The Evolution of Pediatric Emergency Medicine

A conversation with Deborah Hsu, MD, MEd, who came to Stanford as inaugural chief of the division of pediatric emergency medicine at Stanford University’s Department of Emergency Medicine in 2023. Raised in a service-oriented home, Hsu considered a career in education but pursued pediatrics because of the opportunity to partner with families to determine children’s needs for medical care. She was drawn to a fellowship in pediatric emergency medicine because of the team-based collaboration inherent in providing emergency care.

How has pediatric emergency medicine evolved throughout your career?

Hsu: Early in my medical career, healthcare delivery tended toward being physician-centric. In the past ten years, it has shifted to a more collaborative approach involving the entire healthcare team including patients and their families. Emphasis on team-based and patient-centric care has allowed patients access to more diverse expertise.

Pediatric emergency medicine research has evolved from single-center to multi-center studies, and access to information in these diverse settings has resulted in the acceleration of care advancements. Also, the types of research being conducted have expanded to encompass more definitions of scholarship. We now routinely conduct research in education, quality, advocacy, and other fields that fall outside of traditional clinical and lab-based research.

I chose to focus my scholarly efforts on competency-based education, training, and assessment. I had concerns early on about finding ways to share my research, but over time, numerous avenues, including international forums, emerged, fostering widespread dissemination of this type of scholarly work.

What are your guiding tenets in helping individuals and teams be more productive and collaborative?

Hsu: Transparency and inclusion. I practice transparency by providing regular updates on progress and fostering open communication, even on minor details. I tend to over-communicate, but in doing so, I have been successful in providing avenues for input, normalizing collaboration, and optimizing workflows.

In promoting inclusivity, I avoid assumptions about people’s preferences. Earlier in my career, roles were frequently assigned based on perceived talents. Pediatric emergency medicine comprises people with diverse skills; it’s challenging to identify interests solely based on what I may know about an individual. Instead, I make opportunities available to all and employ an inclusive process for selection. This ensures genuine interest, enhancing outcomes.

My approach to patient care is similar. I routinely ask patients and their families, ‘What are your concerns? What specifically can we address during this visit?’ Through these very simple questions, I ensure the ED team isn’t making assumptions about patient needs. This process doesn’t take any more time compared to other approaches and allows for the delivery of individualized care.

Why Stanford?

Hsu: Andra Blomkalns, the chair of Stanford’s Department of Emergency Medicine, played a pivotal role in my decision to come to Stanford. Her transparent leadership, coupled with inclusivity and support for academic pursuits, stood out.

In the interview process at Stanford, I also met amazing and welcoming people who were accomplished and collaborative. That’s the way I’m wired. I knew if I came to Stanford, I would be working with like-minded people to advance pediatric emergency medicine in various ways.

What is your vision for emergency medicine in pediatrics at Stanford?

Hsu: While many aspects excel here, there’s always an opportunity for optimization. Strengthening partnerships with Lucile Packard Children’s Hospital (LPCH) is a priority as the pediatric ED at Stanford Hospital serves as LPCH’s ED. Leveraging technology for efficient but thorough care delivery and minimizing documentation time for ED team members is also key.

Our experiences as pediatric emergency physicians can inform the entire system about what resources are needed for the holistic care of patients. As generalists with undifferentiated patients, our approach is to think broadly, and then focus on immediate care needs. We are trained to deal with uncertainty. It’s ingrained in us to think quickly but thoroughly; to not miss critical issues, and to pivot with flexibility. In so doing, we identify needed resources, bridge gaps, and address social determinants of health as well as make diagnoses and treat acute illnesses and injuries.

How do you see emergency medicine residency training continuing to evolve?

Hsu: To ensure physicians gain proficiency in practice, we must structure education so that competency is measured in specific and quantifiable terms, and constructive feedback is provided routinely to our trainees in a psychologically safe setting. We must shift from norm-based comparisons to providing valid assessments of trainee competency and capabilities. De-emphasizing competition within peer groups facilitates the attainment of competency by all.

We’ve made some significant strides in competency-based education and assessment but there’s so much more to do. I’m confident we can move the needle and I think there will be some significant changes over the next 10 years.

Spring 2024