#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





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 





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)





Teaching Crucial Conversations: The Curse of Knowledge & the ASK Problem

4 09 2012

One of the most interesting conversations that I had recently was at the ABIM Foundation Summer Forum Open Space Sessions.  The ABIM Foundation Summer Forum is a summit of thought leaders and experts representing healthcare organizations, policymakers, patients, payers, doctors, and trainees who come together to tackle a major problem in healthcare.  The topic of this year’s forum was in keeping with the launch of the new ABIM Choosing Wisely Campaign and aptly named “Choosing Wisely in an Era of Limited Resources.”

The Forum has a unique format, employing a mix of routine panel discussions, but also “Open Space” conversations where participants actually drive the agenda, deciding what they want to work on.  One of the Open Space topics that I ended up joining was on how to train physicians to have crucial conversations with patients.   After forming this group, there were some immediate questions raised– why only physicians?  What about other members of the care team, including the patient?  Moreover, individuals in our group each had a different definition of what  “crucial conversations” were.  One clear theme was around end-of-life conversations with patients, but that was not the only one.  For example, how to talk to a patient who is asking for a medical test that is not indicated?

As I returned home, I reread some of the literature I have become acquainted with on why we (humans) don’t communicate as well as we should.  Using this framework, it’s worth considering why doctors and patients may not communicate as well as they should.  Drawing from the knowledge communication literature when an ‘expert’ is communicating to a ‘decision maker’, two distinct problems can arise:

  • Curse of Knowledge– The curse of knowledge, otherwise known as the paradox of expertise, represents the difficulty of experts to use commonplace jargon to communicate their ideas to those that are not experts.  Because experts tend to surround themselves with other experts, it can be very difficult for an expert not to use technical jargon when communicating with people who not experts.  This is easily evident in a variety of scenarios – most notably in the first few seconds of the trailer for the movie Contagion when doctors try to tell Matt Damon that his wife, played by index case Gwyneth Paltrow, is dead.  The doctor starts by saying “I am sorry…she failed to respond”.  On cue, Matt Damon responds, “OK can I go talk to her?” clearly missing the meaning of what the doctor has just tried to communicate.  Likewise, one of the patient advocates at our table shared the story of how she came to know she had cancer – “It’s malignant” …so she deduced from “Mal” and all the words that start with “mal” are bad (malice, malpractice…to name a few) so she thought “Mal … bad”.
  • ASK Problem – the ASK Problem stands for the Anomalous State of Knowledge.  This is a problem that arises when the decision maker does not have the knowledge that it takes to ask questions, since asking questions often relies on having intimate knowledge of the subject at hand.   This is particularly salient since we have major campaigns that often are directed at patients to “ask more questions” of their doctor.  However, it may be very hard for a nonexpert to ask a question of an expert if they don’t have a set of common knowledge to go on.  Asking questions is so difficult that our work shows its rare for even physicians to ask other physicians questions, and instead they opt for what is known as “back-channeling” or saying “Uh-huh” to indicate their agreement.  The only problem with this is that back-channeling is that it can be exhibited by demented patients so it is not necessarily a confirmation of comprehension or understanding.  To make matters worse, a recent study shows that patients may not ask questions for fear of being labeled “difficult”.

How can we get around these problems? Well, improving a conversation requires training on all sides. Patients can also be coached to take a more active role in their care. However, healthcare personnel also need to be prepared so that their newly empowered patients are not an unwelcome surprise. Physicians and other healthcare personnel need to be trained in how to speak to patients about difficult decisions in a sensitive way.   One model curriculum we can learn from has been developed by oncology fellowship directors and is called OncoTalk.  One of the key tenants is the principle of NURSE, which describes how to respond to patient emotions during complex decision-making.

  • Naming the emotion “It sounds like you are afraid of X”
  • Understanding the emotion  “I can understand the fear that goes along with X.”
  • Respecting  “You are asking the right questions…”
  • Supporting  “I am here to support you through this decision…”
  • Exploring  “What are you thinking about now?”

Of course, the age-old question is can you teach empathy? Well, according to one recent study, empathy wanes throughout medical school.   So we should, at the very least, try to at least preserve it.

Vineet Arora MD





Teaching Costs of Care: Opening Pandora’s Box

27 07 2012

Last week, I tried something new with our residents…we tried to talk about why physicians overuse tests.   This is the topic of the moment, as the American College of Physicians (ACP) just dropped their long-awaited new High Value Cost Conscious Curriculum for what has now been dubbed the “7th competency” for physicians-in-training.   In addition to the ACP curriculum, which I served as one of the reviewers for, I also am involved with another project led by Costs of Care to use video vignettes to illustrate teaching points to physicians-in-training called the Teaching Value Project.  With funding by the ABIM Foundation , we have been able to develop and pilot a video vignette that that depicts the main reasons why physicians overuse tests.   The discussion was great and the residents certainly picked up on the cues in the video such as duplicative ordering, and that the cost of tests are nebulous to begin with.  But, before I could rejoice about the teaching moments and reflection inspired by the video, I must admit that I felt like Pandora opening the dreaded Box.   Many of the questions and points raised by the residents highlight the difficulty in assuming that teaching doctors about cost-conscious care will translate into lower costs and higher quality.

1)   What about malpractice?  One of our residents mentioned that really the problem is malpractice and that test overuse was often a problem due to the “CYA” attitude that physicians have to adopt to avoid malpractice.   It is true that states with higher malpractice premiums spend more on care.  However, this difference is small and does not fully explain rising healthcare costs.  More interestingly, the fear of being sued is often more powerful than the actual risk of beingsued.  For example, doctors’ reported worries about malpractice vary little across states, even though malpractice laws vary by state.

2)   What about patients who demand testing? Another resident highlighted that even with training, it was often that patients did not feel like anything was done until a test was ordered.  Watchful waiting is sometimes such an unsatisfying ‘treatment’ plan.  As a result, residents reported ordering tests so that patients would feel like they did something.  In some cases, patients did not even believe that a clinical history and exam couldlead to a ‘diagnosis’ – as one resident reported a patient asked of them incredulously, “well how do you know without doing the imaging test?”

3)   What can we do when the attending wants us to order tests? All of the residents nodded their head in agreement that they have had to order a test that they did not think was indicated, because the attending wanted to be thorough and make sure there was nothing wrong.  I find this interesting, since as an attending, you are often making decisions based on the information you are given from the resident – so could it be that more information or greater supervision would  solve this problem?  Or is it that attendings are hard wired to ask for everything since they never thought about cost?

4)   Whose money is it anyway that we are saving?  This is really the question that was on everyone’s mind.  Is it the patient’s money?  After all, if a patient is insured, it is easy to say that it’s not saving their money because insurance will pay.   Well, what about things that aren’t even reimbursed well..doesn’t the hospital pay then?  Finally, a voice in the corner said it is society that pays – and that is hard to get your head around initially, but it is true.  Increased costs of care are eventually passed down to everyone – for example, patients will be charged higher premiums from their insurance companies who are paying out more.  Hospitals will charge more money to those that can pay to recover any losses.

5)   Will education really change anything?  So, this is my question that I am actually asking myself at the end of this exercise.… Education by itself is often considered a weak intervention, and it is often the support of the culture or the learning climate that the education is embedded in.  The hidden curriculum is indeed powerful, and it would be a mistake to think that education will result in practice change if the system is designed to lead to overordering tests.  As quality improvement guru and Dartmouth professor Paul Batalden has said (or at least that’s who this quote is often attributed to when its not attributed to Don Berwick) “Every system is perfectly designed to achieve the results it gets.”  Therefore, understanding what characteristics of systems promote cost conscious care is a critical step.

However,  before we dismiss education altogether from our toolbox, it is important to note that education is necessary to raise awareness for the need to change.  And in the words of notable educational psychologist Robert Gagne, the first step in creating a learning moment is getting attention.  And, by that measure, this exercise was successful – it certainly did get attention.  Yet, it also did something else…it created the tension for change, a necessary prerequisite for improvement.  It  certainly cultivated a desire to learn more about how to achieve this change….which is what our team is currently working towards with the Teaching Value Project.    So while learning why tests are overused is a first step… judging by Pandora’s box, it is certainly not the last.

–Vineet Arora MD

Special thanks to Andy Levy and Neel Shah for their hard work on this module.





What’s NEXT in Residency Training: Fighting off the Tick Box Zombies

11 06 2012

This weekend, an interesting article on the curent state of UK residency training crossed my Twitter feed.   Due to restricted residency duty hours in the UK (yes they have a 48 hour work week for residents aka junior doctors), they fear they are graduating “incompetent doctors who are putting patients at risk.”

This debate is not just isolated to the other side of the Pond.  In fact, a recent reports in the New England Journal of Medicine documented that nearly half of residents are OPPOSED to restricted resident duty hours, with another paper in Academic Medicine showing that many internal medicine residents were concerned about limited educational opportunities with duty hours.  Finally, in a recent study that we did with the Association of Program Directors of Internal Medicine and the Association of Program Directors of Surgery published in Academic Medicine, program directors feared specific consequences of duty hours related to faculty morale, patient continuity and resident education.

While I could go on, the reason I started to write this post was NOT to rehash the duty hours debate!  Instead, I wanted to highlight a very specific concern that is mentioned in this UK story.  One of the chief complaints in the UK medical training system is that junior doctors were being passed on the basis of dreaded ‘tick-box forms’.  (You gotta love the Brits for colorful names to what we simply call evaluations).

So now at this point, I feel like I am watching 28 Days Later, where all of London was quarantined and zombies took over.   Will the Tick Box zombies come to the United States and take over our GME system?  Have they already?  I hope not…but let’s face it.  Everyone is wondering what comes NEXT with milestones and GME.

The “Next Accreditation System” or NAS (not to be confused with the rap artist) is about documenting the achievement of specific milestones related to specific “entrustable professional activity” or EPA.  An EPA is “simply the routine professional-life activities of physicians based on their specialty and subspecialty.”  For example, for internal medicine, one of the end of year EPAs is “Manage the care of patients on general internal medicine inpatient ward.”  In this way, EPAs are more granular than the 6 “core competencies” and should in theory be easier to observe and evaluate.  Lastly, for each EPA, there will be a “narrative” that programs can select to describe how competent the resident is in that area.

While program directors and others involved in GME are all learning the new “compet-english” that has been developed, many are also concerned about the burden of evaluation in a system that is already overburdened.  In other words, will the Tick Box zombies attack us stateside?   Well, some of this is up to how the residency educator community responds to the charge.  To prevent tick box zombie attack, program directors must resist the urge to create hundreds of milestone evaluations and add them to existing evaluations.   The key is not to reinvent the wheel but to modify existing evaluations to link them to milestones and EPAs. In some cases, old evaluations that were not helpful should be re-evaluated to see if they are necessary.  Moreover, to prevent tick box zombies from striking, it’s important to design and implement ‘good’ measures of resident performance.  A good measure would adhere to some of the same properties of optimal National Quality Forum quality measures: reliable, valid, linked to meaningful outcomes, feasible to collect, and distinguish between good and bad performance.  When good measures of residency performance do not always exist, there is an opportunity to work together to figure out what they are.   While this is definitely a work in progress, one nice thing is that no one is alone.  In Chicago, a citywide meeting of residency leaders of over 10 programs was held to share how best to do this and learn from each other.   After all, to truly make our NEXT step in GME, we must all work together to prevent the tick box zombie attack.

Vineet Arora MD  

Special hat tip to @keitharmitage for inspiring this post with his tweet : )





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

16 02 2012

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

How does this relate to Vegas?

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

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

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

–Vineet Arora, MD, MAPP

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








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