TABLE 4

Domains and Subdomains of Value and Illustrative Quotations

Domain of ValueSubdomainIllustrative Quotation(s)
Clinical
Strange organisms, treatment failure, complex patients“We have a boy with a vascular malformation in the brain that was treated with glue, and he had a massive stroke, and had a huge craniectomy, and has pseudomonas on the surface of the brain and from his ventricular fluid. It’s not so much solving the problem of “Is he infected?” He’s infected; the question is “Is this infection just in dead tissue? Is this a true invasive infection?” Having it in his ventricular fluid somewhat answers that question—but I can’t look this up in the Red Book for a treatment. I need somebody that really has a deeper understanding and better knowledge base of how many drugs do we use? It’s a multiple resistant Pseudomonas that’s notoriously hard to treat. So I need their specialized knowledge for that.” (Intensivist, site B)
Optimizing antimicrobial therapy“One major area of value is guiding antibiotic use. And I know maybe people think they know antibiotics because we all are able to prescribe them but you have to recognize that the science changes. So I would have to keep reading a lot about antibiotics and what’s compatible with what and what synergies there are because the drugs and bugs evolve. And I hardly have enough time to keep up with all my own stuff…I mean, I know my general antibiotics and I know how I would cover pseudomonas but then when you start trying to combine and think about synergies and what penetrates to the abscesses and what doesn’t and what is good for bone and what is good for soft tissue. I think that’s just something which I would have to read a lot on to try and keep up. It’s another subspecialty and antibiotics are really their area of expertise and I need them for this information to get the best outcomes for my patients.” (Orthopedic surgeon, site D)
“Their expertise on antibiotics helps get kids out of the hospital. A lot of these kids sit here for 3 d because the generalist is afraid to transition them to oral antibiotics. Good PID people say, “what are you talking about? The bioavailability is this, it’s that, you could send them home on this. It’s the same oral as IV.’” (Administrator, site E)
Diagnostic acumen“I find them to be immensely helpful to me diagnostically. It would be much more difficult to practice medicine here if I didn’t have them at my disposal. They are extremely knowledgeable about most of pediatrics. It’s the sort of field that requires you to, you can’t just focus on the heart or kidney or lung. You need to have a view of the child’s health in its entirety, so they have to be very open-minded, which makes them excellent diagnosticians. They take a meticulous and careful approach which allows them to figure things out when the rest of us are stuck.” (Hospitalist, site D)
“Ideal” consultant“If I had to pick 2 services that I think are the best consultants to work with they would be 1 of them. Dermatology’s the other 1. The reason why is …they’re able to look at the whole patient often, and not just focus on their little piece of expertise…It’s not like you’re just asking them about the heart; you’re asking them to think about an infection that potentially affects much more than that. And the treatments tend to have effects also on the whole patient. So I find in general that they think like generalists with a specific expertise. And that makes them really valuable as consultants. They make you think about things at a higher level which is better for patients.” (Hospitalist, site C)
“They will never tell you no. I’m not saying they won’t give you the ‘look’ on a Saturday, but they come in and their consult notes are gorgeous. Especially Dr X, he is the quintessential physician. And what I mean by that is he is what was touted in the 19th century as being “I do everything. I make sure that I know all the details, because if I was in a zombie apocalypse and I did not have any antivirals, or antibiotics, I will still figure it out. And mainly it’s because of his history. So he asks the questions, he takes the time, he invests and even on his less than enthusiastic days, where he has 7 consults, he still asks the questions. He still takes the time with every single family. And from a primary physician, you could never ask for more from a consultant. Ever. There are times he puts us to shame, because his notes are so good and so exact and comprehensive that you know as a primary, you should’ve done a better job.” (Hospitalist, site E)
Outpatient home“There is not a lot, I think, that gets sent to ID on the outpatient level, but it should. Immunocompromised patients, kids on long-term antibiotic therapy that need to get levels checked, recurrent fevers, those kinds of things, the general pediatrician might not handle very well or might not have the time to handle well. Most of what we do, it’s outpatient medicine. We have 3 million members and most of them don’t ever get hospitalized. I think the prevailing thought downtown is that there’s just not enough work which I personally don’t believe it’s true. I think there would be enough outpatient work for a full-time ID doc.” (Administrator, site A)
Guiding choice of laboratory testing“It seems like a smaller thing but I think of it as having tremendous value, especially if your kids are already getting chemotherapy and their counts are low or they are anemic, is that they help me pick the optimal tests. You want to minimize sticks. So when you’re drawing precious blood to do tests, you want to capitalize and get the optimal laboratory tests ordered, rather than just testing everything you can think of just because you don’t know what it is. So ID helps me think through what makes the most sense to order.” (Oncologist, site A)
Minimize exposure to excessive intervention“Well, the value is, hopefully, cost-effective diagnosis and treatment, so I could flounder with, “Let’s try this test and do this titer and do this,” or they can come in and hopefully hone it down some. ID can help direct to, “No, you don’t need to have orthopedics involved to go to surgery. We can just treat this with antibiotics,” or, “No, you don’t need to do 4 wk. We only do 2 wk for this.” So, it’s really a matter of working toward cost-effective, quality outcomes, trying to get patients out of here as soon as we can, so if they can help with that, to me, is the value they bring.” (Hospitalist, site C)
Organizational
Antimicrobial stewardship“Yeah, it is important that ID is involved in stewardship because I just don’t think that a pharmacist-driven antibiotic stewardship program feels the same level of ownership for the patients. They don’t sit in the room talking to a family for hours. They’re, quite frankly, not gonna be held to the same standard of liability as would I. So sometimes I think their help is well intentioned—but it rubs me the wrong way a little bit sometimes, whereas I know that my physician colleagues in ID are seeing the patient with me and trying to help me practice evidence-based medicine but with some common sense and with some recognitions of the limitations of their recommendations.” (Pediatric intensivist, site D)
Education“You need to learn not only the medical material, but you need to learn to think in a logical manner and synthesize what you have and 1 of the strengths of ID, in particular, they are not only teaching medicine, but of all the sub-specialties, this sub-specialty teaches young physicians how to think and we don’t do that very well in medicine anymore. We’re very, very quick. We have a lot of information in 2015, but we don’t have a lot of knowledge anymore. And we’re all learners, so it teaches the learners who have, and this is from my perspective, the important point about ID, is it is a thinking specialty and most individuals who gravitate to ID are really good thinkers. They’re good thinkers, they’re good problem solvers, they tend to be, again, I’m profiling, but we all speak from our biases, they tend to analyze things very, very well. So what we are missing, what we’re losing in medicine as we gain information and lose knowledge is the ability to slow down for half a second and to think and we’re doing our patients an injustice by not being able to do that. So what ID teaches, is it teaches the learners, not only medicine, but how to think, but it teaches their peers and their colleagues around them in a didactic setting, like morning report, analyzing a case with a little more depth or a little more detail or listening to an ID person’s thought process.” (Residency program director, site E)
Prestige“We’ve had cases here where ID swooped in and saved a child from a very dramatic illness and that got a lot of media attention. Or if they have research breakthroughs. We appreciate it when they do famous things. We capitalize on fame, it is valuable to the organizational brand.” (Administrator, site D)
Crucial to support other high- value specialties (critical care, hematology-oncology, transplant, etc)“In the world of pediatrics, ID is a pivotal specialty. It is core and fundamental. So, if a program was gonna have gaps, you better not have a gap in pediatric ID. It is so fundamental and critical to the clinical practice of pediatrics not only in and of itself, but because of the ancillary value it brings to other specialties. For example, we’re talking about hematology, oncology. You need a really strong ID consultant or consultants to have that at your hospital. PICU, NICU, GI. The infectious complications are so pervasive that it would be very hard to effectively practice any specialty high quality without strong ID. No question about it. And then, of course, there’s the whole gamut of issues that are directly infectious that are – that keep our hospital full. If we look to the kids at the hospital and there’s really a small percentage that don’t have either a primary or secondary ID issue. So I would see it as the highest clinical value. If I had a gap in service, the last thing – the absolute last specialty I want to have a gap in is ID.” (Administrator, site E)
Communicative
With patients and parents“They provide value in assuaging parental anxiety. Even if I think I know what the kid has, sometimes I’ll bring in ID to help the parents. Parents like to hear the specialist saying the same thing I said. Plus, ID is very thorough and takes their time communicating with families. I don’t always have the time to go into as much depth as parents want…It is kind of magical, parents just seem to feel better once they’ve seen the ID specialist…So, I value the ID specialist for their impact on patient and family relations, even if in some scenarios I’m not necessarily bringing them in for their clinical expertise.” (Hospitalist, site D)
With other members of health care team“We had a patient with AML on the ward who had gotten induction treatment and was profoundly neutropenic for weeks. She developed high fevers, had the usual things that we do for fever and neutropenia, broadening of various antibiotics, CT scan, empiric antifungal therapy. And she had a cough that started to go on and on. So we had ID helping us work that out but they also really helped us push the pulmonologist to do a bronch because what we ended up finding is that the child had Aspergillus in her lungs. Oftentimes, when we deal with other specialties in a very complicated case, having the ID folks at the table to say, “You know, this is actually really important.” Especially helping to convince procedural-based specialties like surgeons, of what we need to do is really so helpful. So we kind of use them to get what we need from other disciplines who might be hard to work with. In this case we were able to change the therapy that the child was on and address her problem more accurately.” (Oncologist, site A)
With community pediatricians“But from a partnership and a collegial standpoint, what they provide for us, we don’t – obviously we don’t get from any other service. We don’t. Because they really are, in many ways, have been trained because of what they do to be really jack of all trades. And really in a – in many instances, whether they like it or not, they’ll agree, they’re kind of acute care pediatricians in many ways. The rashes, the unknown fevers, the baby who has a fever randomly and they want to know why. Pediatricians, who – if they had to call 1 person for any of those things, they’ll call ID. There’s no one else to call. So who do you defer to when you have those tough questions? You call ID. You have a seizure? You call neuro. But if you have all this other random things, [laughter] it literally is infectious disease. They take the role of infectious disease, they take a role of acute care pediatrician, they take the care of rheumatology. If you look at what they provide, they provide the quality of 3 pediatricians, because they bring in so much knowledge and experience because they have to cross specialties to help.” (Community pediatrician, site B)
  • ID, infectious disease.