#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





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

16 10 2013

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

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

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

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

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

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

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





Eating Chocolate and other lessons from the ABIM Forum

19 08 2013

Every year, the ABIM Foundation convenes a set of thought leaders on American health care to answer the tough questions.   At first glance, this year’s meeting  had the same standard agenda –  talks and discussions followed by networking and informal activities. However, for some reason, this Forum was more exhausting. Perhaps trying to solve the nation’s vexing problems facing health care is fatiguing! So, what were some of the themes that we came away with?

  • Intrinsic motivation is powerful, so can we create it? We heard about the potential dangers of extrinsic motivation through financial reward. Pay-for-performance, after all, is a tool that is only as good as the system is designed, and many designs have not been very effective. I was reminded of an unusual medical education experiment when they started paying residents in pediatrics on a fee-for-service model (yes, residents). The residents saw more patients, and their outcomes even improved with fewer ER visits! But, closer inspection yielded that these residents stacked their clinics with well child visits, who were healthier and did not need to visit the ER. So fee-for-service residency was abandoned. While everyone agreed it was time to move away from fee-for-service medicine, do we really think a change in the payment system creates intrinsic motivation? One health system offered their solution: recruit those that are intrinsically motivated. But, that still leaves us with how does one become intrinsically motivated? The answer likely lies in the last session of the meeting –find and cultivate joy in work. After all, if the work of transformation is enjoyable, people will do it for free.  And for physicians, joy does not come from lowering the GDP, but from treating the patient in front of you.
  • A series of small innovations add up to a larger one.  There were a series of innovators highlighted at the meeting who shared their innovation. While many were sharing large-scale innovations and initiatives like ACGME’s CLER Program, I shared a much smaller scale innovation, a redesigned resident clinic handoff using ideas generated from talking with over 100 patients about their experience. I certainly recognized the scale I was operating on was much smaller than some of the other folks in the room who lead large health plans or organizations. Then, one of the speakers who transformed their culture highlighted that it was a series of small innovations adding up to the larger one that made it doable. Featuring innovations at this meeting is not new, but the discussion of scalability was important. As each innovation was discussed, the question became how was this scalable and could be spread to others. This discussion was particularly salient to our Teaching Value Project team as we hosted a breakfast to not only introduce the project, but also discuss the future and how to spread this innovation…so stay tuned.
  • Organizational culture and leadership matters… a lot. While on the subject of necessary ingredients for innovation, the terms organization and leadership would probably be the biggest if we did a word cloud of what people said at this meeting. It can feel trite, but it’s true…leadership and culture are key. The type of leadership that was highlighted focused on nurturing innovators and supporting people in the work that they do. While they are not afraid to take risks, they are also understand their frontline clinicians and patients. Too bad they also sounded like an endangered species. Not surprisingly, many groups had the same action item – train visionary leaders to lead these healthcare systems of the future.  While we can wait for the new visionary leader to be manufactured, culture always halts people in their tracks. How do you create the culture you want? The recurring theme here was to make sure you had good people. In other words, recruit people for the culture you want, not the on you have. And for a real change, a more radical business approach would be to let go of the “protectionist mentality” where everyone is going to keep their job. Moving to a results-oriented work environment would mean not only recruiting the right people but getting rid of the wrong people. I’m not so sure our academic health systems are ready to do this, but it was refreshing to hear from a business leader that term limits and succession planning were the norm. In this way, organizations are automatically refreshed with new ideas from leaders who were prepared to lead.
  • Eating radishes when you want to eat chocolate is work. To summarize, forcing people to exert willpower to resist what they want to do (eat chocolate) by doing something else (eating radishes) translates into hard work to resist, and less patience for something else. A more complete explanation of this study is here. Sure, this sounds simple, but we do keep piling quality measures and requirements on every physician in the context of a 15 minute office visit. Unfortunately, electronic health records are forcing us to eat more radishes, and this comes at the expense of talking to patients. At least two innovators solved this problem by having someone else eat the radishes, such as a scribe in primary care so that physicians could focus on the joy, spending more time with patients.
  • Ask patients to help design the solution.  While this may sound like a no brainer, its not as easy as it sounds!  This is an unusually high level of patient engagement that most of our organizations are not used to. In one stunning example, a hospital in Sweden redesigned its dialysis center so patients can swipe in whenever they want and self-administer their dialysis. In the innovation I presented, we asked 100 patients in our resident clinic what would make their clinic handoff go smoother when they transitioned PCP’s when their residents graduated.  The answers led us to interventions that we never would have thought of, like honoring the patients with a certificate to recognize their teaching efforts of our residents and a cartoon to facilitate patients learning how the process of the handover occurs and what they should do.

So, what does this mean for future doctors? Well, it starts with recruiting intrinsically motivated individuals and training them to be healthcare leaders who can learn to work alongside patients to generate small innovations that can add up to larger organizational transformation.  And let them eat chocolate … so they too can find the joy in their work.

–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)





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.





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.








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