Wisdom of the Crowd: Finding the Most Promising Innovations to Teach Value

16 10 2013

Earlier this year, we launched the Teaching Value and Choosing Wisely Competition in conjunction with Costs of Care and the ABIM Foundation.  Why a competition?   Not surprisingly, traditional “literature review” yielded little by way of promising strategies for educators who wished to learn how to teach about value.  However, we had all learned of isolated stories of success, occasionally through attending professional meetings, sometimes via networking with colleagues, or more often through just plain word of mouth.  To help bring these stories of success to the fore, we relied on a crowdsourcing model by launching a competition to engage a larger community of individuals to tell us their story.  Of course, there were moments we wondered if we would get any submissions.  Fortunately, we did not have anything to worry about!  In June, we received 74 submissions, from 14 specialties with innovations and bright ideas that targeted both medical students, residents, faculty and interprofessional learners.

Reviewing each abstract to determine the most promising practices that could be easily scaled up to other institutions was not an easy task.  One interesting struggle was the inherent tradeoff between feasibility and novelty – what was feasible may not have been so novel, while you were left wondering whether the most innovative abstracts would be feasible to implement.  Fortunately, due to the outstanding expert panel of judges, we were able to narrow the field.  While all the submissions were interesting and worthy in their own right, it was clear that there were some that rose to the top.  For example, while every submission included some level of training, the most promising innovations and bright ideas employed methods beyond traditional training- such as a systems fix using electronic health records, a cultural change through valuing restraint, or oversight or feedback mechanisms to ensure trainees get the information they need to assess their practice at the point-of-care.

Perhaps it is not surprising that several of our winners came from innovations or bright ideas developed by trainees or medical students.  After all, the junior learners are on the sharp end of patient care and in the position to see the simplest and most elegant solutions to promote teaching value. Giffin Daughtridge, a  second year medical student at the University of Pennsylvania proposed linking third year medical students to actual patients to not only review their history, but also their actual medical bill.  As emergency medicine residents at NYU, Michelle Lin and Larissa Laskowski were inspired by Hurricane Sandy to develop an easy to use curricular program for her peers.   At Yale, junior faculty Robert Fogerty instigated a friendly competition among medical students, interns, residents and attending physicians to reach the correct diagnosis with the fewest resources possible during morning report style conferences.

The methods employed to achieve success were equally diverse, ranging from repurposing traditional tools to using new methods altogether.  Building on the traditional clinical vignette, Tanner Caverly and Brandon Combs launched the “Do No Harm Project” at the University of Colorado to collect vignettes about value to learn from. This program also informed the launch of “Teachable Moments” section in JAMA Internal Medicine that is now accepting submissions from trainees.  Meanwhile, Amit Pahwa, Lenny Feldman, and Dan Brotman from Johns Hopkins University proposed individualized dashboards that would make lab and imaging use for each trainee available for feedback and benchmarking against their peers.   And Steven Brown and Cheryl O’Malley at Banner Health proposed a local high-value competition that resulted in more than 40 entries from trainees. Drs. Brown and O’Malley plan to implement the most promising ones.

These are just a few of the innovations and bright ideas that were submitted. You can check out the entire list of innovations and bright ideas on the Teaching Value forum.  Our hope is that this is just the start of developing a network of individuals interested in working together to transform medical education by incorporating principles of stewardship.  So, in this case, we recommend that you follow this crowd.

Vineet Arora, MD MAPP  on behalf of the Teaching Value Team members including Chris Moriates, MD, Andy Levy, MD, and Neel Shah MD MPP 

Join us Thursday October 17th at 9pm EST on Twitter for #meded chat where we will discuss the winning innovations and bright ideas!





From Astronauts to Attendings: Workload, Duty Hours and July, Oh My!

31 07 2013

reposted from Academic Medicine’s blog

Every July, as academic hospitals welcome new interns, a flurry of activity ensues. While learning to care for patients and navigating the complex social territories of their new hospitals, interns also are worrying about “getting out on time” and making sure not to “dump” on their colleagues. This work compression, particularly among interns who are not familiar with the day-to-day operations of wards, can strain the learning environment. With the implementation of resident duty hours regulations, attending physicians are subsequently called to provide more direct patient care. Yet residency is a time for learning on the job, and part of that learning comes from the teaching attendings provide. In our recent study in Academic Medicine, we asked: “So what has happened to time for teaching?”

Given the recent changes in academic medicine, attendings’ workload needs to be examined, especially regarding their role as teachers. Previously, most studies of workload and work compression focused on residents. Moreover, these studies commonly focused on workload as it related to patient census. While patient census is one measure of workload, we all have had the experience of how one very complicated patient can add up to more work than 10 relatively straightforward patients. So, should we instead consider perception of workload rather than actual workload measured by volume?

Borrowing from methods developed at NASA to examine astronauts’ workload, we examined attendings’ perceptions of workload and the relationship of those perceptions to reporting enough time for teaching. In doing so, we found a steep relationship between attendings’ greater perceived workload and time for teaching. Additionally, we analyzed our results with respect to the time of year and to the implementation of duty hours regulations. Implementing duty hours regulations, not unexpectedly, reduced attendings’ time for teaching, but the magnitude of this reduction was humbling.  What was most surprising, however, relates to the time of year, specifically summer, which everyone fears because of the “July effect”.  Interestingly, more teaching occurs during summer than during winter and spring. We also found that attendings’ greater workload during winter and spring was more detrimental to their time for teaching than their workload during summer.

Certainly, having attendings provide more direct care when residents have heavy workloads improves patient safety. However, the cost to residents’ education and subsequent learning and growth is not trivial. Ensuring that teaching on the wards is restored should be a central focus of graduate medical education reform.  Moreover, while winter and spring should be times for continued teaching on advanced topics to ensure professional growth towards achieving competence, for some reason, we fall short. Meanwhile, during summer, attendings may cut back on their own busy clinical practice and/or administrative duties in anticipation of their role as teachers and supervisors. Regardless of the reason, to prepare for future changes to the accreditation system and attendings’ role in documenting progression through milestones, testing and implementing innovative ways of re-balancing workload to restore teaching and learning on the wards is imperative.

–Lisa Roshetsky MD MS and Vineet Arora MD MAPP 





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





The Social History: Going Beyond TED

7 02 2012

As I am on service, I realized that one thing that can be easily lost in the race to take care of patients with limited duty hours – the social history.  The social history is part of the admission “history and physical” that once included a myriad of information about the patient’s job, life, and habits has now “fallen into despair” becoming little more than “negative for TED”, or in other words “no tobacco, alcohol (ethanol) or drugs.”

But, there is so much more to it than that.   How do they afford to pay for their housing, food, and medications?  Do they have insurance?   Where do they live?  Who takes care of them or do they take care of someone else?  Do they have friends or family living nearby?   What do they like to do for fun?  Given that most of the ‘discharge planning’ focuses on these elements of the social history, it seems silly that we don’t include more than just no TED.

So, when I was asked by a very astute medical student if I preferred to hear more in the social history, I said yes.   The information that is usually discussed as the patient gets better and we wonder where they will go was now presented on admission, discussed as a problem just like any other medical problem.   In just a few short days, we discerned that a patient who had chronic hypoxia and shortness of breath worked in a factory which likely contributes to his interstitial lung disease.  Another patient who had been hospitalized for alcohol withdrawal recently broke up with a girlfriend which triggered this bout of drinking.   Another patient who was a Jehovah’s Witness would rather have IV therapy for his wound infection than surgery.  Another patient with repeated hypertensive crisis had skipped his medications since he could not afford them.

Given the tremendous burden of costs of medications and the complex interplay between social factors and health, it’s time that we start teaching people to take a thorough social history. Wondering what should go into a thorough social history, I first did what most physicians do – I went online.  It turns out that Wikipedia has an entry on social history for medicine that starts out with the same substance abuse history.  It also includes occupation, sexual preference, prison, and travel.   I stumbled upon another interesting piece by a medical student in the LA Times who admits that it is easy to skimp on the social history due to the time it takes to take a complete history.  After a brief foray in PubMed, A study demonstrated that internal medicine residents do not often know the social history of patients, and this worsens if the resident is more advanced in training and when the workload is higher.  Then, I recalled the seminal text that is still in use today.  According to the Bates Guide to History and Physical Examination:

The Personal and Social History captures the patient’s personality and interests, sources of support, coping style, strengths, and fears. It should include occupation and the last year of schooling; home situation and significant others; sources of stress, both recent and long-term; important life experiences, such as military service, job history, financial situation, and retirement; leisure activities; religious affiliation and spiritual beliefs; and activities of daily living (ADLs). It also conveys lifestyle habits that promote health or create risk such as exercise and diet, including frequency of exercise; usual daily food intake; dietary supplements or restrictions; and safety measures and other devices related to specific hazards. You may want to include any alternative health care practices. You will come to thread personal and social questions throughout the interview to make the patient feel more at ease.

There is another good reason to teach the social history – another study shows that those residents who took better social histories were actually perceived to be more humanistic.  As others stated, “By knowing patients better—and taking better social histories—we will provide better care and will be more fulfilled and energized in our work as physicians.”

–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)





Whittling Costs in White Coats

10 08 2011

At the beginning of last week, I was excited to be invited to take part in the ABIM Foundation Summer Forum, where the who’s who in medicine convened to discuss how to create a sustainable healthcare system, where costs are controlled and quality of care is preserved.   We heard some bold vision and ideas, many of which were focused on badly needed policy levers or system redesign.  However, as I ended my week on Sunday with investing Pritzker’s new medical student class with their white coats, I was wondering how we can teach and empower individual trainees to do their part.  As our speaker highlighted so eloquently, the most powerful thing about the white coat is what and who is in it…and also the learning that takes place in it.  So, in that vein, here are some thoughts for what students and residents can do.

  • Read up on the topic – some excellent resources I heard about at the meeting
  1. Physician Stewardship of Health Care in an Era of Finite Resources– a recent article in JAMA by Drs. Chris Cassel and David Reuben regarding the various levels of stewardship
  2. Personal Reflections on the High Cost of American Medical Care – a recent article in Archives of Internal Medicine by Dr. Steven Schroeder
  3. The Pricing Of U.S. Hospital Services: Chaos Behind A Veil Of Secrecy – a classic by noted economist Uwe Reinhardt
  4. Less is More Series – a great resource in Archives of Internal Medicine edited by Rosemary Gibson and others.
  • Listen to the patient  Of course, this sounds simple…but the truth is that more times than not, the answer is in the patient history.   With duty hours and workload, taking a detailed history sometimes takes a backseat to reviewing the electronic iPatient.  One approach is to start with two open questions:  (1) Tell me about yourself; and (2) What are your healthcare goals?   Often, the key is to try to understand the baseline.  I once took care of an older patient who had abdominal pain and had received over 40 abdominal CTs over the past several years.  When we were able to gather more information from the patient and her family, it turns out that she has had bad abdominal pain for over 30 years that would come and go!   By working this information into her discharge summary and plugging her into primary care, our hope was to have her avoid future costly and harmful workups.  As I’ve mentioned before, students often have more time with patients than residents or attendings and can often take the most helpful and detailed history!
  • Learn the physical exam Often times, we rely on tests since we do not trust our physical exams.   It is too easy to get an echo when you are wondering if you are truly hearing a murmur.  The lore here is that you need to  listen to a lot of normals to be able to detect the abnormal.  Because of this, when I am on service, I usually invite the third year student to examine every patient with me so they can see a lot of exams.  Usually by the end, they are more confident in their ability to detect crackles or murmurs.  As stated by our white coat speaker, the stethoscope is indeed a powerful tool.  Interestingly, with the infectious increase in global health experiences among medical students and residents, working in resource poor settings requires ingenuity and reliance on the lowest technologically feasible solution.   Closer to home, volunteering in a free clinic is likely to provide one with the same experiences.
  • Don’t just check boxes but ask why the test is indicated Trainees can ask the difficult question – why are we ordering this test or medication?  Is it indicated?   An even better question to research is whether there is a CHEAPER (we can’t shy away from using that word anymore) alternative that would provide the same information?   For example, before every PE protocol CT or Doppler to rule out DVT, I always ask my team to calculate the Wells score so we understand if the test is indicated and what our pretest probability is.  In addition, every study has a downside, whether it be hospital-acquired anemia from phlebotomy or incidentalomas and pseudodisease from excessive imaging.  It is easy to check boxes, it is harder to question why you are checking them.
  • Try to find out how much the test costs While the answer is elusive, the goal is to start the conversation in your own backyard.  There are anecdotal reports of residents going back over 10 years who have tried to work with their hospital billing departments to find out how much things cost.  Moreover, greater knowledge of costs will change practice patterns as we’ve discussed before.
  • Counsel patients One impressive thing about the ABIM Foundation Forum was the representation of patient advocacy groups who were willing to partner with physicians and physician groups to reduce the costs of care.  While the image that may immediately come to mind most is of a patient coming in to request a test that is not indicated, engaged and informed patients expressed the desire to work together and that less is more.   In some communities, there is a lot of distrust of the medical care system and these conversations have to start one patient at a time.

Unfortunately, whittling healthcare costs is not as easy as teaching trainees.  As long as our systems and the faculty within them promote costly workarounds such as misrepresenting tests as urgent to expedite them, ordering tests as fast as possible for fear of discharge delay, or wasteful lab testing, trainees will be reprimanded for NOT doing something.  Therefore, to truly make change in our teaching hospitals, we must also ask that our faculty reach deep into their own white coats and find the courage to say “Don’t just do something, stand there.”

–Vineet Arora, MD





Help Debunk A Medical Myth About Patients Leaving AMA

11 07 2011

This week at FutureDocs, we are working with our friend and colleague Glass Hospital as well as one of our medical students and a recent residency graduate to bring to light a medical myth about hospitalized patients who leave against medical advice.  Here is an excerpt from his post about our work which includes a new Squidoo page created by Gabe Schaefer MS3 on what to do when patients leave AMA and the video vignette below.  Let us know what you think and please share this with anyone who you think may benefit!

Excerpt from this week at GlassHospital:

Like Mikey, the Life cereal kid who died from mixing Pop Rocks and Coke, or the spider eggs in Bubble Yum that help make it so soft and chewy, Medicine has its share of urban legends.  Did you know, for example, that if you’re hospitalized and decide that you want to leave “Against Medical Advice” [AMA], that your insurer won’t pay for the hospitalization?

Bunk.

Apparently, this canard is pervasively believed amongst doctors and passed from generation to generation of trainees just like the nonsense about cute ol’ Mikey.  A few years ago, a medical student came to me with a case of moral distress. She had seen the doctor-in-training with whom she was working become upset at a patient for declining an invasive heart procedure.

Rather than reason with the patient and convince her that the test was indeed indicated and would be of greater benefit than possible harm, the resident doctor in question quickly informed the patient that if she refused the procedure and signed out AMA, she’d be financially responsible for the entire cost of the hospitalization, as her insurer would decline to pay.

This left our student wondering if this was true, and if there were ethical safeguards against this.   Her moral distress led to a research project that debunks this notion [we hope] once and for all.

I can’t give you the specifics (an article on our findings is under review at a medical journal) just yet, but GlassHospital and FutureDocs are happy to share with you the educational fruits of our findings to date. You can click over here to learn more in true interactive fashion, or if you prefer, watch only the cameo-encrusted video tour-de-force right below. [Who is that guy playing angry Mr. Smith? He looks familiar. And who, for heaven's sake, does his wardrobe?]

Let us know your thoughts! On the video, the website, the urban legend. What other medical urban legends would you like to see debunked?








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