Dear Stewardship People: Can't We All Just Get Along?

The following post is by Dr. Jasmine Marcelin from University of Nebraska Medical Center.

Teams should work together, not compete

I am an Antimicrobial Stewardship Leader. As the Associate Medical Director of Antimicrobial Stewardship at my institution, I work with another physician (Antimicrobial Stewardship Medical Director) and an ID-trained Antimicrobial Stewardship PharmD. We have a great setup, share audit and feedback responsibilities, and have different interests clinically and for research, which makes it great to divide tasks for initiatives. I focus on outpatient ASP and SSI prophylaxis, PharmD on AU initiatives and cost, and other MD on CDI. We cover for each other, review and co-author each other’s grants, papers and presentations, and present education to various hospital groups together. We work well as a TEAM.

Teams are great things. Nothing meaningful can be accomplished when working alone and in silos. Some ASP teams also include nurses, infection preventionists, advanced practice providers and laboratory personnel, and the specific ASP leadership model will depend on the resources at an individual hospital. Each of these groups bring a very specific and unique skillset to the ASP team. Why is it then, that we seem to find ourselves in the midst of an MD-PharmD power struggle?

In February 2018, the IDSA, SHEA and PIDS released a statement that ID physicians should be leading the way in Antimicrobial Stewardship. This statement shared the unique skillset that ID doctors bring to the ASP table, including years of clinical training in the diagnosis and management of infections. This position paper reads as a statement of support from our societies demonstrating our value to hospital leadership. “Hey C-suite, we have these requirements for ASP, and it says you need a leader that has ID expertise. We literally went to school for ID, and we already work for you, so here are these reasons why you should actually PAY us for what we know how to do well, instead of asking us to do it for free while we are on hospital consults?” The position paper did not say, “ID physicians are better than Pharmacists at ASP”. In fact, the document went on to state, “An ASP should also include at least 1 pharmacist, ideally with subspecialty training in ID. While ID physicians and pharmacists may often have the most central roles in an ASP, all members of the ASP team, including microbiologists and infection preventionists, provide distinct skills of great value.”

Notwithstanding the explicit acknowledgement of the value of the team model of ASP, perhaps the conclusion “ID physicians are well equipped to lead multidisciplinary ASPs given their training, expertise, and experience” offended some of our pharmacist colleagues. The publication was followed by a letter to the editor in May 2018 that stated, “In identifying ID physicians as uniquely qualified for these functions, the paper fails to acknowledge the essential leadership and skill set of ID pharmacists in stewardship”. The letter then concludes, “Best care for patients is achieved through multi-disciplinary stewardship where pharmacist leaders are key to success”. This letter led to a flurry of social media posts misguidedly comparing the “value” of ASP physicians vs pharmacists. A real world study of ID fellow experiences with ASP shared that fellows looked to “pharmacists, not ID physician leaders as primary resources for antibiotic teaching”, and there was a social media frenzy that pharmacists should lead ASP, not ID physicians.

Seriously?

People, this is not a competition! Pharmacists are uniquely equipped to lead ASP because of their special training in the PK/PD of antibiotics, adverse drug effects, drug-drug interactions, and costs. ID physicians are uniquely equipped to lead ASP because of their special training in direct patient care, being boots on the ground as well as eyes in the sky, and can always use the “peer” card when approaching rogue prescribers. The thing is, we are BOTH essential for a successful ASP, and organizations should strive to fund BOTH, because we complement each other. The thing is, we ID physicians have had a long struggle for institutional acknowledgement and respect of our invaluable contribution to patient care. In our fight for recognition, perhaps we have failed to let our pharmacist colleagues know that we appreciate what they do, and that our work is enriched by their contributions. Perhaps we should be intentional to thank our pharmacists for this contribution so that they do not feel we are trying to usurp them and dismiss their value.

Physicians acknowledge and applaud pharmacists’ tireless contribution and value added to the ASP team. We support you in leadership roles. When we say we as physicians are suited to be ASP leaders, it is because we are. It does not diminish your role as co-leaders in a multidisciplinary team; neither does your teaching of antibiotics to ID fellows diminish our role as clinical experts to trainees. Can’t we all just get along? Time to put this superfluous competition to rest and support each other’s value, for the patients’ sake!

Time, Power and Infection Prevention

With the increased attention to infection prevention and antimicrobial resistance globally, we now have more seats at the table. In fact, many of us are or will soon be at the table in positions of leadership (power) in our hospitals or organizations. We can include our colleagues at CDC, who are being asked to do more and manage larger research portfolios. The time we imagined 10-20 years ago, where our clinical and research roles would be appreciated is now, but with the now comes an overwhelming urgency - we are overworked.

With that in mind, I read a very interesting post by Maria Popova on UC Berkeley psychologist Dacher Keltner's book, The Power Paradox: How We Gain and Lose Influence. Two quotes in particular struck me as they applied to our current situation as hospital epidemiologists and infection preventionists:

"The power paradox is this: we rise in power and make a difference in the world due to what is best about human nature, but we fall from power due to what is worst. We gain a capacity to make a difference in the world by enhancing the lives of others, but the very experience of having power and privilege leads us to behave, in our worst moments, like impulsive, out-of-control sociopaths"

"But in reading these alarmingly consistent studies, I had to wonder about one crucial confound(er) that remains unaddressed: People in positions of power also tend to be busier — that is, they tend to have greater demands on their time. We know from the now-iconic 1970s Good Samaritan study that the single greatest predictor of uncaring, unkind, and uncompassionate behavior, even among people who have devoted their lives to the welfare of others, is a perceived lack of time — a feeling of being rushed. The sense of urgency seems to consume all of our other concerns — it is the razor’s blade that severs our connection to anything outside ourselves, anything beyond the task at hand, and turns our laser-sharp focus of concern onto the the immediacy of the self alone."

I encourage you to read her full post and ponder how the Power Paradox might (or might not) apply to our new and larger roles in infection prevention. For example, I've noticed during discussions at national meetings and in peer-reviewed publications that we're blaming healthcare workers if they don't wash their hands or criticizing physicians if they overprescribe antibiotics. Keltner suggests that the Paradox can be handled by putting our focus on other people including empathizing, giving, expressing gratitude, and telling stories. It might seem that our focus on others (patients) might protect hospital epi folks, but what about the people we need to work with if we're to be successful - other healthcare workers?