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





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





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





Advocate to Preserve Residency Funding

30 10 2011

bills,budgeting,businesses,cash,cost cutting,currencies,dollars,savingsSo, you have probably heard about the Supercommittee (gang of 12) and the need to brace for massive cuts to control federal spending.  But, do you know that the chief target is RESIDENCY TRAINING!   That is right.   Funding for residency largely comes from Medicare, and the general concern is that they are paying too much and not getting their money’s worth.  Of course, this comes at a time when there is a shortage of residency spots given the expansion of US medical schools, and a dire need for physicians, especially in primary care, to meet the needs of healthcare reform.

So, in this perfect storm, 40 medical groups (yes, there was that much consensus) sent a letter to the Supercommittee pleading with them not to cut GME funding.   Now the situation is dire enough that the AAMC advocacy leaders are in high gear encouraging those in graduate medical education to encourage their residents to write to their Congressman.  (And yes, if you live in a Supercommittee state, its even more important for you to do this).

So if you are a resident or future resident or can sympathize with the need to have future physicians, now is the time to take action.   For my fellow medical educators out there, you don’t need to be left out.  The American College of Physicians has a very broad (don’t need to be an internist)  easy-to-use advocacy website to shoot of a quick note to your Representative and Senator about the need to preserve GME funding.

Medical educators have actually started a dialogue about the role of advocacy in medical education.  Specifically, the Editor of Academic Medicine has challenged us to come up with how advocacy should properly be integrated into medical training.  I can think of no other way than advocating for preserving funding for the system by which we train our nation’s future physicians.

Vineet Arora MD

(AAMC email encouraging residents to take action)

***************************************************************

Dear Resident:

I encourage you to take a few minutes to  visit the AAMC Legislative Action Center (http://capwiz.com/aamc/home/), select “Residents”,  and send an electronic letter opposing cuts in Medicare funds that support residency programs.   With the zip code you enter, the letter will be sent automatically to your Senators and Representatives urging them to oppose GME cuts as part of deficit reduction.  PLEASE USE YOUR PERSONAL EMAIL ADDRESS (eg, gmail.com), AND NOT YOUR INSTITUTIONAL EMAIL ADDRESS.

Congress is discussing a deficit reduction proposal that would cut funding by as much as 60%, or $60 billion, for Graduate Medical Education (GME) and jeopardize residency training programs across the country. Given the current and growing shortage of physicians, GME cuts will reduce access to health care and threaten the well-being of all Americans.

It is most important that residents enrolled in programs in Arizona, California, Washington State, Massachusetts, Ohio, Pennsylvania, Montana, Michigan, Maryland, Texas, or South Carolina, voice your concerns.    You are represented by members of the “Super Committee” that will finalize the deficit reduction plan.

Thank you for your help.

Atul Grover, M.D.
Chief Advocacy Officer
AAMC





Differences Between Real & Fake Patients

9 10 2011

Each morning this week, I am rounding on a busy inpatient general medicine service in an academic hospital seeing real patients.  Each night this week, I am also studying for the internal medicine recertification exam where I am doing countless MKSAP questions which present the diagnostic and management conundrums of “fake patients.”   While there are a variety of things I could say about the process, one thing is clear- the real patients don’t ever come as neatly wrapped and easy to figure out as the pithy and succinct questions based on fake patients in the prep questions!   Perhaps the most distinct differences are that real patients suffer from real problems that plague real people…and that is of course why one of the most important lessons for our medical students is that being a good doctor is more than just how well you do on a standardized exam.  It is knowing how to mobilize a team and resources to tend to all of these problems in the same patient.   Here are just a few ways in which the real patients we see differ from testable “patients.”

  • Social problems trump medical problems – Many of the patients we see suffer from poor health literacy, lack of insurance, access to safe housing, affordable healthy food, and access to healthcare outside of the hospital that prevents optimal care and treatment of their medical conditions.  Understanding how to bring up and address these problems is equally important to design a customized care plan for a patient that will ensure their most optimal recovery and health outside of the hospital.
  • Caregiver support- Many older patients who are chronically ill are cared for by family members who suffer a lot of stress.  This stress manifests in different ways and sometimes you see that sigh of relief when they come to the hospital since they are in need of as much care and support as their family member.  Arranging home services and providing and ensuring caregiver support is a key part of hospital care these days.
  • Insurance compatibility – Most patients require services that go beyond hospital discharge, such as home IV antibiotics or short-term rehabilitation stays after hospitalization to recover.  In addition, patients often require close follow up after hospitalization. Unfortunately, arranging such things for patients who are uninsured or underinsured is increasingly difficult.  Perhaps this is one thing that we can hope to change with the implementation of the Affordable Care Act- lets at least hope so.  But for now, it’s sometimes a guessing game how to piece together the most logical plan that will also be optimally covered.
  • Medical necessity – These days, patients can’t stay in the hospital to “recover” unless it meets strict criteria for inpatient admission.  This process is audited by private contractors so hospitals are required to follow strict guidelines or face harsh penalties from Medicare.  The challenge is that for a variety of social issues documented above, patients may not be ready to go home (caregiver not ready, patient lacks understanding regarding illness, etc.) but they have to go home or be faced with footing the bill for their stay.   Given that rock and a hard place, it’s a difficult position for any doctor to be in.

Because medicine does change and evolve very quickly, we refresh our medical knowledge every 10 years by testing our clinical acumen through ‘caring’ for fake patients on a written exam.  But, a written exam can only go so far…Given the sea changes occurring on a daily basis in our healthcare delivery system, it is equally important to stay up-to-date on systems-level changes that influence how we can actually provide care for real patients.  After all, both are necessary for good doctoring.

Vineet Arora, MD





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








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