Clinical Care​

John Hartline, MD, FAAP

In all likelihood, fellowship will have prepared you well for the clinical challenges in practice. Even for unfamiliar clinical diagnosis or symptom complexes, our training prepares us well to analyze symptom complexes, review patient data and images, search the literature, communicate with consultants, and interchange with associates.

Therefore, successful integration into the clinical area of practice will have less to do with "how to do the job" and more to do with "how the jobs get done." Here the interests are not specific patient issues, but rather:

• how the expertise of the practice colleagues are applied to the clinical responsibilities within the practice, and
• how the practice associates intercommunicate, and
• how practice outcomes influence future patients.

The organizational structure of the practice affects how these goals are accomplished. Within the clinical arena, there are a number of important aspects to review when looking at a practice. Practices have as many ways to distribute responsibilities as there are practices. Many of these are effective and equitable ways to share responsibility within a group; some are not. Careful exploration of how a practice handles its clinical responsibilities involves distribution of rounding among intensive and lower levels of care, call and coverage schedules, duration of continuous on-duty time, availability to families, and means of communication among colleagues and staff. Closely related activities such as daily patient coding and outcomes analysis of the practice are sometimes classified as clinical, but some groups see these activities within administration or education. The duty areas of a practice are not mutually exclusive!

Medical practice within Neonatal-Perinatal Medicine is a component of a systems-based endeavor we call neonatal intensive care or, in expanded scope practices, the practice of newborn medicine. Patient outcomes derive from the effectiveness of these systems. Professionals representing other components of this multidisciplinary team expect physicians to be proficient in their roles and cooperative with other disciplines.

"On-service" time is that time during which the neonatologist has responsibility for the day-to-day management of patients and coordination of their care. Contemporary practices have a variable spectrum of inpatient clinical duties, ranging from admissions for intensive care to well baby care. This responsibility usually will include some or all of:

• personal responsibility for daily patient rounds, notes and orders, and interaction with consultants;
• collaboration with advance-practice nurses and/or physician assistants;
• oversight of care given by students, residents and/or fellows, which usually includes some degree of hands-on care; and,
• documentation in the patients' records.

Personal responsibility for patient care

Levels of care: Clinical responsibilities each day will inevitably involve several levels of care and patient acuity. As you meet with potential associates, explore the clinical coverage required on a daily basis and the manner those responsibilities are met. Neonatologists' duties may include convalescent or well premature patients, delivery room neonates, Level II or Level I nursery patients, infants in outpatient clinics, or infants seen in consultations. Often, responsibilities may be divided among several units within a hospital or among several hospitals. After adding a new associate, how does the practice envision the distribution of the clinical workload?

Availability. "On-call" time is used to denote the way by which the practice assures 24/7 availability to the neonatal intensive care unit, to delivery facilities, to level II or I units, and the manner it uses to cover nights, weekends and holidays. Some practices maintain 24-hour in-hospital coverage; others provide availability from home, with immediate responses to patients provided by house officers, fellows, nurse practitioners, physicians' assistants, residents, and/or staff nurses. Practice expectations of the on-call physician should be developed, understood, implemented, and reviewed. Although the duty time restrictions and sleep issues have been promulgated to regulate the work expectations of residents and fellows, duration of continuous time on duty and sleep deprivation are important contemporary factors in practice organization, quality assurance and risk management. Practices have implemented many innovations in coverage in response to studies on effectiveness and patient safety. Supported by these data, consistent with the importance of life balance among Generation X and Generation Y (Millenials) and with the physiological effects of age on Baby Boomers, many physicians are seeking practices that value balance between work, family, and personal priorities and which allow non-traditional positions such as job-sharing, part-time work, and the like.

Outcomes analysis. Although some may consider theses activities to be in the realm of administration, outcomes analysis, quality assurance, and implementation of needed changes in care practices are essentials in the clinical realm of the neonatologist. Reflected by the newly-adopted requirements of Part 4 of Maintenance of Certification in Pediatrics, Sub-board of Neonatal Perinatal Medicine, neonatologists enrolled in Maintenance of Certification must document meaningful participation by each diplomate in sanctioned outcomes analysis, quality assurance, and patient satisfaction projects that have been sanctioned by the American Board of Pediatrics (ABP).

New methods or medications. Innovations in care are constantly proposed in the literature, at meetings, and in discussions among colleagues. Differences in approaches to innovation occur among practices and among individuals within practices. Changes in established routines introduce some stress and confusion, and yet are inevitable if progress is to occur. Entering a new practice, a physician will bring some new and perhaps even better ideas into the practice. On the other hand, in the name of consistency, some approaches learned in training are best modified to conform to established patterns that are working well in the new venue. Each practice should have procedures and processes, ideally driven by evidence-based medicine, by which variations among group members, differences of approach and opinion, as well as consideration of new technologies, treatments and/or medications are evaluated and incorporated into the group's practice. Variety implies that more than one approach may be acceptable. Often, members of a practice group will differ in their care practices. Although evidence-based medicine would not require practices to choose one from the others, the working environment and communication with families often becomes much easier when one option is chosen. Variation implies a gap between what is done and what ought to be done. In these situations, care and outcomes analysis should resolve the variations as practices examine data from collaboratives (Vermont-Oxford Network, California Perinatal Quality Care Collaborative, Pediatrix Medical Group, State-based collaboratives, NICHD, etc), identify areas for needed change, and follow their data to document results. Some of these activities will conform to ABP criteria for part 4 and facilitate individual neonatologists' MOC.

Conflict. Differences of opinion are inevitable among group members and potentiate discord. The process and procedure used to manage differences should be established and implemented with the intent to avoid conflicts, cliques, and discord. Individual practice members will each have unique strengths to offer the practice. Observation of the interchange among practice associates as treatment options are considered can be helpful. Structured self- and peer-evaluation can help groups capitalize on members' strengths and enable growth in areas of weakness. [See section on collegiality]

Collaboration. Many practices have incorporated advance practice nurses (APN) or physician assistants (PA) into their clinical coverage patterns. For those practices, the spectrum of responsibilities given to APNs and PAs and the manner of oversight should be observed. An important component in this collaboration is documentation of direct physician involvement for any activity assigned a code and submitted for billing under the physician's billing numbers.

Oversight. Neonatal practices have significant interaction with educational programs providing fellowship training in NPM; pediatric, family medicine, and obstetrics/gynecology residencies; and nursing and other health professions. Although time spent in these endeavors may be classified as education, the physician-patient/family relationship requires added effort in assessment and documentation.

Documentation. Documentation traditionally is accomplished through progress notes. The old adage "If it isn't documented, it didn't happen," is especially pertinent in today's healthcare environment. The progress note not only records patient status and plans, but also indicates the level of physician involvement in the evaluation and management of the infant, the physician's participation in medical decision making, and provides the requisite documentation necessary for audits of diagnostic coding and patient billing. The practice should have a compliance program to assure that group members apply uniform standards for documentation and billing. Some practices are using computer-generated record keeping for some or all of the medical record. Others have incorporated voice-activated dictation systems. A most important component of clinical responsibility is the way patient information, clinical management plans and reports of communication with families are conveyed to group members assuming clinical responsibility from the former "on-service" or "on-call" physician.

Characteristics of Patient Load

This section addresses the environment in which the practice works. Whereas an earlier section dealt with the manner the practice distributes its work, this part looks at the practice environment and workload.

Analyzing the clinical load of a practice is complicated, and comparisons among units and/or practices may be difficult. Every practice has or should have some means of evaluating its clinical activity and for making year-by-year comparisons. Informed analysis of these data assists in understanding the potential for matching the interests of the neonatologists with the realities of the practice.

A major factor affecting patient load is the presence of an active Maternal-Fetal Medicine practice and the activity level of that practice. Inquiring as to the number of MFM physicians, the number of deliveries by MFM (especially referred from other institutions), and the role of neonatology in prenatal patient conferences and prenatal consultations can give an idea of the relationship between the specialties and of the time commitment of the neonatology practice required to support the MFM program. Pediatric surgery is a second specialty with major impact on neonatology. If surgical patients contribute to the NICU load, the relationship with neonatology pre- and post-operatively should be determined.

All data are dependent on the definitions used. Nowhere is this more important than in the analysis of an NICU or of a practice of neonatology. What is an NICU admission? This simple question implies that there is some degree of uniformity in NICU admission criteria. Some units incorporate well-baby and intermediate level care among the NICU admissions; other units do not. The number of babies with less than 1500 grams birth weight admitted annually can give an approximation of unit acuity. Review of definitions used for coding purposes is essential. Review of CPT coding, Relative Value Units (RVUs) or similar data can be used reliably for internal comparisons, but may not be as helpful in external comparisons unless the NICUs compared share a similar understanding and application of CPT coding.

The clinical load of the practice may go beyond neonatal intensive care. For some, neonatology involves almost entirely intensive care of sick infants, usually with related research and teaching responsibilities if an academic practice. For others, the practice may include the entire spectrum of sick and well newborn infants at the hospitals covered by the practice. Determination of the spectrum of newborns contributing to the practice's clinical load is essential to understand workforce needs and distribution of time commitments. In addition, many practices will spend a significant amount of time providing services to older patients through developmental follow-up programs or through continuing medical services to NICU graduates with BPD, with special nutritional problems, or on home monitors.

Some practices cover only one institution, others have responsibility at several hospitals each day and the clinical load(s) at each may be very different. The individual physician's experience will be quite different depending on the number of units, their sizes, and the level(s) of patient acuity at each. If your assigned responsibility is away from the level III unit, learning from the experiences of other colleagues assigned to the level III unit will be more difficult than if all are in one institution. On the other hand, expertise in administration can be gained by more than one colleague if several members of the group are given directorship roles at level II or level I nurseries.

Administrative Duties »​