Cultivating Creativity in Medical Training FedEx Style

14 01 2013

Over the holidays, I took full advantage of this opportunity to read a book from start to finish.  I chose Daniel Pink’s Drive.  It was actually recommended by @Medrants and I read it partly to understand why pay-for-performance often fails to accomplish its goals for complex tasks, such as patient care.  However, the thing I found most interesting about this book was the way in which creativity is deliberately inspired and cultivated by industry.

I could not help but think about why we don’t deliberately nurture creativity in medical trainees.  Why am I so interested in creativity?  Perhaps it is the countless trainees I have come across who are recruited to medical school and residency because of their commitment to service who also happen to have an exceptionally creative spirit.  Unfortunately, I worry too many of them have their spirit squashed during traditional medical training.   I am not alone.  I have seen experts argue the need to go from the traditional medical education that is fundamentally oppressive, inhibits critical thinking, and rewards conformity.   Apart from the criticism, it is of course understandable why medical training does not cultivate creativity.  Traditional medical practice does not value creativity.  Patients don’t equate ‘creative doctors’ as the ‘best doctors’.  In fact, doctors who may be overly creative are accused of quackery.

So, why bother with cultivating creativity in medical training? Well, for one thing, creativity is tightly linked to innovation, something we can all benefit from in medical education and healthcare delivery.   While patients may not want a ‘creative approach’ to their medical care, creativity is the key spice in generating groundbreaking medical research, developing a new community or global health outreach program, or testing an innovative approach to improving the system of care that we work in.  Lastly, one key reason to cultivate creativity in medical trainees is to keep all those hopeful and motivated trainees engaged so that they can find joy in work and realize their value and potential as future physicians.  In short, the healthcare system stands to benefit from the changes that are likely to emanate from creative inspired practicing physicians.

So what can we do to cultivate and promote creativity among medical trainees? While there are many possibilities including the trend to implement scholarly concentrations programs like the one I direct, one idea I was intrigued by was the use of a “FedEx Day”.  FedEx Days originated in an Australian software company, but became popularized by Daniel Pink and others in industry.  For a 24 hour period, employees are instructed to work on anything they want, provided it is not part of their regular job.  The name “FedEx” stuck because of the ‘overnight delivery’ of the exceptionally creative idea to the team, although there are efforts being undertaken to provide this idea with a new name. Some of the best ideas have come from FedEx Days or similar approaches, like 3M’s post-its or Google’s gmail.  I haven’t fully figured out how duty hours plays into this yet… so before you report me or ride this off, consider the following.  Borrowing on the theories of Daniel Pink, we would conclude that trainees would gladly volunteer their time to do this because of intrinsic motivation to work on something that they could control and create.  And to all the medical educators who can’t possibly imagine how would we do this during a jam packed training program, lets brainstorm a creative solution together!

Vineet Arora MD





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 : )





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








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