Ryan Schulteis, MD, will soon be presenting two abstracts at the annual SGIM meeting in Toronto. In this Faculty Spotlight, Schuletis talks about each of those abstracts, using technology and innovation to improve the delivery of care, and his terrifying but rewarding experiences as Chief Resident of quality improvement and patient safety at the Durham VA.
How long have you been at Duke? How long have you been at the division of General Internal Medicine?
I started medical school at this fine institution at the turn of the century. Other than a short hiatus back to my home state of Wisconsin, that means I’ve essentially been here for 15 years. I’ve been in the division for almost two years, since the end of my residency (with an extra year as Chief Resident).
What are your responsibilities within the division? What does a typical day for you look like?
I am a hospitalist at the Durham VA Medical Center. Most of my time is spent taking care of veterans that have found themselves sick enough to warrant inpatient care. A portion of my time, however, is spent conducting health services research within GIM. Another portion of my time is spent doing quality improvement work within the division.
What I’m most passionate about is using technology and innovation to improve things. I believe that starts with making doctors more efficient. With improved efficiency, doctors just might find themselves to do things with their time that are more valuable and more rewarding than concerning themselves with the nuances of ICD10 or generating redundant documentation. They might find themselves with more time to spend with patients and more time to teach residents and students. This trickles down and improves the patient experience.
Just like we use technology in our everyday lives to help us communicate and schedule, there is room to make better use of technology in healthcare. I love combining my interest in software engineering with my training in the principles of QI and statistical process control. It’s really fun, and when you see a software application that you developed in action and you start counting up the hours that it saves people – that’s really exhilarating.
You’ll be presenting two abstracts at the 2015 SGIM meeting in Toronto later this month. Can you briefly describe the research behind each of these abstracts?
Like most hospitals, we’ve been tracking our readmission rates at the Durham VA. One thing that we’ve been doing differently than most, however, is using a predictive model to calculate, for each patient, the a priori risk of readmission at the time of discharge. In this way, we hope to better measure which interventions are working.
If you just track your readmission rate, you might get a false sense of security when your monthly readmission rate goes down … or you might overreact or misplace blame when it goes up. These fluctuations might be random, and our healthcare system can’t afford to waste precious time and money chasing random noise.
There is a national push to have patients seen in clinic within seven days of discharge. We presented data at the 2014 SGIM meeting showing that early follow-up appointments were strongly and independently predictive of INCREASED readmission rates. This data was met with surprise and disbelief by many. We decided to do a subgroup analysis to see if all clinic visits (or only some) are associated with an increased readmission risk. We were interested in comparing clinic visits with a Primary Care Physician (PCP) vs. non-PCP.
Furthermore, we were really, really interested in comparing clinic visits with a PCP that is familiar with the patient vs. other. Our hypothesis was that PCPs that know the patient well would be less likely to admit patients to the hospital even if, shortly after a rugged hospital stay, the patient arrived at their clinic visit somewhat weakened and still on the road to recovery.
And that is what we found. If you are discharged from the hospital, a follow-up visit with your own doctor decreases your risk of being readmitted by about 20%. If you see a different PCP, one that has not seen you before, it doesn’t affect your readmission risk at all. If you see a non-PCP, however … just pack your bags because you are getting readmitted.
What about the second abstract?
Joel Boggan, MD is the lead author of the second SGIM project that I contributed to. Joel created evidence-based guidelines for the use of routine echocardiography with the help of Mark Donahue (within the Division of Cardiology). It was interesting that, right after the intervention, the ordering of “echos” decreased quite a bit.
Over time, however, the ordering rate started to creep back towards the baseline. It demonstrates a principle of Quality Improvement – that an intervention is like a drug … the effect of which decays over time. Until we find the “cure” for that deep-seated need we all have to order echos on all our inpatients, the only solution is to re-dose the QI interventions at regular intervals!!!
Aside from these abstract presentations, what are you most looking forward to at the SGIM conference?
Toronto may be cold but the fine people of Canada are notoriously polite and the crime rate is quite low!
Three years ago, you became the Durham VA’s first chief resident of quality improvement and patient safety. What did you learn from that position? Looking back, what stands out as the most memorable moment of that experience?
I had the opportunity to speak at the Department’s Grand Rounds four times during those 12 months! Those four engagements were the most terrifying and the most rewarding experiences. I learned a bit more about myself (and a bit more about some of the faculty) with each one. Honestly, as I’ve written before for the Chief Residents’ newsletter, that year was, professionally, the most rewarding of my life. Of the top 20 moments of my life, other than those that involve Brett Favre, Aaron Rodgers, or weddings/childbirths…many occurred during my year as Chief Resident.
What passions or hobbies do you have outside of the division?
I enjoy coaching pee-wee football and, once per year, donning a suit that would make Lombardi proud and coaching the Legendary VA Jets in our annual bid to upset the talented but universally-loathed Duke Marines in the proud Turkey Bowl tradition of Duke Medicine. I enjoy flying RC planes and racing RC trucks with my kids. I enjoy trips to the beach and mountains of North Carolina. There is a ukelele that I occasionally strum whilst at the beach … you can often hear the sounds of children begging for mercy singing along.
Have you recently read any books, articles, blog posts or other material that would be of interest to the division?
I have found many interesting blog posts about the intersection of health care with predictive analytics and software innovation at the following URL: http://schulteisventures.net/. I also enjoy books about shameless self-promotion.
Schulteis and his family at the Wright Brothers Museum in Kitty Hawk, NC.
