Intro: Welcome to Pediatric Voices, Duke Children's podcast about kids healthcare. Now, here's our host, Dr. Richard Chung.

Richard J. Chung, MD (Host): Hello and welcome to Pediatric Voices, expert insights about timely topics in children's health, brought to you by Duke Children's Hospital and the Department of Pediatrics at the Duke University Medical Center. My name is Dr. Richard Chung, a physician at Duke Children's and a co-host of this show.

Today, we will explore the topic of teaching hospitals. All healthcare professionals go through schooling and training that prepares them to provide high quality services for patients and families. This includes doctors, nurses, physician assistants, pharmacists and a range of other healthcare professionals.

How exactly does this education and training happen? And what does it mean for patients getting care in these teaching hospitals? To help us understand this better, I'll be speaking with Dr.Kyle Rehder. He is a Professor of Pediatrics and a pediatric intensivist, or ICU doctor, at Duke Children's Hospital, who also serves as the vice chair of education for the Department of Pediatrics. In that role, he helps lead a team that oversees medical training at multiple levels: medical students with their first exposure to caring for children, doctors training to be pediatricians, and pediatricians training in many different pediatric subspecialties. He is also a native North Carolinian, a husband and the father of two teenage girls. Welcome, Kyle.

Kyle Rehder, MD: Thanks for having me.

Host: Sure. It's a great pleasure. And I'm so thankful that you've found time in your busy schedule to have this conversation. Kyle, let's start with you as a person. Can you tell us a little bit about your day-to-day work obligations? What exactly do you do?

Kyle Rehder, MD: Sure. So, I kind of split my time three ways with my jobs at Duke. First and foremost, I am a clinician, so a physician who takes care of kids. And I do that as you mentioned in the pediatric ICU. And most people hear that and they think the neonatal ICU with the little tiny babies. I'm in the intensive care unit for children of all ages. And in fact, that can sometimes range up to late 20s or even 30s if there's something that we can potentially care for better than an adult ICU, depending on what's going on with that patient. We can also have patients that are sometimes just a few hours old, so babies up to young adults. And any child who is too sick to be cared for in a regular floor bed, and when I say floor bed, it's that general hospital bed, and so children who need special therapies that's maybe extra sick. And that may be kids after trauma or after major surgeries that may be with severe infections or respiratory failure, any number of things like that. So, that's one aspect of my job.

The next one and the reason I'm here today is because am very involved in teaching and that's something I'm passionate about. And I've been fortunate to serve in this role of vice chair for the last couple of years where I get to work with learners of many different stages of their training, students, residents, fellows and then, get to mentor some junior faculty as well, which is great. So, that's a good chunk of my time. Not as much time necessarily teaching in front of people as I would enjoy anymore, there's enough administration supporting behind it. But nonetheless, I get meaning out of working with these trainees.

And then, the third aspect of my job is I'm also involved in some quality and safety work here at Duke. And, fortunately, a lot of my work there actually is also teaching. I get to teach the interprofessional team about teamwork and communication, about safety culture, about how to interact with each other to make sure we provide the best care to patients. I get to use my teaching skills in that quality and safety world, but also bringing that passion to the best care of patients.

Host: Got it. Thank you for that overview. You sound like a busy guy. It's interesting as I hear you talking about the three segments of your work, you're actually literally the perfect person to talk about the topic of teaching hospitals, because you directly provide care, you oversee education, and then you also ensure quality, right? And I think that is a key question when we're talking about different hospital venues and how families might think about the care that they're getting, but more on that in just a moment. Can you tell us a little bit about your sort of origin story as the superhero that you are? How did you get involved or interested in children's health?

Kyle Rehder, MD: So, I will admit I had no plans to go to med school until it was very late in the game. I was an engineer undergrad and I come from a family of engineers. And so, that's what I was going to do. And then, as I got into working for a few different companies and doing summer experiences, I realized I wanted to be somewhere where I could have a more direct impact on people. So, I think there were some true altruistic reasons I got into medicine in addition to some career things, about the way that the lifelong learning that happens in medicine, I think really attracted me. The ability to have a little bit more control over my own career was a big plus as well. But nonetheless, I really wanted to make that daily difference in people's lives. And maybe it's some of my own impatience that I wanted to be able to see that difference right away, as opposed to work on a project for years that you may not see the outcome for that project until well down the line.

And then, I went on to med school. And, you know, I thought I might end up being a surgeon because I liked tinkering with things. And I liked that kind of aspect, I like working with my hands. But I liked really all the rotations I did, there was aspects I like. And for those of you who aren't familiar with how medical training goes, there is a year during medical school where you spend time on kind of all the different core rotations. You spend time with the obstetrics and gynecology team and doing OB-GYN and family medicine and internal medicine and psychiatry. And all of those had their intriguing points to me.

But the moment I realized where I needed to be was after I got off my pediatrics rotation. I said, "Okay, that was fun." And I went on to my next one and then realized every subsequent rotation, I missed being on pediatrics. I missed being with the pediatricians because of the way they thought and the way they talk with people and talk with families We'll get into more, you know, how passionate I am about teaching, but I think pediatricians are natural teachers. They are not only taking care of that child, but they're taking care of the family and a lot of education comes with that. And so, I think that part of it, I really liked.

And I like the acuity that we see in pediatrics as well. Kids do get sick really fast. They also get better and they have this immeasurable capacity to heal that we don't see in the adult population. And so, all of those things drew me in, in addition to the idea of being preventative and how we can hopefully prevent those long term diseases that we see in adults and getting in early to do that. So, that all kind of brought me into pediatrics.

And as I was going through my training, I realized that somehow being involved in education was going to be an important aspect of my career. That was something that brings me joy. That brings me meaning beyond just the taking care of patients, not just, but nonetheless, beyond taking care of patients. So in the setting of that, I knew I needed to be somewhere where I was involved teaching. We'll also talk about this. There's a lot of different settings where we teach. And it's not necessarily just at teaching hospitals. But nonetheless, opportunities became available and I was really happy to be able to stay here at Duke Children's for what has been my career so far.

Host: Great. Thank you for that, Kyle. Really well stated. And it was really fun for me just to kind of hear you sharing all of your motivations to go into pediatrics and to focus on children. You know, we may use that segment as a commercial in the future for anybody listening who's thinking about pediatrics maybe as a career.

Let's dive into the topic of teaching hospitals a little bit. I've been really looking forward to this, Kyle. I don't know if you remember, but I actually trained at Duke and was one time a fledgling intern and actually a fledgling resident in the pediatric ICU. And I think you were my fellow.

Kyle Rehder, MD: I do remember and I think you have it accurate.

Host: And I have very fond memories. And actually, and I'm not just saying this because you are the guest and, you know, we're being recorded, but I really remember just how impactful you were as an educator and as a teacher. And I'm assuming I was one of the best residents you've ever trained. You don't have to say that on the record today.

Kyle Rehder, MD: Naturally.

Host: Anyway, it's just really fond memories of the past, and it's fun to talk about what exactly goes on in those interactions during those key moments. And so, let's start with kind of some of the semantics of it all. So Kyle, the 101 on this, what is a teaching hospital? What's an academic medical center? What do these terms actually mean?

Kyle Rehder, MD: So, I think it can be a little tricky when we talk about that. Because as I mentioned a minute ago, teaching happens at many hospitals. And so, you could go with the mindset of a teaching hospital is any hospital where we have learners engaged. And that's really almost any hospital in the country because there are always people learning. Even our faculty are having ongoing learning, that we have nurses who are orienting. And so in that way, they're constantly learning. So, how do we separate out all of those hospitals to what we would call teaching hospitals? And you may hear the term academic medical center as well. And so, most people will equate teaching hospitals to what we call academic medical centers. And those hospitals are hospitals that are associated with a medical school is the traditional description. And so if we look here in North Carolina, that's really Duke, UNC, Atrium Hospital, Baptist Wake Forest, ECU and Vidant and then Moses Cone. Those of you who are familiar with the state realize I left out a few. What about Carolina's Medical Center? What about Mission? There's any number of other hospitals in the state where learning happens. But along those lines, the ones I mentioned upfront are the ones that are affiliated with a medical school. Now, some of those others, and I think Carolina's Medical Center is probably the largest, has multiple residency programs. So, they still have physicians in training at their place. And Carolina, I believe, is working on currently a medical school right now, but traditionally has not been in that mode or that model.

Host: Got it. That's very helpful. And so, what I heard you say is that teaching and learning, as a part of that, happens really in many different venues and really should in the spirit of really doing the best that we can for any patient in front of us. And then, the academic medical center is really more of a technical term related to this affiliation and that sort of thing. So, that's a very helpful distinction.

Just kind of speeding forward to the take home points, you know, if somebody only has a few minutes to listen to Dr.Kyle Rehder talking about this, what are the most important points you feel like families should know when thinking about a teaching hospital, particularly when they're seeking care for their kids?

Kyle Rehder, MD: Well, first and foremost, I think you should be not scared of going to a teaching hospital. And in fact, hopefully, I'll make the case that you should want to go to a teaching hospital, because I think there are a lot of advantages. Yes, there are learners there, but that also means there's probably a lot of research. There is a lot of good conversations about what the right thing is to do as opposed to decisions being made in isolation. You see a lot of group talk and a lot of people working together to make the right decisions. And at the same time, because there is this constant learning, these are the places where you see the cutting edge techniques and the cutting edge therapies that you may not get to see elsewhere. And we'll talk a little bit more about how the data supports that the best care is really provided in these academic medical centers and these teaching hospitals.

And then, the other aspect is, as you go into a teaching hospital, understanding there's a lot of different roles. It will take you a little bit of time to understand how the different roles fit together and who's coming into your care. But talk with them, talk about where they are in their training and realize that all of these folks are there to provide the best care to your child, and that's why they're there and they're all working together. So hopefully, we can take down any fear that might exist about coming to a teaching hospital, because I think it's really a great place to work and it's absolutely the best place to receive care.

Host: Yeah. You mentioned a lot of really important points within that because of the overlay of training and teaching that's going on. There are a lot of these conversations, questions being asked and answered that then have impacts on the care of individual patients, right? And I imagine that that has an additive. So, one thing that I have noticed when I am working with a learner and, for me, it's mostly in a clinic setting, is they ask all sorts of curious questions, right? Because they're seeing things the first time or the second time, whereas I might have seen them for the hundredth time that day. And I think we all know that the more you see something, the less curious you might be about that particular thing. And, you know, when a learner asks a question, it often piques in me something that I didn't think of. It allows me to continue to even grow myself in terms of the practice that I do and the care that I provide. I think the other thing is I know that when a learner is watching, there's an accountability there, and I'm always trying to show the highest quality exam maneuvers or talk about things at the greatest depth because I'm not only trying to serve the patient in front of me, but also the students who are trying to learn. Have you experienced that sort of same dynamic as well?

Kyle Rehder, MD: Absolutely. Working with learners every day keeps me on my toes constantly. And, you know, they read voraciously. And I do my absolute best to keep up with all literature. But they're at a place where they have a little bit more time to do that, and they are reading on things and asking me about them. And so, I do have to stay on my toes and I've been doing this for a while. And I'll admit that there are trainees come through that intimidate me with the amount of their knowledge and the extent of their knowledge. And so, I do have to make sure I'm on my game to keep up with them.

And then, at the same time, you know, as part of that teaching, I was actually meeting with trainees about an hour ago. And the phrasing I use with them is, you know, a lot of the folks you work with will know the right thing to do, but won't necessarily know why we do it. And putting words behind that and understanding the rationale and the reasoning behind why we're going to do something, because then that helps you understand when we don't need to do that thing, even though it's kind of the typical standard that we do and understanding those patients who might be a little bit different for this reason or that reason. Those are the types of discussions we have all the time at the bedside and in conference rooms and teaching sessions around the hospital.

Host: And I imagine because those conversations are being had, that also then helps us in explaining the care to the patients actually receiving it, right? Meaning that it's not just that they're coming in and getting a particular service, but we are having those conversations not just for the benefit of the student, but also for the patient so that they fully understand the experience they're going through.

Kyle Rehder, MD: Yeah, absolutely. The patients, the families, the staff as well, the phrase I use constantly with learners is learn to think out loud. "This is what I want to do. And this is why I want to do it." "What I'm seeing, what I'm thinking, do you all agree? What am I missing?" Asking for that input from the team so that we really make this a team sport. So, we're using all the expertises in the room because every single person on a healthcare team, including the parent of the family, including the patient themselves, brings a key perspective that we want to include. The nature of our discussions, I think, really do foster that environment.

Host: Yeah. That's really great and well stated. You alluded to the fact that research actually has been done on this particular topic. Now, you and I have both trained in a teaching hospital and I've been working in teaching hospitals for some time. And so, we aren't necessarily the most unbiased judges of different hospitals and such.

Kyle Rehder, MD: Fair enough.

Host: And so, what is the actual evidence to support this notion?

Kyle Rehder, MD: Yeah. And I think this can sometimes play into a little bit of fear, nervousness around teaching hospitals. It can play into a little bit of that fear and nervousness, because you can go onto Google and find a study that will support anything that you think you might think. You can find a few individual studies that suggest that maybe this doesn't happen as well in a teaching hospital, or maybe this outcome isn't as good. But when you look at the research that's been well done, where they've looked across large studies, looking at multiple hospitals, where they've looked across large populations and when they've accounted for how sick the patients are, the studies have pretty consistently shown that quality of care and outcomes for patients are better at teaching hospitals. And so, that can be a host of things. It can be how frequently we provide what we would consider the best evidence-based care. That may be the newest techniques, or it may be something that's really well-proven, but do we provide that consistently to every single patient? And that's something that typically happens better at these teaching hospitals.

How about mortality? How often do patients die in teaching hospitals versus non-teaching hospitals? And the fact of the matter is, when you control for how sick the patients are, even if you don't control for how sick the patients are, and they tend to be sicker at the big teaching hospitals, the mortality outcomes still tend to be better. There was one study, admittedly an adult study that was published a few years ago that showed for every 67 patients who were admitted, you would see the benefit of one additional patient surviving across teaching hospitals, which I think speaks pretty highly, as we're thinking about that life and death situation.

Now, I will admit a lot of this research has been done in adults rather than kids. And so, why is that? Frankly, there's just a lot more adults admitted to the hospital than pediatrics. And so as we're talking about these big studies trying to get those numbers up, we can do it better in an adult population. We also can look at the fact that there's a lot more hospitals that only treat adults. We may get into talking about that specificity of a children's hospital compared to a broader non-children's hospital. But nonetheless, there's just a lot more hospitals to compare that treat primarily adults. And so, that's where a lot of the data is. If we really try to look at the children's hospitals, so often those children's hospitals are naturally tied to an academic medical center and to a medical school, because of the subspecialties that are needed to take care of children. And there's added layers of complexity for everything, not just the physicians, but for all of our subspecialists, for our pharmacists, for our child life specialists, for our respiratory therapists, our nurses. There's often that tie, so it's sometimes hard to compare direct head to head for children in the same way it is as in adults.

Host: Thank you, Kyle, for that overview. That's really helpful just to kind of know that there is evidence out there that indicates that there could be this particular benefit that you and I perceive and have felt and experienced ourselves in different ways, but to know that the evidence exists is heartening and helpful for sure. I did want to touch on the role of research within the context of an academic medical center and how that kind of interplays with the teaching hospital itself. How would you talk about that in terms of the role of research studies and other initiatives within an academic medical center, particularly as it directly impacts the care being rendered in that hospital?

Kyle Rehder, MD: Yeah. So, I think the natural thing we think about is, "Oh, if I go to this center where research is taking place, that means I'm going to have access to some new trial or new drug or some new technique that's being done. And that's definitely true. We certainly try things out. And as you look in the media, we recently had the first partial heart transplant done here at Duke by our pediatric heart surgeons that was happening nowhere else in the world. We do thymus transplants, which is a very unique thing that was started at Duke. And for years, we were the only place in the world doing that. Those are the things that you can experience and get access to sometimes when you're at children's hospitals, that what is that most up-to-date therapy? Sometimes that may not even be accessible elsewhere. Sometimes it's just done much more frequently or more accessible at academic teaching centers.

That being said, I think it goes deeper than just that. Because certainly, there's opportunities to be involved in research studies where we're doing the research because we don't know if it's the absolute best thing or not, and we're collecting that information. And so, patients and families are really important partners in helping us advance medical knowledge. But what it does, if we think about the bigger culture of a place that is a research institution, is it sets up this, what we call, an environment of inquiry where we're always questioning. Is this the right thing? What is the right thing? How can we best take care of this patient? You know, yes, we've been doing this this way a long time. Is that still the right way? Is that still the best way? One of the phrases that one of my former mentors used is the only thing we're not allowed to say is, "It's because it's that's how we've always done it." That's not an okay answer for anything, that we should always be questioning and looking for the best thing.

And so unfortunately, we know that sometimes, and this gets into my quality world a little bit, even when we have a really good research study that defines a new best practice, now we know if we do X, it's going to be better than what we used to do as Y, it sometimes takes as many as 10 years for that new best practice to become what we'd call the standard of care, something that's done routinely in every hospital across the country. But that process has sped up a little bit in the teaching hospitals, so it doesn't take quite as long for it to start to be practiced in these teaching hospitals because of that environment of inquiry, because we're so closely tied to the research and reviewing the research and reporting out on things so frequently.

Host: Kyle, thank you for connecting the dots around all of these different facets of a teaching hospital that really impact the care of kids in a positive way and helping families to understand what it means to seek care in a teaching hospital. I wanted to ask, just to kind of hold ourselves accountable, if we had to say, what is the main downside of seeking care in a teaching hospital? Just to recognize that no place is perfect, certainly, and there's always sort of pros and cons, but if you had to say, what is the main downside?

Kyle Rehder, MD: Yeah. So, I think, as I've spoken to, there's a lot of people around in a teaching hospital, and there's a lot of people in different roles. And so, the thing that I think sometimes can be challenging is making sure that the communication that patients and families are receiving is consistent, not only within a medical team, because on my medical team, when I'm on in the intensive care unit, I have the attending, which is myself; I have a fellow, I have a resident, we have our nurses, a respiratory therapist and such, but we also have a lot of consultants that come in. And so, any given child, if they're sick enough, may be seen by our infectious disease specialists or oncologists or our nephrologists or our kidney specialists. there's a lot of folks around and every single one of those teams often has trainees at multiple levels. So, that certainly is one of the things that can be challenging when you've got that many faces around, making sure the communication clear and consistent for families. And often we may be saying the same things, but we're using different words and that can still sound like we're saying different things and sound like we're not on the same page. So, that's certainly one downside.

There's been some research that suggests that maybe the cost of care is higher in teaching hospitals as well. And that's not completely surprising, given the number of people who are involved in care and consults and things like that. Now, what those studies have shown is that cost is not greater for the individual patients and families who come in. The cost is borne by the greater insurance companies or in the case of the state for Medicaid and Medicare recipients. So, I will say we, as physicians usually the bedside, have no clue what insurance you're on or anything else. We practice the same way no matter who comes in. And it's always interesting to me if a family queries that and I'm like, "I don't know," or, you know, "I don't know where that's coming from. We're just doing the right thing for your child," and that's where our focus is. But that is one other potential downside that we've seen, is if you look at the greater cost, it sometimes runs a little bit higher. But it is hard to tease out because I mentioned earlier, we do often have the sicker patients. And so, those really ill patients, complex patients are seeking out the teaching centers because of the care that we provide. And so, that also comes with its higher costs.

Host: Kyle, thank you for providing such a really eloquent and nuanced overview of the teaching hospital. I think you've really done a nice job of helping our listeners understand what exactly a teaching hospital is and how that affects the care of families who go there. My last question to you is this. At the top, I mentioned that you have some teen daughters at home. As their father, would you bring them to a teaching hospital if they needed healthcare? And would you do so on the 1st of July, the first day of training experiences for residents?

Kyle Rehder, MD: So, along those lines, I can say, yes, I would and, yes, I have. My oldest daughter was born on July 9th at this teaching hospital that I'm sitting in right now. But nonetheless, you know, I think, number one, let me address this idea of the July effect of every year everyone turns over in July 1st. And there is a natural concern of do more medical errors happen and do we get poor care in July? And that's certainly one of those misnomers that exists out there. And I'll say the data doesn't really hold up. Those of us who have been in teaching hospitals for some time know that in July, we're sometimes going to have to provide a little bit more extra help, a little more supervision. And so, we're around a little bit more making sure that all those I's are dotted and T's are crossed. Fortunately, the data doesn't really show that the care is substantially worse in July. And in fact, it's really hard to tease out that it's different at all.

And then, in terms of bringing my children to the teaching hospital, I mean, we've had great experiences when we have brought them in. The people that I work with and we think about students and residents and fellows, these are folks who have really dedicated their lives to the care of patients and, in my case, care of children that we see. And these are really intelligent people who not only are dedicated, but they are compassionate and they have been really great with my family when I brought them in. And so, it's something that I absolutely have no qualms about bringing my family to be cared for here.

Host: Yeah. I think that's really well stated. And, you know, when I think about the students I work with and the residents I work with, they are incredibly bright, highly diligent and very highly motivated to provide the highest quality care. And to have somebody in that particular moment on your side is really a privilege.

Kyle Rehder, MD: And these are people who are not just straight out of the classroom and they've only taken a few classes and are good to go. I mean, these, folks have often already had years of training before they're really engaged in this type of work.

Host: Exactly. Really great point. Thank you again to Dr. Kyle Rehder for teaching us about teaching hospitals today. I think we've illuminated a lot of the key nuances that families deserve to know as they seek care for their kids.

Pediatric Voices is produced by the team at DoctorPodcasting. The show has been developed by Rebecca Casey, Dr. Angelo Milazzo and me. Thanks to Dr. Ann Reed and the administrative team at Duke Children's for their support. Find our show and hit the subscribe button wherever you find your favorite podcasts, Apple podcasts, Google, Stitcher, TuneIn, iHeart Radio and Spotify. We also want to hear from you. You can connect with us at dukechildrens.org, Facebook, Twitter and Instagram. Please send us your feedback about the show, including your suggestions for future topics. Thanks for being a part of the show. I look forward to talking with you again.