#AAMC13 #BeyondFlexner: Tweeting Back to the Future

5 11 2013

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

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

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

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

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

–Vineet Arora MD





The 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





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








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