From Curricula to Crowdsourcing: Trainees Taking Charge to Teach Value

6 06 2013

As part of this week’s Association of American Medical Colleges Integrating Quality (IQ) meeting, we are featuring a post that originally appeared at Wing of Zock about trainees efforts to teach value.

Medical education’s efforts to incorporate the teaching of value-based care into formalized curricula have been remarkably few and fraught with challenges. More than 60% of med school grads feel they get inadequate instruction in medical economics, a figure that hasn’t budged in more than five years. At the same time, residents are subjected to the insidious influence of a “Hidden Curriculum” that seems to shun conservation in favor of consumption. The result is predictable: we are churning out providers that feel neither prepared nor compelled to allocate clinical resources more sustainably.

It’s not uncommon for trainees to contemplate the cost of a test or treatment. But that thought rarely ends up being more than a fleeting curiosity. Whilst juggling an exponentially increasing body of data and evidence, consensus-based guidelines, attending preferences and the increasing complexity of patients, the thought of adding another variable to our calculus seems daunting.

The common refrain is we don’t have enough information to make value-based judgments. Discussion of cost-effectiveness among trainees usually centers on price transparency, or rather, a lack thereof.  Survey the workroom of an academic hospital and you’ll get five different estimates for the cost of a CT scan. The monumental price tag of some items is even the source of folk-lore among residents: “Did you know that stress test costs $5,000?!” Adding to the myth’s power is the fact that prior to the recent decision by Health and Human Services to release hospital chargemasters, these documents have been treated like trade secrets. And even if an enterprising resident were able to obtain the classified dossier, the listed charge would bear no relation to the price the patient eventually pays.

But clinical malaise and the abstruse nature of hospital pricing should not prevent us from grappling with the excess and overuse typical of most training environments. As tertiary referral centers, teaching hospitals attract a subset of patients seeking an exhaustive work-up or more aggressive care from thought leaders – our mentors – in subspecialty fields.  Accordingly, these mentors are more likely to ask, “Why didn’t you order test X?” ratber than, “Why did you order test X, and what are you going to do with the information?” . A superfluous test is a “good thought.” A step-wise evaluation is often “expedited” with a single round of testing. An outside work-up is repeated to have “all the data in-house.”  These behaviors are then reinforced by our conferences, which focus on extensive diagnostic evaluations of rare diseases.

At its core, this is an issue of culture and our unbridled pursuit of clinical excellence. Trainees can and should help refashion this culture to achieve better value for patients. Student activism has heavily influenced the practices of today’s medical schools and residency programs, perhaps best evidenced by the American Medical Student Association’s PharmFree Campaign. The success of the Institute for Healthcare Improvement in spreading the principles of quality improvement (QI) can be attributed in part to the enthusiasm of trainees, empowered by the Open School to create and champion their own curricula. At a microsystem level, residents might incorporate value into QI projects and institutional research or lobby at an administrative level for increased information about the costs of their practice. As individuals, we can leverage our greater familiarity with new media and technology to promote resources such as Choosing Wisely, Healthcare Bluebook, and Consumer Reports Best Buy Drugs.

There are promising signs that current physicians-in-training are committed to championing the principles of resource stewardship. Costs of Care, a 501c3 non-profit social venture founded by trainees, has used crowdsourcing to engage both patients and physicians in the discussion of value-based care. More than 300 real patient and physician stories illustrating opportunities to provide high value care have materialized from their widely publicized annual essay contest. More formalized curricula in cost awareness at UCSF and UPenn originated from the work of residents. As a medical student, I was fortunate to be a part of a team that created a web-based curriculum in overuse.

There are undoubtedly other examples of “conservationists” in training out there. We want to meet you! We will be presenting our work at the upcoming AAMC IQ conference on June 6th. Come to Chicago, tell us about your project, be it a completed program or just a fresh idea. Or you can find us online at http://teachingvalue.org/competition.

–Andy Levy MD & Chris Moriates MD

(members of the Teaching Value Team)





Cultivating Creativity in Medical Training FedEx Style

14 01 2013

Over the holidays, I took full advantage of this opportunity to read a book from start to finish.  I chose Daniel Pink’s Drive.  It was actually recommended by @Medrants and I read it partly to understand why pay-for-performance often fails to accomplish its goals for complex tasks, such as patient care.  However, the thing I found most interesting about this book was the way in which creativity is deliberately inspired and cultivated by industry.

I could not help but think about why we don’t deliberately nurture creativity in medical trainees.  Why am I so interested in creativity?  Perhaps it is the countless trainees I have come across who are recruited to medical school and residency because of their commitment to service who also happen to have an exceptionally creative spirit.  Unfortunately, I worry too many of them have their spirit squashed during traditional medical training.   I am not alone.  I have seen experts argue the need to go from the traditional medical education that is fundamentally oppressive, inhibits critical thinking, and rewards conformity.   Apart from the criticism, it is of course understandable why medical training does not cultivate creativity.  Traditional medical practice does not value creativity.  Patients don’t equate ‘creative doctors’ as the ‘best doctors’.  In fact, doctors who may be overly creative are accused of quackery.

So, why bother with cultivating creativity in medical training? Well, for one thing, creativity is tightly linked to innovation, something we can all benefit from in medical education and healthcare delivery.   While patients may not want a ‘creative approach’ to their medical care, creativity is the key spice in generating groundbreaking medical research, developing a new community or global health outreach program, or testing an innovative approach to improving the system of care that we work in.  Lastly, one key reason to cultivate creativity in medical trainees is to keep all those hopeful and motivated trainees engaged so that they can find joy in work and realize their value and potential as future physicians.  In short, the healthcare system stands to benefit from the changes that are likely to emanate from creative inspired practicing physicians.

So what can we do to cultivate and promote creativity among medical trainees? While there are many possibilities including the trend to implement scholarly concentrations programs like the one I direct, one idea I was intrigued by was the use of a “FedEx Day”.  FedEx Days originated in an Australian software company, but became popularized by Daniel Pink and others in industry.  For a 24 hour period, employees are instructed to work on anything they want, provided it is not part of their regular job.  The name “FedEx” stuck because of the ‘overnight delivery’ of the exceptionally creative idea to the team, although there are efforts being undertaken to provide this idea with a new name. Some of the best ideas have come from FedEx Days or similar approaches, like 3M’s post-its or Google’s gmail.  I haven’t fully figured out how duty hours plays into this yet… so before you report me or ride this off, consider the following.  Borrowing on the theories of Daniel Pink, we would conclude that trainees would gladly volunteer their time to do this because of intrinsic motivation to work on something that they could control and create.  And to all the medical educators who can’t possibly imagine how would we do this during a jam packed training program, lets brainstorm a creative solution together!

Vineet Arora MD





Making the Most of the iPad Mini on Medicine Rounds

20 12 2012

On my birthday several weeks ago, I was lucky to get an iPad Mini from my husband. I already have an iPad and have shared my experience. In fact, we gave all of our residents iPads (one of them contacted Steve Jobs and got a response), and documented an improvement in efficiency on the wards. So why the Mini? What is all the fuss? Well, after finishing 2 weeks on service, I can finally tell you why the Mini is the new must-have for doctors and future doctors.

  1. It fits in your white coat! Yes, while there were entrepeneurs who started creating the iCoat, the truth is who wants to wear a coat with a huge pocket on the side? This means that you also don’t need to wear the “strap’ that we require our residents to wear for the iPad since we did not yet invest in the iCoat.
  2. You can hold it in one hand! This for me is the best part and very underappreciated point in the blogs and reviews I have read. This means you can tough the screen with one hand while you are palming it with the other. I don’t even have the largest hands so I would say it definitely was just at the reach of my palm grasp but I can imagine it would be perfect for my male colleagues.
  3. It fits in your purse! While the female docs may find palming the iPad mini not as easy as the men, never fear…since this one is for the ladies. Many female doctors are always on a quest to find the right handbag/workbag combination. Owning an iPad always meant buying boxy “folio” type purses or shoving it to barely fit in a handbag. The mini is the PERFECT size for a medium size handbag – hobo or satchel. This means that you can go from day to night without carrying your “work bag” to the restaurant. And for the men out there, you can always get a “murse” this holiday season. I hear that they are making a big splash.
  4. You’ll carry it more. Number 1 through 3 really boil down to the fact that it is hard to carry the iPad. Because it is so easy to carry, you won’t find yourself without access to the electronic health record or paging directory. You may be more apt to show patients their images or X-rays or look something up because it is not as hard to use.
  5. You’ll make friends. Basically the minute I brought out the Mini, everyone…nurses, social workers, residents, students, and yes patients were interested in seeing it – “Mini envy” as my students called it. It’s a conversation starter that can improve collegiality and teamwork. When I visited floors that I did not usually work on (overflow patients), I met a nurse who asked me about the Mini – and the next day, she came to our rescue when we were trying to decipher the timing of a patient’s medication and a potential new allergy.
  6. It is more discrete to use at a conference (once everyone stops staring). The Mini is smaller so a bit more stealth in terms of answering a text page or checking a lab while you are sitting in case conference, and you can easily stash it back in your purse as noted above.

Some things to think about. The Mini is not without its pitfalls – many of which are predictable due to its size and interface.

  1. For the visually challenged, it can be hard to see. Sure… you can always “magnify” things with the correct gestures. But, if you are in your Citrix Client looking at your electronic health record, it may not be so easy to magnify and you may have to hold it up closer to your face which can be awkward. Maybe I just need to get my vision tested? Either way, something to be aware of.
  2. Easy to lose. As part of the residency program project, the nice thing about the iPad with strap is you an see it on the resident and its harder to walk off with. The Mini could disappear in a snap. Could someone even “pick-pocket” a doctor coat? Very possible.
  3. It is not a complete substitute for a workstation or pen and paper. This is not unique to the Mini. There is a reason that mobile tablet computing is not a complete substitute for a workstation – the lack of a keyboard. As a result, some our residents carry “paper notes” with their iPad – the paper notes are to take notes of the to-do list that is created on rounds -nothing like checking all those boxes off as an intern. The iPad does not replace that so readily – and while there others thinking about this space, its worth noting that the preference for pen and paper to organize one’s thoughts is very strong. I have to admit, watching the catchy commercial for the Windows Surface, there is still something so appealing about an external keyboard.

So what is the verdict for the Mini? Well, as we say in medicine, the risks of the Mini are outweighed by its benefits making it the perfect prescription for all the physicians or physicians to be in your life. And there’s still a few shopping days left before Christmas…

Happy Holidays!

Vineet Arora MD





Where are the Lollipop Men in Healthcare?

9 04 2012

I recently watched Dr. Atul Gawande on video describe how what American healthcare needs is pit crews and not cowboys.  This sentiment is also memorialized in his thought-provoking writings for the New Yorker.

Interestingly, Dr. Gawande is not the first person I have heard to suggest such a thing.  A colleague named Dr. Ken Catchpole actually studied Formula 1 pit crews and used the information to guide improvements in pediatric anesthesia handoffs.  His observations were astounding and really highlighted how the culture of medicine is different from Formula 1. In Formula 1, pit crews have a ‘fanatical’ approach to training that relies on repitition.   In healthcare, the first time we often do something is “on the fly”.  Moreover, on-the-job training usually means ‘checking the box’ by attending an annual patient safety lecture.   Perhaps the most important was the role of the “lollipop man” in pit crews.   And yes, even thought it’s a funny name, it’s a critical job.   As shown in the video, the Lollipop man is responsible for signaling and coordinating to the driver the major steps of the pit stop.  When it is safe to step on the gas, the Lollipop man will signal to the driver.  Sounds like a thing so perhaps it can be automated.  Wrong.  When Ferrari tried replacing the Lollipop man with a stop light that signaled the driver, the confusion created (does amber mean stop or go?) led to a driver leaving the pit with his gas still connected.  Quickly after this incident, Ferrari announced it would go back to the tried and trusted Lollipop “hu”man.

So, who are the Lollipop men (or women) in healthcare?  Turns out that Dr. Catchpole and his team observed that it was often unclear who was leading the handoff process that they were observing in healthcare.  With team training and system reengineering, Dr. Catchpole’s team was able to reorganize the pediatric handover so there was a Lollipop man (anesthesiologist) at the helm.

While these handoffs represent a critical element of healthcare communication in a focused area, it is symbolic of a larger problem in healthcare – we are still missing “Lollipop men” to coordinate healthcare for patients across multiple sites and specialties.  This is even more critical on the 2-year anniversary of healthcare reform and this month’s match results. At a time when we need to cultivate and train more “Lollipop men” to coordinate care for patients, we have had stable numbers of students who enter primary care fields.   And like the lessons from the Ferrari team, it is doubtful that a computer (even Watson who is now working in medicine apparently) will be able to do the job of a Lollipop man.

So, how can we recruit more Lollipop men?  While it is tempting to blame the rise or fall of various specialties and market forces, it is important to recognize that being this is a difficult job to do when the Lollipop is broken or even nonexistent.  Without the tools to execute the critical coordination that Lollipop men rely on, they cannot do their job.  So, the first order of business to ensure that the Lollipop, or an infrastructure to coordinate care for patients through their race that is their healthcare journey, exists.  As the Supreme Court debates the future of the Accountable Care Act, there is no greater time to highlight the importance of the Lollipop.

–Vineet Arora MD





What Happens in Vegas Can Be Used to Teach Costs of Care

16 02 2012

Funded with a grant from the American Board of Internal Medicine Foundation,  Costs of Care has partnered with medical educators at Harvard Medical School and the University of Chicago (that would be us!) to start addressing this problem. We are developing a series of web-based medical education videos that use clinical vignettes to illustrate core principles of cost-consideration, including how to communicate with patients about avoiding unnecessary care and reducing overused or misused tests and procedures.  As part of the project launch, we released a new teaser video today called “What if Your Hotel Bill Was Like a Hospital Bill?”. The video is a tongue-in-cheek depiction of the challenges patients face in deciphering medical expenses, and their additional confusion when they learn doctors are not trained to consider costs.  – Excerpt from Costs of Care Press Release by Dr. Neel Shah  

How does this relate to Vegas?

On a recent trip to Las Vegas with my family for the holidays, I was in the Bellagio lobby admiring the Chihuly glass ceiling.  While that was impressive, I was also watching the clerks check in and out the long lines of visitors to the hotel.  The staff explained any charges on the bill, confirmed that the bill agrees with the expectations of the patron and then finalized the transaction, printing a copy on the spot for the traveler before they got in the cab to the airport hailed by the bellman.   What a far cry from hospitals where most of the hospital staff have no idea how much anything costs!  After all, doctors are notoriously bad at considering costs in the doctor-patient relationship, as demonstrated by a great piece by Dr. Peter Ubel on his experience with the cost of his own prescription medications. As Paolo (or Paul who works as our research project manager in his day job) from Hotel Hospital highlights, “our hotel staff specifically focus on the highest quality of care…I doubt that they even know how much anything costs here.”  The rest of the script was easy to write.  Shooting was a lot harder since we had to find a spot in the hospital that looked like a hotel but thanks to some creative camera angles and props from our MergeLab team, we were able to get it done.

Learning about costs of care is critical to taking care of patients.  This was especially poignant during my recent inpatient service block at a nearby community hospital, since I cared for many uninsured patients who paid out of pocket for their medications (not to mention their hospital stay).   Our residents were concerned about one patient who was uninsured and would have difficulty paying for Plavix, a critically important drug after his heart procedure.  Review of his medications also revealed he was recently put on Lexapro, a nongeneric antidepressant (with a sordid history) that was costing him over 100 dollars a month when there is a generic alternative for 4 dollars a month, which would help him afford his Plavix.   When physicians do discuss costs, they also get it wrong and perpetuate a ‘medical urban legend’ like stating that patients have to pay when they leave the hospital against medical advice (this is not true!).   These are just a few of many examples of why teaching students and residents to bring up costs and arming them with tools to address the issue with their future patients is imperative.  Without considering costs of care, we all take a ‘gamble’ that costs of care are not an issue for patients….Of course, the odds are against that.

Stay tuned for more work from our Teaching Value Project from Costs of Care funded by the ABIM Foundation. 

–Vineet Arora, MD, MAPP

Special thanks to our production team and actors: Mark Saathoff , Andy Levy MS4, Kimberly Beiting, Paul Staisiunas, Jeanne Farnan, and Neel Shah!





A Modern Day Fairy Tale for Medical Education

28 12 2011

Recently, I was asked to speak about innovations in inpatient medical education for leaders in general internal medicine.  Knowing that I would be last in a distinguished lineup of speakers and that my charge was to discuss novel ways to teach in the inpatient setting, I thought it would be important to review how its been done for a long time — so long that it is embodied in one of my favorite fairy tales…

You see, Cinderella dreamed of one day becoming the best clinical educator in the academic kingdom.  Unfortunately, her evil stepmom “Mrs. Dean” scoffed at Cinderella and said “teaching does not pay…look at your hard working and loyal stepbrothers….“Bill” has been our primary breadwinner due to his high volume of Patient Care and “Grant” –yes, while its feast or famine with him, just got a big payout for his Clinical Research.  Teaching? That’s no way to make a living.  Go work work for them until you figure you what you want to do.” 

So Cinderella toiled away…until one day, she met the Godmother of a grateful patient “Mrs. Fairy” who donated a small sum money to improve inpatient teaching…and with this Cinderella was able to transform herself into one of the leading teachers of the new curriculum (she was also able to get a raise to update her wardrobe!).  She quickly became a hit among all the medical students and residents who were truly “charmed”.  Then one day, at the stroke of midnight, Cinderella’s protected time ran out…and all of her work went up in smoke as she was forced back to her life of hardship seeing patients and doing research.  The students and residents were distraught at the thought of losing their most prized teacher and searched the academic complex for her –they were so moved they wanted to award her the precious “Glass Slipper” teaching award, which not only is bestowed with honor, but also a promotion to become a tenured educator in the academic kingdom.   And she lived happily ever after…

While you may think that this is the stuff of fairy tales (especially happily ever after), we all have Cinderellas at our institutions.  And those Cinderellas want to teach, but they struggle not only with funding, but also the realities of today’s inpatient environment.  So, what are these Cinderellas to do? Well, there are few of the ways to ensure that clinical teaching is rewarded – and possible resolutions for the New Year for medical educators.

  • Focus on a gap that needs to be filled:  Protected time is most likely be awarded to someone who is filling a need – think new curriculum that is mandated by LCME/ACGME or other alphabet soup organizational body.  What is the specific need that you can fill with teaching?  Often this may require thinking about a topic that may not exactly match your initial interest, but it is more likely to lead to funding for your teaching.
  • Learn new teaching methods:  Teaching methods for today’s wards are not well developed in the land of an organized chaos.  By incorporating a new platform for teaching (think case blogs, video reflection, standardized patients, or a host of other ideas), you can breathe new life into an old topic.  For example, using simulation to teach end of life discussion, or using blogs to teach about professionalism, can result in a novel curricular program that not only engage next generation learners, but also gains attention of leaders in medical education.
  • Document the effectiveness of the teaching – it is only through methodological evaluation that one can document that teaching translates into practice.  By showing that teaching can be linked to improvements in knowledge, attitudes, or practice, it is more likely that someone (maybe a fairy) will finance this teaching as critical to the mission of the hospital.  Think about procedural training that shows reduction in central lines.
  • Work with a mentor – Just like ‘big research’, mentorship is still important although not always emphasized. To be honest, mentors can serve to mobilize resources or promote your work with senior leaders.

However, regardless of these strategies, funding for teaching requires institutional leadership to recognize that the academic mission of teaching hospitals is still ‘to teach’.   Of course, this mission is sometimes lost in the chaos of teaching hospitals surviving budget crisis in an increasingly competitive environment.  So during this holiday season as everyone is reminded of the time of giving, now is a great time to remind the fiscally minded Mr. Scrooge in your C-suite that the greatest gift they can give is enabling a teacher to teach the future doctors of our nation.

–Vineet Arora MD





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







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