compartment, the critical access ed, or your own backpack, and how to translate these lessons to your pediatric practice.

Dr. Gabrielle Hester: Before we dive into our conversation today, I just want to put us into the context of what an outside hospital is. There’s an old video on YouTube from residents at the University of Pennsylvania called Outside Hospital, and it starts with a mocking testimonial of a guy who’s probably about 20 stating that the year prior, he’d gone to outside hospital with a case of diarrhea. This guy goes on to say, “That while they ultimately diagnosed me with a virus, it was really nice that they’d done that cardiac cath so that now I know my diarrhea was not caused by a coronary blockage even though I’m now on dialysis from the cath. Thank you, outside hospital.” So I loved that video as a resident and really was used to receiving pages looking to transfer a patient from the outside hospital. But what exactly is an outside hospital?

Isn’t it really just any hospital other than your own? And why have the hospitals within the community gotten such a bad reputation? So as some of you may know, over the last year, I’ve really changed my role from being medical director of quality improvement and a pediatric hospitalist at Children’s Minnesota where we know there’s over 400 beds working in the urban setting, lots of subspecialists, really all the resources you could need to take care of kids. And now I work in a small community hospital in Northern Minnesota and in so doing, I became an outside hospitalist. So our peds unit is often empty, and I will admit that sometimes on my 24-hour shift I might be hanging out in the employee massage chair or riding bike in the physical therapy gym. And yet even with that, there are still moments of excitement and challenge.

Like in the middle of the night you get a call from the ER because a really sick kid has come in and you are the only pediatrician in house or when the pregnant woman in triage delivers her 24-week-old baby precipitously and there’s no NICU there to rescue you or the baby. So those are just some of the jobs of the outside hospitalist. So in this new series, I’ll really be shifting a bit from a former Guidelines with Gabi persona where my focus was what should we do to an approach more of what do we do? Guidelines are often developed by and for hospitals with a rich resource environment. So how do you take care of kids when that’s not the case when you’re literally in the woods or on the plane? And I hope to highlight some of the really awesome things that happen outside or in outside hospitals by outside hospitalists because who knows, maybe someday you’ll find yourself becoming one too.

Today, I’m excited to have a conversation with two physicians that I know very well. First is Dr. Emily Korman, who you’ll hear a little bit about her journey from being an outpatient pediatrician to becoming the pediatric hospitalist at a community hospital. And sort of the reverse of that, we’ll be talking also with Dr. Marit Knutson, who had a different career path to date, practicing for a long time at a tertiary children’s hospital as a hospitalist and now is in more of a hybrid role in the community setting. Starting maybe with you, Marit, I wanted to ask both of you, what comes to mind when you hear the term outside hospital?

Dr. Marit Knutson: Well, I think when I was practicing in a tertiary care facility, outside hospital to me was a community hospital that really took care of local cases, the feet on the ground, probably fewer resources available compared to what we had with a lot of subspecialists and really just seeing more bread and butter cases and not necessarily all the zebras that I was used to seeing. So that’s what I initially thought of as outside hospital when I was not practicing at one. And now that I’m practicing at the outside hospital, I am seeing there are resources available that I previously wasn’t aware of at outside hospitals. And you really can manage a lot at an outside hospital with telephone supportive specialists and you can certainly triage things very effectively without having all the subspecialists available and get them to the right place as soon as possible.

Dr. Gabrielle Hester: I, for one, have definitely used the Children’s Minnesota children’s physician access line a time or two to get an expert opinion when I was definitely in need of one. Emily, what about you? You’re really in a new role in the last few years. Tell us a little bit about what your career journey has been and where you find yourself practicing now.

Dr. Emily Korman: My journey was in a small private pediatric clinic, so the amount of resources to us I feel like was even less than what I have now where I would take my own X-rays, I would do my own casting. I would sometimes do point of care tests or be the nurse as well as triaging patients. So actually coming to an outside hospital actually gave me more resources than what I had, which is probably a little bit different than Marit’s journey.

Dr. Gabrielle Hester: And Marit, I certainly know your story pretty well, but for our listeners, tell us a little bit what career shifts you’ve taken in the last few years and some of the reasoning or thought process behind some of those shifts.

Dr. Marit Knutson: So I worked for almost 10 years at a tertiary care hospital. I was at Children’s Minnesota as a full-time hospitalist and had three kids while I was working there as an attending and husband was staying at home and eventually decided we wanted to make a family shift to be close to where I grew up. So moved up north, Northern Minnesota, close to my family and it just also happened at the time that I was thinking, working a lot of night shifts and weekends was not great for a family with three young kids. And so for me, actually transitioning to a hybrid practice of some outpatient clinic that’s daytime hours, weekdays, minimal call combined with still keeping up some hospitalist practice was a really huge draw and has been a great fit for my family.

Dr. Gabrielle Hester: Our careers naturally are going to shift and evolve and change over time and that’s okay. And Emily, tell us a little bit about what your transition was like and how you sort of prepared yourself from going from that private pediatric clinic where you were doing your own casting. Oh my gosh, I’m a little jealous and also terrified at the idea of having to do that. Were you going from that type of setting to more of a community hospital inpatient setting?

Dr. Emily Korman: So like Marit, the driving force that made my husband and I decide to make the transition was family. And I felt almost the opposite because I was from a small private clinic, I felt like I was always on call. Patients were always sending me messages, you’d always get refill requests, we just can’t turn it off. You’re of course going to reply because you know that that parent is worried. And so that all accumulated I think to a little bit of burnout and maybe not burnout, but me just saying, “Hey, with me trying to raise a family, I need to take a step back and realize that there’s boundaries between my time and clinic time.”

Dr. Gabrielle Hester: We’re all of a similar sort of generation, we’re maybe mid-career shall I say, depending on what age we get to retire at. And I think back to physicians maybe 30, 40 years ago, a generation or two ahead of us who might’ve been doing house calls or sort of being the one provider in the really small town sort of always theoretically on call. How do you think our generation of physicians, practitioners of different kinds, how do you think we are advocating for finding a different model in healthcare and what do you think are some of the maybe the good things that have come out of that and maybe some of the pitfalls?

Dr. Marit Knutson: I think we all are so grateful for the generations ahead of us who worked so hard and carved a role for female physicians in this field and advanced practice providers in this field who are female and also even our male colleagues who want to have a really balanced family life. We are seeing a shift now quite profoundly I believe the people that I’m talking with of really setting boundaries between what happens at work and what happens at home. So we have resources available if we’re willing to use them of nurse triage lines and on-call partners and shift work and a lot more ancillary support at boundary between home life and work life.

Dr. Gabrielle Hester: And I think for everybody it’s going to be different. Mine boundaries might be different from yours or Emily’s, but where you sort of find that boundary, you may cross it at some points. You’re not always going to be perfect. And I think allowing yourself the grace to say, “In this one instance, I am going to be looking at the chart late at night when maybe otherwise I try not to after dinner when I’m putting the kids to bed.” So I think just the idea of creating boundaries for yourself is a really important first step in that journey and allowing yourself that imperfection. One of the things I think about with boundaries, what we’ve sort of been talking about and changing of careers is sort of that looking at healthcare as maybe a continuum and the ability to flex into different roles and take on new challenges and at some point having sort of ebbs and flows in your career.

And I remember getting great career advice when I was starting early on from a mentor and leader of mine who was saying that there are going to be times in your life where you’re going to have a lot going on at home. Your kids are going to be really active in doing things and you’re going to really need to lean in at home and maybe take a step back from work a little bit. And then there’s going to be times where it’s a little quieter and you’re going to want to step into things more at work.

I think having that mindset has been really helpful for me and in making the change in my career that I’ve done in the last year, part of it was related to those ebbs and flows in the life outside the hospital for me and to recognize that and give myself the grace to say, “Yeah, I really need to put my mental health, my family health really into the picture and equation,” I think was really important for making that career change and to recognize that it’s okay to step to a different role for a while and see what that new challenge can be.

We’ve talked about changes in careers and sort of new roles and how that has a little bit of a different lens on things. Marit, you had touched earlier on sort of, I don’t want to say a new respect for, because I’m sure you always had a lot of respect for outpatient pediatricians, but I think a new awareness maybe of some of the challenges that they face. How do you think some of that new awareness has changed either how you function in your newer role as an outpatient provider, but also you’re still in the inpatient setting? So how does your new awareness of what it’s like to be that outpatient provider receiving that patient after the hospital discharge, how has that changed how you function as a hospitalist?

Dr. Marit Knutson: I have been thinking a lot lately about my skills of knowing sick versus not sick, which were I thought well honed as a hospitalist and I’m learning more and more that actually the clinic pediatrician has to have very, very astute skills for seeing sick versus not sick, which asthmatic do you keep in the office and do a couple more DuoNebs on and give them their steroid in the office before you send them to the ER or send them home. It was very apparent to me as a hospitalist that the kids were sick because somebody else had already decided they were sick and admitted them. But now I’m really honing in my practice of managing complex kids outpatient and trying to decide what is okay to observe at this point? What should come back in one day? What should come back in three days? What should come back in two weeks? Who should I send to the ER now and who should I directly admit? So it’s a lot more complex decision making and all that I had previously realized.

Dr. Emily Korman: As an outside provider, I think you look at your patients as I will do everything possible for this patient to keep them out of the hospital. And when you realize that, “Okay, I’ve done everything I’m calling now to have them admitted that I don’t necessarily appreciate that.” So now going the other way, when I get that phone call from a provider, I automatically say, “Yes, send them,” because I know in my mind that they have done everything that they possibly can for that patient. And even if they’re on the fence with should they be admitted or not, I always say, “Yes, let’s admit them because they have obviously done everything that they possibly could.”

The other appreciation I had was going from clinic where you would try to order a head CT or an MRI and they’d say it’s two weeks out, or, “Oh, they need to be sedated so they have to go this first,” and so my new appreciation is now when a patient is admitted, I think of, “Okay, what’s everything that we can do during this hospitalization as far as testing and workup to save them that headache, not only the parents but the provider as an outpatient.”

Dr. Gabrielle Hester: Marit, what’s your favorite thing about your current role or roles that you have?

Dr. Marit Knutson: It’s a little bit old school. It’s a little bit doing it all, but I do have separate days for clinic and separate days for hospitalist, so I’m not doing both at the same time and overworked.

Dr. Gabrielle Hester: You and I had practiced alongside each other at Children’s Minnesota as inpatient hospitalists for many years, and I suspect you’re similar to me, where I really kind of developed this worldview that the kids are not all right, that there’s a lot of sickness and that tragic things are happening all around us in families and with children. A large portion of our patients have medical complexity that families were navigating. How did shifting outside of that hospital based setting change your view on the world of pediatrics at large?

Dr. Marit Knutson: For nine years, I was only seeing sick kids. I was never seeing healthy kids or if I was, it was just at the very end of their hospitalization when they were recovered from their illness and sending them home was really satisfying and so exciting. And that was the happiest day when you could tell parents, “Your kid is well enough to go home.” And now in the office trying to mostly practice with more of a well bias, like most kids are generally healthy and will recover from routine illnesses. And I don’t always have to be looking for the needle in the haystack, keep my little radar out for when it does pop up, but it is a bit of a different practice model. So I’m working a little bit more on that. I do love seeing well children. I love seeing healthy kids. I also like that there is continuity if needed between the inpatient and outpatient for me.

So I have some kids who have unfortunately had to be admitted for something else and maybe that I actually have a shift coming up. And so I see them for one of my shifts and that’s really cool. Or at least I’m in really close communication with the hospitals who’s on and they give great report back to me. So that helps being in the same organization, at least in my current role. But I love the mix and I love working some more regular hours in clinic, not without its own challenges, but really love seeing healthy kids and then also maintaining my hospital skills for the sicker kiddos. That’s great.

Dr. Gabrielle Hester: And Emily, aside from of course, having awesome colleagues, what is your favorite thing about your current role?

Dr. Emily Korman: My favorite thing is seeing a sick child come in and then seeing them get better in front of my eyes is really amazing. I think having the parents trust and seeing their child be really sick and them worried and giving them reassurance that their child will be okay. I also really like that we cover newborns. That’s an big part of our job here and I love it. I mean, it’s still a miracle every single time I see a baby born and then seeing those parents get to bond and giving them advice on what to do and go home is one of the best parts of my job.

Dr. Gabrielle Hester: With all the joys that we have in our roles, of course there’s always going to be some challenges or opportunities, shall we say. Emily, have you noticed anything with sort of that career transition that has been either a challenge or an opportunity for growth?

Dr. Emily Korman: So the number one thing that I miss with being a clinic doctor is having that follow-up and that continuity of care. As far as the hardest part about my job right now is one shift work, working overnights, and then two, just the unknown. You just never know what’s coming through the door, what 24 weeker’s going to be born, all of that. But I also think you have that always in clinic too.

Dr. Gabrielle Hester: All of us still have the opportunity to work with students and residents to some capacity. As you’re talking with people who are launching a career or maybe even before they’ve decided on health care, what advice would you give them about navigating career decisions and potentially making changes throughout?

Dr. Emily Korman: It is not a race. A journey, like you said, will ebb and flow. And so once I started having that mindset that medicine in and of itself is a journey, it made life a lot easier for me.

Dr. Marit Knutson: I do like to talk with residents and students about what would be a good fit for their temperament personality, so introvert, extrovert, how much time do you like to be face-to-face with patients versus speaking with specialists or doing rounds and if you envision yourself with a family or doing a lot of traveling or something like that, think about choosing a career position where you have flexible time. And I think another thing is just remembering that we’re all people. No one is perfect. You will never know everything. So know your boundaries, know the limits of your knowledge, and if there’s something you know, it’s okay to say you don’t know and it’s okay to ask for help. And it’s actually really brave to ask someone for advice or to ask a specialist for more information. And you will grow as a clinician the more you ask and the more you read.

Dr. Gabrielle Hester: So transitioning from one setting to the next, for me, one of the things that I hold dear in medicine and taking care of patients is I might not know the answer right now, but I need to know how I’m going to get that answer and what resources do I have to get there. Marit, have you found any particular resources that you turn to, either from a previous role that you’ve been in or that have helped you practicing in a setting where specialty resources or clinical guidelines from that place might not be as readily available?

Dr. Marit Knutson: I have a couple ideas. One really pertains to helping your patient find resources. So social supports, mental health supports, financial assistance, housing issues and therapists, things like this, it’s called resourceful.com, I believe, and it’s just a great way to put in your zip code and put in what you’re looking for and see what shows up. And that has been really helpful for some of my patients.

As far as my own resources, I have done some trainings with the psychiatric assistance line. That’s a program through PrairieCare and program through Minnesota that has webinars for primary care physicians or practitioners who are looking to deepen their knowledge about pediatric mental health diagnosis and management and medication use. And so those have been really helpful. And they have a free access call line where you can set up a time to call one of them and ask questions about kind of difficult or more challenging psychiatric cases you might have as far as outpatient med management. And then finally, I did do some further education for myself on Hippo Ed, which is an online platform with some just different subjects that you can learn about. And I reviewed all the well-child checks, what you’re going to learn at every well-child check, and when you do different screenings and when you do different labs and what you’re looking for in development. And so that was really great for me to go back to outpatient medicine, to just relearn kind of all the well-child care stuff, and I know they have lots of different topics and resources.

Dr. Gabrielle Hester: Emily, from your perspective, what are some of the resources that you’ve found to be helpful practicing in a different type of community setting?

Dr. Emily Korman: The biggest, I think for me, going from clinic to inpatient was just brushing up on my NRP skills. I had to be re-certified in that. But there again, using the book and scanning the QR code gives you a bunch of awesome modules to look at. Brushing up on my PALS in ACLS was another thing. I feel like I’m still continuing to learn. As far as resources for parents, the biggest, I think going from outpatient to inpatient was parents ask me, “Well, what doctors should my kids see as follow-up,” and so that’s been just a continuous growth as far as asking colleagues, other nurses, other parents, where are they from and where can I get them connected.

Dr. Gabrielle Hester: Well, thank you both so much for speaking with me today. I appreciate you taking your time out to chat a little bit about your career changes, and I look forward to talking with you guys offline about this too in the future.

Dr. Kade Goepferd: Thank you for listening to Talking Pediatrics. Come back next time for a new episode with our caregivers and experts in pediatric health. Our showrunner is Cora Nelson. Episodes are produced, engineered and edited by Jake Beaver and Patrick Bixler. Our marketing representatives are Amie Juba and Krithika Devanathan. For information and additional episodes, check us out on your favorite podcast platform or go to childrensmn.org/talkingpediatrics.