Fellowship Spotlight: Operations Administrations Fellowship with Dr. Michael Holbrook

In this new video series, ACEP's Young Physicians Section explores the diverse world of emergency medicine fellowships. This episode features Dr. Michael Holbrook, an Operations Administrations Fellow at the University of Cincinnati. Watch the video for a quick overview of his role and keep reading for more details about his fellowship experience.

YPS: Tell us a little bit about the fellowship, and walk us through your day-to-day. What does that look like for you?

Dr. Holbrook: Absolutely. Thanks for having me. I’m excited to talk about the Operations Fellowship in general and University of Cincinnati’s (UC) specifically. The Operations and Administrative Fellowships can be one or two years depending if there’s an advanced degree and that can be program specific. UC has the opportunity for both and whether it’s a one-year or a two-year track, it does involve an advanced degree. UC has a great relationship with the Lindner College of Business where we can get an MBA or an MHA. In this role at UC I work closely with the operations team. I work with the medical director and the associate medical director. The goal is to provide a holistic experience that focuses on project and team management, leadership, departmental operations and research.

I think about my day-to-day in two buckets. I have my clinical bucket and my fellowship bucket. Clinically I operate as an attending, and work about eight to nine shifts a month which is about 70 to 80 hours amongst three different departments. One is our academic flagship tertiary care downtown center, and then we have two community hospitals. The other bucket is the fellowship work and that I see that in two groupings as well. So there's the meeting part and then there's the project part. On top of the eight to nine clinical shifts a month I have about three to four meeting days to help me understand the needs of the department. These are medical director meetings as well as other things to help me understand the totality of my department’s situation such as peer review and quality assurance, informatics and how EMR is affecting our operations, the division specifically – whether it’s site specific or part of the hospital-wide divisions.

There are also joint division meetings with areas such as trauma, airway, psychiatry, stroke care, STEMI and radiology. These happen at different frequencies whether it be weekly monthly, bimonthly, quarterly etc. I’ve come to appreciate the help when trying to initiate policy or understand clinical situations that may arise.

Projects are the third part of this fellowship, and they vary based on what’s going on in the department. For example, we’re aware that boarding can be difficult and so I’ve been working to revamp our triage process to be able to see patients despite what goes on with the limitations of boarding. Then other projects arise such as a unique one related to coding documentation changes which came up at the start of this year. I'm also involved in a door-to-door needle project. So the buckets are clinical, and then the fellowship bucket is meetings and projects, and that’s how I spend largely the majority of my time.

YPS:  What's unique about your fellowship?

Dr. Holbrook: I think Operations and Administration Fellowships in general are unique because of the flexibility. They’re not ACGME accredited programs, so that allows different programs to do different things whether it’s a one-year or a two-year program with some flexibility to make it what you want and find out what they do or don’t do. There are some great things that make the UC Operations Fellowship quite unique, first and foremost it being part of the UC Emergency Medicine department which is the first residency of emergency medicine. There are some great academic minds, great leadership and great mentorship – people you want to learn from.

The UC Fellowship also has an Operations Leadership Academy, which is a rotating curriculum built around operations and logistics and leadership. It’s similar to a journal club with quarterly meetings to discuss a topic specific to operations. It’s hosted at an attending’s house and there’s a didactic portion, an interactive portion and then a social aspect. The last time we met we discussed risk management, decision rules, risk tolerance and those types of topics. In the coming year we’ll be talking about operations and will touch on topics like queuing theory, batching and what you do to work through a shift to have the smoothest flow for yourself and the department as a whole.

UC also helped me attend the Emergency Department Directors Academy (EDDA) which is a one-week immersive experience that ACEP sponsors. We listened to thought-leaders in emergency medicine, and specifically, emergency department operations to really understand the intricacies that affect medical direction and hospitals both internally and externally.

YPS: Why were you interested in this particular fellowship?

Dr. Holbrook: My story is one of those “eureka” moments that doesn’t happen to everybody in this way. Before medicine, I worked as a surgical representative for a medical supply company and I was in charge of a particular instrument. I saw the interplay between the medicine and the bedside and the business operations needed to run a medical practice. I had a particular situation where there seemed to be two different conversations occurring during a surgery between a hospital administrator and a clinical physician about the use of one particular piece of equipment, and I was realizing they weren’t communicating and having a hard time conveying their point.  This comes back to the flexibility in this fellowship – as I had gotten my MBA in medical school and was able to speak both languages – being able to know the patient-centered outcome and see the patient experience and being able to attend these meetings and talk to people who aren’t necessarily involved in bedside. I’m also participating in a group that is working toward documentation for a new stroke narrator or the charting. I can see how that is clinically implemented and I can create leverage for my colleagues to make things smooth at the bedside while having it make sense for the department at large.

YPS: What has surprised you about it??

Dr. Holbrook: One thing that really surprised me – although it shouldn’t have – is just the value of relationships. Sometimes a situation arises where a person will have to be confronted or a process will have to be reviewed or there’s something else to focus on, and you’ll have had these relationships and camaraderie that have developed over time as opposed to this being the first time you’ve interacted.

I also value having that physician perspective. There’s great value to having clinicians at the bedside when things are changed because as I mentioned previously, I’m not the only one experiencing it, but my colleagues are too, and I can hear their recommendations and take them back to those with the power for change.

So those are really the two things – the value of relationships both with physicians and our nursing colleagues or those working with HER, psychiatrists, social work and all those behind the scenes in making a patient’s experience what it is.

YPS: What's your favorite part about it, and what's your least favorite part?

Dr. Holbrook: My favorite part is being able to do what interests me. For example, I have a particular interest in coding rules because that’s something that affects every patient I see. So I’m going to be presenting on it later this month and I think it will help me moving forward.

I don’t know if I really have a least favorite. The most difficult part is coming into a new area and not knowing people. This is such a paper-based and person-based specialty, and you need to learn to open up, interact and be willing to say hi and make yourself known. I wouldn’t say it’s the least favorite, but the most difficult part is becoming a new person in a system where everyone largely knows each other while you’re trying to move a project through. Those relationships take time. In emergency medicine we’re very used to seeing a process – they’re having trouble breathing, put a machine on them and they turn around, often in a matter of seconds or minutes. But the long process of change can often be frustrating.

YPS: How do you hope to incorporate the lessons that you've learned in this fellowship into your career plan? And then is this something that you would consider a long term?

Dr. Holbrook: This fellowship applies to anybody in emergency medicine and whether you’re thinking about academic or community medicine, simply put you’re going to come in front of situations that will need change or you’ll have something new that’s being rolled out. And so learning those tools, whether they be project management or finding stakeholders or diagramming your interventions or monitoring change, or planning due-study act cycles, those are all going to make you seen as an asset and you’re seen as a doctor who be able to create a solution and make our lives better and patients’ lives better.  

And by implementation, I mean how am I going to move this forward or what are my next steps?  I know I’m working extra clinically, but I see this as something project-oriented and that’s what I’m drawn to. My advice is if you are interested in changing things in your department, if you see something that is frustrating and needs a better solution, this might be a fellowship for you. I love to take care of patients and will always be at the bedside. But when I come across something that may need a little bit of tweaking, I think having had these experiences or knowing how many people work behind the scenes and having an understanding of everybody involved, will make better and more efficient changes.

YPS: Do you have any advice for others who may be interested in a research fellowship?

Dr. Holbrook: If this is something you’re interested in, there are a variety of tools you can use in medical school or residency. The Institute for Healthcare Improvement has a basic science and quality and safety course [full disclosure, I was pretty involved with them during medical school] and if your medical school or residency has a relationship with them, I think that that course is free. They have an Organizing for Leadership and Change course where you identify a project and a process and map it out. Those are the things that I did during my MBA year and incorporated into the fellowship. And I’m still using the principles from that course in some of the projects that I’m working on. So if solutions-based situations are interesting to you, this might be the fellowship for you.