#AAMC13 #BeyondFlexner: Tweeting Back to the Future

5 11 2013

I am just returning from AAMC 13 in Philadelphia, which happens to be the site of the very first AAMC conference in 1876.  Perhaps it is this historic backdrop which made it more poignant when AAMC President and CEO Dr. Darrell Kirch charged the audience to rise to the occasion during our most challenging time, or our healthcare system’s “moment of truth.”  Between sessions on how academic health centers needed to evolve to survive healthcare reform and how medical students need to avoid the “jaws of death” from the Match, there was certainly much to fear and much to learn. In spite of this, there are always moments where it was undeniable that the future was bright.  But, the most interesting moments at this meeting where when it felt like we were going back to the future.

One of those moments was sitting in on the CLER (Clinical Learning Environment Review), or the new ACGME institutional site visit process which is not meant to be scary, but helpful!  As a non-punitive visit, its meant to catalyze the necessary changes needed to help improve the learning climate in teaching hospitals. This session was particularly salient for me as I transitioned from being an Associate Program Director into role of Director for GME Clinical Learning Environment Innovation about a month ago.  At one point, Dr. Kevin Weiss described the CLER site visitors observing a handoff- and in that one moment, they saw the resident bashing the ER, failure of supervision, the medical students left out, and an opportunity to report a near miss that was ignored.  Even though CLER is new, he made it sound like the site visitors were going back in time and nothing had changed.  Have we not made a dent in any of these areas?  I guess it’s probably safest to pretend like its 2003 and we need a lot more training in quality, safety, handoffs, supervision, fatigue, and everyone’s favorite…professionalism.

After being the only tweeter at times in the Group of Resident Affairs sessions, I ventured into the tweeting epicenter of the meeting at the digital literacy session.  There, I not only learned about a very cool digital literacy toolkit for educators, but also got to connect with some awesome social media mavens who use technology to advance medical education. While I have access to these technophiles through Twitter (you know who you are), it was NOT the same as talking about the future of social media and medical education face-to-face.  Call me old-fashioned, but connecting with this group over a meal was just what this doctor ordered.  My only wish is that we had more time together…

Lastly, we went back to the future in our session showcasing the winners of the Teaching Value and Choosing Wisely Competition at both the AAMC and ABIM Foundation meeting last week.   One of the recurring themes that keeps emerging in these sessions, in addition to a recent #meded tweet chat, is that the death of clinical skills (history taking and physical exam) promotes overuse and reliance on tests in teaching hospitals.  Could it be that by reinvigorating these bedrock clinical skills and bringing back the “master clinician”, we could liberate our patients from unnecessary and wasteful tests?  I certainly hope so…and it can’t hurt to be a better doctor.  Moreover, one of the most powerful tools that was mentioned was the time-honored case report!  In fact, case reports have been resurrected to highlight avoidable care in a new JAMA Internal Medicine series called “Teachable Moments.”

And lastly, in the spirit of going back to the bedside, our MERITS (medical education fellowship team) submitted a video entry to the Beyond Flexner competition on what medical education would be like in 2033.  While the impressive winners are showcased here,  our nostalgic entry was aptly titled Back to the Future and Back to the Bedside, and envisioned a future where all students, regardless of their year, are doing what they came to medical school to do, see patients.

–Vineet Arora MD





The 5 F’s for Futuredocs and New Interns

26 06 2011

 

Yesterday, a tweet caught my attention from @JasonYoungMD who stated “My Five Foundations of Felling Fine: Food, Fitness, Friends & Family, Falling Asleep, Fulfillment.”  This seemed like the best advice I had heard for the newbie interns taking teaching hospitals by storm as well as the rising third year medical students who are about to be unleashed on the wards (if they haven’t already).  It also is a great starting point for program directors who are wondering how to ensure that their residents are “Fit for duty” according to the new ACGME rules.

 

  1. Food – While this is basic part of sustenance, finding food sometimes in the hospital can be challenging, especially at odd hours.  Fortunately, this has gotten better, but the choices may not be healthier.  In my own hospital, I’ve seen the front lobby transform from a small coffee kiosk (Java Coast which was celebrated when it arrived) to a full fledged Au Bon Pain (ABP as we affectionately refer to it).  While ABP was a welcome addition, it is easy to consume a lot of empty calories eating muffins or breakfast sandwiches!  To make matters worse, research from one of our very own sleep research gurus has shown that the more sleep deprived you are, the worse food choices you make!  Therefore, the thing you will reach for after a night shift is going to be the carbohydrate loaded Danish.  Residency programs must know this and usually have morning reports full of this type of food. So, consider how you will make healthy food choices – whether that be bringing your own food, or finding out where the healthy options are.  Lastly, don’t forget about the empty calories that come with beverages, especially coffee-related drinks.  For you Starbucks fans, there is an app for that – and I guarantee you may change your choices.
  2. Fitness – Like food, fitness can be hard to come by.  Interestingly, working in the hospital can actually be a way to get exercise.  For example, some studies demonstrate that residents walk as much as 6 miles on call!   However, its also just as easy to sit behind a computer and take a “mission control” approach to your call night where you are monitoring all your iPatients.  So, think about this and consider wearing a pedometer and most importantly getting into a routine.  When time is of the essence, find a way to work fitness into your day like taking the stairs in lieu of the elevator, or parking farther away.  If you join a gym, you have to make sure you go…and one easy way of doing this is to make sure your gym is on your way home from work and that is your first stop.  During residency, I actually switched to a gym that was directly on my route home that had a parking lot so I literally had no excuse and actually felt guilty while I drove by and did not stop there.  Others opted for 24hour gym craze that that could work for anyone’s schedule.  Lastly, exercising with a friend will likely lead to greater results than the solo work out.
  3. Friends & Family – Speaking of friends and family, this is the support system that gets interns through residency.  Fortunately, another omnipresent F can be helpful here – Facebook.   Busy interns or students can at least get reminders to electronically wish your friends happy birthday or log in on that random Monday off to reconnect with friends.   It’s also important to set appropriate expectations with your friends and family, for example when you are starting on a time intensive rotation that can be demanding.   Because of the intense nature of working in the hospital, some of you will form fast friendships with your co-interns and residents which can be helpful to get you through.  However, even your closest friends (including those at work) will ask you to choose between them and sleep- which can be very tough when you are running low on sleep.
  4. Falling asleep –So, speaking of sleep, my first question was where do I sleep?   Sounds silly I know, but I actually did not know where the call rooms were or did not have the call room key for my first call night ( I actually can’t remember which) so I ended up going to sleep for an hour in an unoccupied hospital bed.  So, this may not be possible today for 2 reasons: (1) interns are not likely sleeping when working the jam packed 16h shifts; and (2) hospital beds are nearly always filled! Still the challenge for today’s interns is getting sleep when working odd hours, especially if starting night shifts on night float or ‘night medicine’ as programs are evolving to include more night rotations.  If this means you have to invest in window treatments or wear an eyeshade at night, just do it.  There is nothing better than sleep for a resident and the more the better.  While your sleep at home may be limited regardless due to your other family obligations, its important to know your limits and set aside nights where you will recover.
  5. Fulfillment – Last but not least, its important to figure out how to keep yourself happy and fulfilled during your residency.  In some cases, that is a particular hobby or loved one that you need to stay in touch with.  In other cases, fulfillment is more complex.  It is not uncommon to have doubts about your future career as you stand by the fax waiting for outside hospital records, wait on the phone to schedule a follow up appointment for a discharged patient, or even transport a sick patient to get a needed test.  While many are working on ways to reduce the burden of this largely administrative work, interns and medical students are still straddled with a large amount of scut which can be demoralizing.  So, where do you find the fulfillment in your work? Well, you will find it when you least expect it – in the words of a patient who is eternally grateful.  In other cases, you will meet a mentor or role model who shares your passion and interest in medicine, whatever that may be, and can inspire you to keep you going. Whatever it is, find it and hang on to it for dear life during your darkest hours and it will pull you through.

I do need to add one more F to this fine list –  So provided that you are keeping up with the first 5 F’s, the best thing is that being in the hospital, learning medicine, and caring for patients is actually FUN!  So, don’t forget to pause and enjoy it…these tips will also serve you will in the FUTURE!

–Vineet Arora, MD

Other helpful posts to conquer any FEARS of starting on the wards:

What NOT to Wear on the Wards

How to Present to Your Attending





The “Social” Side of Hospital Rounds

17 01 2011

This weekend, I just finished another 2 weeks on service – the first 2 weeks of 2011 in fact.  This time, I had also had a shadower, but one of a different kind.  As part of our Institute for Healthcare Improvement (IHI) Open School, we are making an effort to have collaborative learning opportunities for our medicine and health administration program students.   Achieving true interprofessional learning is challenging for schools like ours without a pharmacy or nursing school.    

To jumpstart our collaboration, a team of us traveled to at the Institute of Healthcare Improvement conference.  It was there over dinner that Jeff Kunkel, one of the Social Work students, asked me if a lot of social work issues came up in hospital care rounds.  I laughed momentarily and reassured Jeff there would be lots of social issues and invited him firsthand to witness them on rounds.  Unlike the premeds that I sometimes take on the weekend, I wanted him to come during the week so that he could also attend the multidisciplinary rounds with our case managers and social workers that our attendings go to daily. 

The opportunity presented itself that first Friday – our team was on call so it was a perfect day since we did not have many patients and were able to delve into their problems.   While there are social issues every day, dealing with them becomes exponentially harder over the weekend when you only have social workers on call.  This makes Friday an especially important day to advance care or facilitate any discharges.  While some believe that doctors don’t work on weekends, the truth is that they do.  The problem is that not everyone else works on the weekend making the hospital inefficient over the weekend and nothing gets done.

 I introduced Jeff to our housestaff team as a social work student who was especially interested in the social issues.  For each of the presentations, they started with a one liner to brief our student on the patient’s problem but also described the social issues.  In doing so, the social issues that sometimes plague our rounds (and our residents) all of a sudden became the highlight of rounds.  The patient that leaves AMA, the patient who was homeless, the patient who did not want to go to rehabilitation but was too weak to go home, the patient who was uninsured and could not afford his medications…  the list goes on.

Afterwards, we had an opportunity to debrief.  It was fascinating to hear what Jeff found interesting.   He noted that I sometimes have to ‘talk patients’ into leaving the hospital.  I told him that the sad truth is that patients often expect to stay in the hospital longer than they can and should.  Not only is staying in the hospital dangerous and costly due to hospital-acquired infections and other hazards, hospitalizations are increasingly scrutinized to ensure that each hospital day is ‘medically necessary’ by auditors who are incentivized to penalize.   Given this, managing patient expectations becomes very important and something that the attending often ends up participating in. 

As we think about the increasing pressure to ensure that patients who don’t need hospital care go home, it is equally important to ensure a safe care transition to avoid a preventable readmission.  While optimizing these decisions requires clinical judgment, it cannot be done without thinking through and addressing the social issues.  This makes having a great social worker even more important for the future.  Unfortunately, like many other healthcare fields, there is an impending social work shortage as highlighted by a major capitol briefing held by the National Association of Social Workers.  While many of us tend to focus on the need to train competent physicians and nurses, we must not forget the that we need good social workers too. 

–Vineet Arora MD








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