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 





Not Getting Sick in July

1 07 2013

Today is July 1st.  While everyone has heard the old adage about not getting sick in July because of new interns, the truth is that new interns nationwide have started already. Yet, you don’t hear much about the “late June effect?”  So is the July effect overblown or true?  Well, there have been many studies – so many so there was a recent systematic review co-authored by one of my own co-interns a long time ago.    While I am sure it was hard to synthesize the studies of often sub-par quality, the review does state “studies with higher-quality designs and larger sample sizes more often showed increased mortality and decreased efficiency at time of changeover.”  The study I recall best examined over 25 years worth of death records and found a pattern.  In the 240,000 deaths due to medication errors, mortality rates did increase in July, especially in counties with teaching hospitals.  I’m not sure death certificates are accurate as a way of diagnosing cause of death but that’s another story.

While it’s not possible for patients to time their illness, the question becomes what can be done to ensure July is as safe as possible? While there is scant literature on this topic, over the last several years, I have had the privilege of attending in July.  While I ended up attending in June this year before the interns switched, I was reminded of several ways in which July is different and can be made safer.

  • July requires more intense supervision.  Residency is a time of graduated supervision.  In June, a few weeks before third year residents graduate, it would be tragic or perhaps a sign of a problem if an attending had to oversee every little decision in the moment.  It would also annoy the senior residents to no end.  The senior residents have matured to the point that they are the team leaders and you are often the advisor and hearing about their decision-making and rationale and providing advice and guidance where needed.  That is certainly not the case in July.  In July, attendings often are hovering (even if they don’t admit it) or “epic-stalking” checking on every lab and medication.  Moreover, greater attending supervision is more commonplace since 2011 due to a huge push by accreditation agencies and in part due to shorter resident duty hours.   The truth is that interns are rarely acting alone and are often working in tandem with a more advanced resident and attending.  While a recent ICU study questions the utility of overnight attending supervision, a systematic review from our group found that enhancing supervision was associated with improved patient outcomes and resident education in a variety of settings.  Faculty can be more formally prepared for their bigger responsibility in July as it will not only require more time, but also more intensity of supervision. While this would include traditional in-person supervision, attendings can be taught to provide formal oversight of care through technology tools, such as the EHR, mobile computing, and yes, even Google Glass.
  • The residents are more eager to learn in July.  July is a time when interns and residents want to learn.  They are eager for feedback.  It is much harder to teach interns and residents in June since they have gotten good at their role…and picked up a lot of medical knowledge on the way.  Because of their umpteenth case of a certain disease, they may not find any additional learning in the case.  Of course, there are always more things to teach, but it is just a little harder than in July when your new interns are ready to soak up knowledge like a sponge.  You can also have a big impact on practice patterns before they form and cement best practices.  While some faculty shy away from signing up for July, many I know prefer to do July because of this reason!
  • Everyone is new in their role in July. July is a time of transition for all residents, such as senior residents, chief residents, not to mention new attendings.  Moreover, other health professional training programs are turning over too such as pharmacy residents.  One potential solution that has been mentioned is to stagger the start date of various specialties/professions so that not everyone is new in July.  While this is probably not as feasible as it sounds (and it doesn’t sound feasible), it is an interesting idea worth entertaining.
  • Anticipate the inefficiency. Because of the turnover in all staff, everything is a little less efficient.  While a little less efficiency may not seem like much, for a resident team, less efficient means likely higher census because of delayed discharges.  These higher patient workloads make caring for existing patients hard, and admitting new patients even harder, and of course all of this is under the pressure of the time clock.  Although not commonplace, I have heard of some programs lower workloads early in the year, anticipating this inefficiency.  Another way is to restructure teams so that there is more ‘redundancy’ on the team to help care for the patients.  Either mechanism seems like something to consider especially for teams that are struggling to get all the work done in time.
  • The patients seem to get sickest when the senior resident is off.  In the back of my head, I know this is probably some type of heuristic in which I am overweighting what the days are like when my senior resident is off….  Regardless, for some reason, it does seem like a good practice to anticipate patient illness on those days. And of course, extra supervision and assistance to the intern when the senior resident is a terrific idea.

While these observations may refer to July, just when the residents get accustomed to their role and rotation, its time to switch.  For this reason, it could be that August (and even September) is not that different from July…so while we focus a lot on July, it may be better to prepare for the Summer of Supervision.

Vineet Arora MD





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)





What Can the Unmatched Seniors Tell Us?

18 03 2013

Yesterday, after the mayhem and jubilation of celebrating a successful match at the Pritzker School of Medicine with our students, I went onto Twitter to follow the #match2013 hashtag to understand what the reactions were.  Most were positive, but one headline caught my attention ‘In Record-Setting ‘Match Day,’ 1,100 Medical Students Don’t Find Residencies.”

It is true this was the largest match because it was “All-in” – programs either were in the match for all their positions (including international medical graduates or IMGs) or they were not.  Obviously, many programs put more positions up for grabs in the Match.  After I reposted this article to Twitter, there were many theories and questions about who these unmatched students were and why  – some of which I have tried to answer to the best of my ability below.  I welcome your input as well.

  • Are these IMGs?  This number is US Senior medical students who have been admitted and graduated from US medical schools but now have no place to go to practice medicine.
  • Does this include those that entered the “scramble” now called SOAP. Technically, those that entered SOAP and were successful would have been counted as “matched” on Friday.   Last year,  815 Us seniors went unmatched after the SOAP.
  • Did they choose to go into competitive specialties? We have to wait for the 2013 NRMP statistics, which will likely address this.  The 2012 data shows that more unmatched seniors did choose to go into competitive fields.  Last year, the % unmatched is much higher for students applying to radiation oncology, dermatology, and competitive surgical fields for example.
  • Did they go unmatched to due to poor strategy or poor academic performance? While poor strategy such as ‘suicide’ ranking only one program is related to the risk of going unmatched, the truth is getting into residency is competitive and there are some who will not match because of poor academic performance. Some even argue that medical schools have little incentive to fail students and a portion of these students should not be graduating to begin with.
  • If they had gone into primary care, would they would have matched?  I hear this myth that program directors in primary care fields only take international medical graduates (IMGs) since not enough US medical graduates apply.   This is due to the largely untested assumption that any US Senior would be preferred to an IMG.  However, I personally know program directors who would definitely take a seasoned and high performing IMG over a below-average US Student.   The reason this is important is the rationale for not lifting the GME cap is that we have 50% of certain fields filled by IMGs and those spots would naturally be filled by US grads. Interestingly, many of these spots happen to be primary care driven fields.   Yet, it is still unclear if US Seniors will displace IMGs for spots in IMG oriented residencies.  It is also unclear if they will be willing to apply to programs that typically cater to IMGs, since they are often not considered as prestigious or geographically desirable to US students.
  • Is this related to the lack of GME spots? Certainly, it is true that more effective career advising may have resulted in applicants being more strategic about their rank list and not reaching for a competitive field.  However, we cannot ignore the supply/demand side of this equation.  At a time when there is a shortage of physicians and a call to increase the number of physicians, the US medical school system by responded to this call.   New medical schools have opened.  Existing medical schools have increased their enrollments.  So, there are now more US Seniors entering the match and there will be even more in the future as new medical schools mature their entering classes to graduating students over the next four years.  Given that the supply of matched candidates includes both foreign-born IMGs and US-born IMGs, there are more candidates than spots.  And while many believe IMGs will be the ones that get “squeezed out” in this shortage situation, again this is an untested assumption.  It is also important to recognize that IMGs often play a significant role in ensuring primary care for rural populations and underserved communities,which are often not geographically desirable by US graduates.

 We are left with a fundamental question:  Do we owe it to our entering medical students who successfully graduate from medical school to have a residency spot?   At a time when we have a shortage of physicians and a call for medical schools to increase in size, should we not expand our residencies?   Unfortunately, GME funding is on the chopping block because of the belief that too much money is being wasted on residency training.  Moreover, hospitals seem less enthusiastic about expanding residencies, as it is not as much of a bargain due to caps on hours residents work, and all the other new accreditation standards for residency training.

There is a potential solution.  The “Training Tomorrow’s Doctors Today Act” by Reps. Aaron Schock (R-Ill.) and Allyson Schwartz (D-Pa.), and the “Resident Physician Shortage Reduction Act of 2013” sponsored by Sens. Bill Nelson (D-Fla.), Charles Schumer (D-N.Y.), and Majority Leader Harry Reid (D-Nev.) would enable training 15,000 more physicians over 5 years.   Moreover, spots would be distributed to programs and specialties in critical shortages, like primary care.

Given the time that it takes to train a physician, now is the time to act to ensure we have the doctors we need for the future.

 –Vineet Arora MD MAPP





Love Letters for Med Students Follow-Up

27 01 2013

futuredocs:

For any students wondering what to do if they write or receive love letters from residency programs, here is an oldie but goodie to help. Since this post, we conducted a 7 school study in 2010 of graduates that showed that almost one-fifth reported feeling assured by a program they would match there but did not despite ranking that program first. Nearly one-fourth said they changed their rank order list based on communications with programs. The conclusion “Students should be advised to interpret any comments made by programs cautiously.” And of course be mindful that the 2013 Rank order list certification deadline is Feb 20th at 8pm Central Time. Good luck!

 

Vineet Arora MD

Originally posted on FutureDocs:

While Valentine’s Day is coming soon, a different sort of ‘love letter’ may be sent or received by senior medical students.  As recruitment season draws to a close, residency programs and applicants may be busy exchanging notes of interest, affectionately dubbed “love letters” by scores of medical students and on StudentDoctor.net.

What do these love letters mean?  Some students have asked us whether it is a Match Violation to get or send a love letter.  Others have worried they did not send enough or what type of language they should use.  Well, here are some quick tips on how to approach this somewhat awkward situation.

  1. Is it a Match Violation? It is not a Match Violation for a program or a student to express interest in the other.  However, these statements of interest cannot be binding (i.e. we will only rank you highly if you rank us #1).  If there is any part of it…

View original 711 more words





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





Time to Fight Horrors of Healthcare Costs by Taking Charge of Teaching Value

31 10 2012

This Halloween, several creative costumes have emerged from the zingers of the Presidential debates – Big Bird costumes are selling out like hotcakes. For a more do it yourself look, here’s a recipe for Binders full of women.  The debate over the best way to contain healthcare costs have also been a central part of the debates, and yet medical bills do not seem to make popular costumes. Maybe that is because that unaffordability of healthcare is too horrifying for ironic humor – even on Halloween.

As we head into the election, patients are increasingly being terrorized by runaway healthcare costs.  Americans outspend our peers two to one and still seem to be worse off. We overtest and overtreat to the point of absurdity.   According to a recent report, “The U.S. did 100 MRI tests and 265 CT tests for every 1000 people in 2010 — more than twice the average in other OECD countries.”  The causes are multifactorial but the solutions can’t be left to presidents and policymakers alone. An important part of the responsibility rests with healthcare professionals and the educators who train them.

Experts in health professions education and economics have lamented the poor state of education on healthcare costs.  Over 60% of U.S. medical graduates describe their medical economics training as “inadequate.”  Not only are medical trainees unaware of the costs of the tests that they order, they are rarely positioned to understand the downstream financial harms medical bills can have on patients.  More recently, Medicare, the largest funder of residency training in the United States, is concerned that we are not producing the physicians to practice cost-conscious medicine in an era of diminished resources.

We have been scared in the dark too long and this Halloween the time has come to Take Charge.

Join us now at http://teachingvalue.org/takecharge

About Teaching Value: the Costs of Care Teaching Value Project is an initiative of Costs of Care that is funded by the ABIM Foundation.  Our team is comprised of medical educators and trainees who believe it is time to transform the American healthcare system by empowering cost-conscious caregivers to deflate medical bills and protect patients’ wallets.  Our web-based video modules are designed to be easy to access for anyone anywhere and provide a starting point for tackling this problem. It’s time to emerge from the darkness and do our part to tame the terror of healthcare costs.








Follow

Get every new post delivered to your Inbox.

Join 16,210 other followers

%d bloggers like this: