Transforming Medical Education: Trust, Time, Teams & Technology

28 11 2011

This past Thanksgiving, I was able to reflect on the always jam-packed and inspiring Association of American Medical Colleges 2011 Meeting that took place earlier this month in Denver.  The theme of the meeting was transformation.  It was certainly an interesting theme with the undertones of economic recession and the GME funding crisis- and that was before the failure of the Supercommittee to reach a resolution.  So, how does medical education need to transform?  In more ways than one, it turns out.  So here are just 4 that were the recurring themes of the meeting and being a fan of alliteration, they all begin with “T”.

  • Trust – it was clear that we need to restore the Americans people trust in physicians and in the medical education process.  While students enter medicine to make a difference, something that they see in their journey to becoming a physician makes them jaded and they sometimes lose sight of their initial intention. Is it debt, burnout, role models…Or likely some combination of the 3? It does not matter, because we have to restore their faith in teaching– yes teaching.  Teaching is the heart and soul of our medical education and it is sometimes the easiest to lose in an academic health center focused on NIH dollars or US news world report rankings.  In addition to teaching our students, it is time to teach another constituency, our patients and Congress about the critical need for medical education.   And in fact, advocacy is something we need to be teaching our own trainees so they can engage in the dialogue regarding the future of healthcare.
  • Time- perhaps the most radical proposal advanced was by Victor Fuchs who suggested that we radically redesign medical school to have medical students specialize 2 years after medical school and enter specific pathways like they do in many other countries and in other fields.  I’m all for shortening dwell time for our medical trainees, but I am not so sure that young people are ready to make a serious commitment about what they want to do at such an early age.  There has to be a middle ground since at the same time, one of the most well attended sessions was “who cares about the 4th year of medical school?” which included many insightful comments about the need for reflection and consolidation of core skills.  So, clearly not all time is easily tossed to the waste side.
  • Teams- given the projected shortage of over 90,000 physicians by 2020, it is important to reorganize care into teams.  While there is a lot of controversy about what to call nurses who have PhDs, that was not the focus of the meeting. It was about how can you encourage everyone to practice to their highest level of certification.  Team based competences have actually been developed by several groups and have been advanced by many schools with inter professional learning.  One difficulty we face at home is that we don’t have allied health professions, but we are brainstorming how to involve actual nurses and pharmacists in training medical students.
  • Technology -there was a lot of discussion about technology to boost medical education.  There was even a technology in medical education abstract session moderated by @motherinmedicine and including podcasts, iPads, and social media in medicine.  Perhaps the most interesting speaker was Chuck Friedman at the University of Michigan who is the former technology czar of the US and eloquently highlighted the need for moving medical education from wrote memorization to a distributed knowledge where the most important information future physicians will need to know is not what the information is off the top of their head BUT how to access information.  He went so far to say testing would move to “unassisted testing” followed by “cloud-supported testing” which would then merge into a pass or fail based on performance on both.  I know all of us who certified or recertified recently would welcome assistance from the cloud- it is after all the closest approximation to real medicine.  However, my hands down favorite moment of this session was when someone astutely asked what about these physicians when the power goes out or when the computer system fries.  His response was simple and so spot on… “Dont get me started on the state of IT in our teaching hospitals”.
So, while we just celebrated a holiday and accompanying ritual to give thanks, it is now time for medical educators to transcend the traditional status quo and instead test novel techniques to transform medical training — not only to restore public trust but so we can also train the trainees who will treat us in the future.
–Vineet Arora MD

Electronic Health Records, Quality & Safety: Pritzker IHI Open School Recap

13 11 2011

computer hardware,doctors,healthcare,males,medicine,men,PCS,people,people at work,persons,physicians,science,stethoscopes,technology,x-raysA classroom at the University of Chicago’s Pritzker School of Medicine was packed earlier this month with both medical students and students in the Graduate Program in Health Administration and Policy (GPHAP) interested in learning more about the IHI and quality improvement.   Dr. Chad Whelan, a hospitalist and institutional leader on quality improvement, facilitated an open discussion about some of the challenges in using electronic health records to improve quality of care and encourage physicians to practice more evidence based medicine.  Some of the topics covered included the unintended consequences of using electronic records, the benefits of an electronic record from an administrative standpoint, and issues surrounding the quality of documentation.  The meeting was organized by students in Pritzker’s Quality and Safety Track with guidance from Laura Botwinick, Director of GPHAP.   During a lively and interactive question and answer session, here are just a few of the questions that were raised by students and the discussion that ensued.

How interoperable are the record systems?  Why aren’t we using one single interoperable system?  While interoperability is a focus of “meaningful use” that is part of American Recovery and Reinvestment Act of 2009, electronic health records industry is also a marketplace with vendors competing for market share.  Because of that, interoperability may not have been achieved earlier. For larger healthcare systems such as the VA, the implementation of CPRS represents an example of an interoperable system across many hospitals nationwide.   Since academic medical centers often have several teaching hospital affiliates, physicians and trainees have to learn to work in several different systems, some of which may not even talk to each other.  While many urban medical centers have adopted electronic health records, a recent study demonstrated only 17% of hospitals capital investments.

What are the reasons behind the findings in the literature that mortality and errors sometimes increase when an EHR is installed?  Medicine is a complex system and sometimes changing one thing without changing another will yield unexpected outcomes.  Furthermore, if bad processes are automated, errors can happen much more quickly and systematically if they were being made in the first place.  That is why it is important to use QI tools to improve systems before an EHR is laid over them.  For example, during a QI intervention for pressure ulcers, the implementation of EHR for nursing documentation actually led to a decrease in the physician recording of pressure ulcers since they did not know where to access nursing notes.

How much training do practicing physicians get when an EHR is deployed?  Training is definitely part of the EHR implementation strategy.  One commonly used approach is to actively train early adopters who can champion it for the late adapters and laggards. At our hospital, that training included several hours of classroom time PLUS watching online video trainings at home with practice tutorials.  However, as the faculty and others present agreed, the learning curve is steep and learning is an ongoing process.  Anecdotally, there is often “reverse mentoring” with many of the residents who learn on the job are able to teach the attendings tricks of the trade.

What can be done to avoid the cut and paste problems that have emerged?  Interestingly, hospitals often have the choice whether to disable cut and paste or keep it active.  By disabling it however, the ability of EHRs to make doctors more efficient is sacrificed.  However, enabling cut and paste creates the risk that the information is out of date or inaccurate.   While many egregious examples have been described in the literature, there are some novel experiments being tried around the country include trying to use different colors for pasted information or creating patient records like wikis so multiple people are updating.   In a handoff curriculum for residents, we do highlight avoiding CoPaGA syndrome (Copy and Paste Gone Amok) by highlighting that it is allowed to cut and paste but their responsibility is to cut, paste, and update.

Are medical students getting trained on electronic health records?  Most learning at present is orientation to a specific system and on-the-job training.  Principles of effective practice with EHR need to be translated into medical education as it is an important core skill that all medical graduates will need.  While medical informatics is covered by in some form in many medical schools, recent debates highlight that more robust teaching on electronic health records needs to evolve and expand.   Moreover, the EHR can be used to actually advance medical education by providing a record of what types of patients a resident sees and assist in performance evaluation of patient care.

–Anthony Aspesi MS2 (with Laura Botwinick and Vineet Arora)


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