Transforming Medical Education: Trust, Time, Teams & Technology

28 11 2011

This past Thanksgiving, I was able to reflect on the always jam-packed and inspiring Association of American Medical Colleges 2011 Meeting that took place earlier this month in Denver.  The theme of the meeting was transformation.  It was certainly an interesting theme with the undertones of economic recession and the GME funding crisis- and that was before the failure of the Supercommittee to reach a resolution.  So, how does medical education need to transform?  In more ways than one, it turns out.  So here are just 4 that were the recurring themes of the meeting and being a fan of alliteration, they all begin with “T”.

  • Trust – it was clear that we need to restore the Americans people trust in physicians and in the medical education process.  While students enter medicine to make a difference, something that they see in their journey to becoming a physician makes them jaded and they sometimes lose sight of their initial intention. Is it debt, burnout, role models…Or likely some combination of the 3? It does not matter, because we have to restore their faith in teaching– yes teaching.  Teaching is the heart and soul of our medical education and it is sometimes the easiest to lose in an academic health center focused on NIH dollars or US news world report rankings.  In addition to teaching our students, it is time to teach another constituency, our patients and Congress about the critical need for medical education.   And in fact, advocacy is something we need to be teaching our own trainees so they can engage in the dialogue regarding the future of healthcare.
  • Time- perhaps the most radical proposal advanced was by Victor Fuchs who suggested that we radically redesign medical school to have medical students specialize 2 years after medical school and enter specific pathways like they do in many other countries and in other fields.  I’m all for shortening dwell time for our medical trainees, but I am not so sure that young people are ready to make a serious commitment about what they want to do at such an early age.  There has to be a middle ground since at the same time, one of the most well attended sessions was “who cares about the 4th year of medical school?” which included many insightful comments about the need for reflection and consolidation of core skills.  So, clearly not all time is easily tossed to the waste side.
  • Teams- given the projected shortage of over 90,000 physicians by 2020, it is important to reorganize care into teams.  While there is a lot of controversy about what to call nurses who have PhDs, that was not the focus of the meeting. It was about how can you encourage everyone to practice to their highest level of certification.  Team based competences have actually been developed by several groups and have been advanced by many schools with inter professional learning.  One difficulty we face at home is that we don’t have allied health professions, but we are brainstorming how to involve actual nurses and pharmacists in training medical students.
  • Technology -there was a lot of discussion about technology to boost medical education.  There was even a technology in medical education abstract session moderated by @motherinmedicine and including podcasts, iPads, and social media in medicine.  Perhaps the most interesting speaker was Chuck Friedman at the University of Michigan who is the former technology czar of the US and eloquently highlighted the need for moving medical education from wrote memorization to a distributed knowledge where the most important information future physicians will need to know is not what the information is off the top of their head BUT how to access information.  He went so far to say testing would move to “unassisted testing” followed by “cloud-supported testing” which would then merge into a pass or fail based on performance on both.  I know all of us who certified or recertified recently would welcome assistance from the cloud- it is after all the closest approximation to real medicine.  However, my hands down favorite moment of this session was when someone astutely asked what about these physicians when the power goes out or when the computer system fries.  His response was simple and so spot on… “Dont get me started on the state of IT in our teaching hospitals”.
So, while we just celebrated a holiday and accompanying ritual to give thanks, it is now time for medical educators to transcend the traditional status quo and instead test novel techniques to transform medical training — not only to restore public trust but so we can also train the trainees who will treat us in the future.
–Vineet Arora MD




Rising Above the Sea of MacBooks: “Edu-tainment” and Other Tips

12 09 2011

Although Steve Jobs has stepped down as CEO of Apple, his legacy for physicians-in-training is very palpable. Or should that be visual – As I looked into the auditorium of eager and bright incoming medical students this Summer, I saw a bunch of Apple’s staring back at me – sleek, silver and unmistakably MacBooks.  This is the millennial generation so why would I be surprised?  Maybe because it is more ever-present than before this year.  Could it be that the entering class of 2015 had more millenials?  Actually, another hypothesis has also been put forth that is equally if not more plausible…our medical school auditoriums were installed with new desks and chairs.  While these were well received, the desks served as an inviting surface just beckoning for the MacBooks to be placed there.    As a result, you’re never sure if you’re competing with Facebook, the worldwide internet, or even email messages that appear more interesting than your class.   Since lecture capture technology has made it possible for people to view lectures from home, it’s important to make attending lecture in person worthwhile.  Well, here are some tips for medical educators who ‘lecture’ in this new age.

1.  Engage in “edu-tainment” – As Scott Litin at Mayo refers to it, “edu-tainment” is the goal – entertainment via education.  How does one incorporate entertainment into lecture style?  Well, the easiest way is through humor.  This is difficult since not everyone is funny by nature so it may be that you have to inject humor in odd ways.

2. Play games – Games are inherently fun and interactive can stimulate a lot of learning and discussion.  While you may be thinking about computer games, easy games can often stimulate learning.  One of our research ethics faculty played 20 questions with the group of students to teach about landmark research ethics cases.

3. Turn into a talk show – There is nothing more boring than watching the same person for an hour give a talk.  It is much more interesting to watch a panel of people tell a story about themselves – whether it be a patient, another physician, or another student.  I still remember medical school lectures with invited guests that had this talk show appeal due to the lack of power point and focus on the story.  While I’m not suggesting a Jerry Springer approach, who doesn’t love Oprah – at least Chicago has several role models to choose from.

4. Showcase video – Video is one of my favorite teaching tricks.  One well made video can communicate a thousand research articles.  In our week of Scholarship and Discovery, our faculty used videos from Xtranormal (no it was not the famous orthopedics vs anesthesia) but a similar one.  One faculty who could not attend taped a welcome introduction, and another used a clip from “Off the Map” which is now off the air but is still an effective reminder of how NOT to perceive global health.

5. Use audience response – Use of Turning Point clickers can result in instant feedback and engagement with students as they see the results of their poll immediately. It also tells you how many people who up to class!  The only problem is that passing out the clickers and collecting them can be rather time consuming.  So, another possibility is to issue them at the start of class which is done in some colleges and used as a way to count attendance (until a brilliant undergrad brings in a bunch of clickers to class to vote for their lazier friends!).  Here Steve Jobs can help again – Turning Point has audience response systems for iPhones and iPads that can be used and automatically identify people- but it would require that everyone have a smartphone and purchase a license to the software.

6. Refer to the internet– Given that students are on the computer, you can take advantage of it and ask them to visit internet resources in class by showing them urls or web pages that are of use.  Sometimes you may actually refer to your own course website like we do.

7. Provide fancy color handouts – While handouts may sound like they have gone by the waste side, there is nothing like a fancy color brochure or handout to create a “buzz”.  It’s almost like a souvenir of their hard journey to class that day.  If you ever want to provide someone with a ‘leave behind’ that looks important, lamination is key.  A color laminated leave-behind is even better.  Pocket cards are some of my favorites.

Is there any guarantee these tips will work?  Of course not.  But, what’s the harm in trying?  While some professional schools have gone so far as to block wireless in lecture halls, the truth is that current medicine is augmented with the help of computers and online resources- so we should figure out how medical education can be too.

–Vineet Arora, MD





The 5 F’s for Futuredocs and New Interns

26 06 2011

 

Yesterday, a tweet caught my attention from @JasonYoungMD who stated “My Five Foundations of Felling Fine: Food, Fitness, Friends & Family, Falling Asleep, Fulfillment.”  This seemed like the best advice I had heard for the newbie interns taking teaching hospitals by storm as well as the rising third year medical students who are about to be unleashed on the wards (if they haven’t already).  It also is a great starting point for program directors who are wondering how to ensure that their residents are “Fit for duty” according to the new ACGME rules.

 

  1. Food – While this is basic part of sustenance, finding food sometimes in the hospital can be challenging, especially at odd hours.  Fortunately, this has gotten better, but the choices may not be healthier.  In my own hospital, I’ve seen the front lobby transform from a small coffee kiosk (Java Coast which was celebrated when it arrived) to a full fledged Au Bon Pain (ABP as we affectionately refer to it).  While ABP was a welcome addition, it is easy to consume a lot of empty calories eating muffins or breakfast sandwiches!  To make matters worse, research from one of our very own sleep research gurus has shown that the more sleep deprived you are, the worse food choices you make!  Therefore, the thing you will reach for after a night shift is going to be the carbohydrate loaded Danish.  Residency programs must know this and usually have morning reports full of this type of food. So, consider how you will make healthy food choices – whether that be bringing your own food, or finding out where the healthy options are.  Lastly, don’t forget about the empty calories that come with beverages, especially coffee-related drinks.  For you Starbucks fans, there is an app for that – and I guarantee you may change your choices.
  2. Fitness – Like food, fitness can be hard to come by.  Interestingly, working in the hospital can actually be a way to get exercise.  For example, some studies demonstrate that residents walk as much as 6 miles on call!   However, its also just as easy to sit behind a computer and take a “mission control” approach to your call night where you are monitoring all your iPatients.  So, think about this and consider wearing a pedometer and most importantly getting into a routine.  When time is of the essence, find a way to work fitness into your day like taking the stairs in lieu of the elevator, or parking farther away.  If you join a gym, you have to make sure you go…and one easy way of doing this is to make sure your gym is on your way home from work and that is your first stop.  During residency, I actually switched to a gym that was directly on my route home that had a parking lot so I literally had no excuse and actually felt guilty while I drove by and did not stop there.  Others opted for 24hour gym craze that that could work for anyone’s schedule.  Lastly, exercising with a friend will likely lead to greater results than the solo work out.
  3. Friends & Family – Speaking of friends and family, this is the support system that gets interns through residency.  Fortunately, another omnipresent F can be helpful here – Facebook.   Busy interns or students can at least get reminders to electronically wish your friends happy birthday or log in on that random Monday off to reconnect with friends.   It’s also important to set appropriate expectations with your friends and family, for example when you are starting on a time intensive rotation that can be demanding.   Because of the intense nature of working in the hospital, some of you will form fast friendships with your co-interns and residents which can be helpful to get you through.  However, even your closest friends (including those at work) will ask you to choose between them and sleep- which can be very tough when you are running low on sleep.
  4. Falling asleep –So, speaking of sleep, my first question was where do I sleep?   Sounds silly I know, but I actually did not know where the call rooms were or did not have the call room key for my first call night ( I actually can’t remember which) so I ended up going to sleep for an hour in an unoccupied hospital bed.  So, this may not be possible today for 2 reasons: (1) interns are not likely sleeping when working the jam packed 16h shifts; and (2) hospital beds are nearly always filled! Still the challenge for today’s interns is getting sleep when working odd hours, especially if starting night shifts on night float or ‘night medicine’ as programs are evolving to include more night rotations.  If this means you have to invest in window treatments or wear an eyeshade at night, just do it.  There is nothing better than sleep for a resident and the more the better.  While your sleep at home may be limited regardless due to your other family obligations, its important to know your limits and set aside nights where you will recover.
  5. Fulfillment – Last but not least, its important to figure out how to keep yourself happy and fulfilled during your residency.  In some cases, that is a particular hobby or loved one that you need to stay in touch with.  In other cases, fulfillment is more complex.  It is not uncommon to have doubts about your future career as you stand by the fax waiting for outside hospital records, wait on the phone to schedule a follow up appointment for a discharged patient, or even transport a sick patient to get a needed test.  While many are working on ways to reduce the burden of this largely administrative work, interns and medical students are still straddled with a large amount of scut which can be demoralizing.  So, where do you find the fulfillment in your work? Well, you will find it when you least expect it – in the words of a patient who is eternally grateful.  In other cases, you will meet a mentor or role model who shares your passion and interest in medicine, whatever that may be, and can inspire you to keep you going. Whatever it is, find it and hang on to it for dear life during your darkest hours and it will pull you through.

I do need to add one more F to this fine list –  So provided that you are keeping up with the first 5 F’s, the best thing is that being in the hospital, learning medicine, and caring for patients is actually FUN!  So, don’t forget to pause and enjoy it…these tips will also serve you will in the FUTURE!

–Vineet Arora, MD

Other helpful posts to conquer any FEARS of starting on the wards:

What NOT to Wear on the Wards

How to Present to Your Attending





Can We Trust Medical Trainees with Social Media and Other Digital Dilemmas

18 04 2011

Last weekend, I was on a panel for internal medicine residents at the American College of Physicians Council of Associates forum in San Diego.  I was invited by Erin Dunnigan and Baligh Yehia, the Co-Chairs of the Council, a position that I have also held earlier in my career.  The topic – was about the debate on social media use among medical trainees and whether it was professional.  Fortunately, I was lucky enough to do it with my rock star colleague Darilyn Moyer, the program director at Temple, who also moderated last years panel on Mean Girls in Medicine with me.

The Temple chief resident, Brooke Worster, started us off by asking the much debated anathema in medical education – what is professionalism – and if it is in the digital domain, it’s even harder to describe.  Then she proceeded to show some videos of medical students that you could say exercise some creativity – from the harmlessly funny to incredibly poor taste and ranging from schools such as UT Southwestern to my own alma mater Washington University in St. Louis.

The questions from the residents were spot on and here were some of the Q&A that followed:

Medical trainees are people too – shouldn’t they able to express themselves in ways  using colorful medical humor either in a show or their profile?

The objection is not for class shows and parodies – those have existed since the very first class medical show that took place at the University of Michigan and called the Galen’s Smoker (this year’s name- “Spleen Girls”).  The issue is more complicated with public consumption of materials never meant to be seen by a public audience.  Then, when a video is seen by a patient, an employer, or another interested stakeholder, alumni, philanthropists, those that donate their body to science (to name a few), the meaning of the video is not clear and those individuals often lose faith in the medical system.  There have been cases where patients have refused care by a residency trainee after seeing their Facebook profile with images that don’t seem suitable for their doctor.  So, while medical trainees deserve the right to blow off some steam and exercise creativity, it should not compromise their ability to see patients or work in the future.

Shouldn’t we just trust students and residents to police themselves on social media?

The answer here is that while most students are capable of policing themselves, a breach of professionalism on the internet is like a NEVER event – especially if it relates to patient information or trainee information that could result in harm.  So, opting for a putting out fires approach will not be effective and it’s important for medical educators to teach students and residents about responsible use of social media.  The good news is that the more one uses social media, the more likely they are to be able to draw that line in the sand.  Our research shows that superusers, or more frequent users, are more likely to oppose regulation but are also more likely to believe that they are responsible for portraying a professional image.  So, by teaching people to use it appropriately, we may actually prevent violations and breaches.

Should schools screen social media as part of its application process?

Interestingly, some students and faculty in the audience advocated for ‘second chances’ and redemption if a student had a inappropriate picture posted since Facebook privacy settings are initially confusing and a student could be misguided initially. But, let’s face it… screening applications for admission to medical school or residency is hard and takes time.  People are looking for ANY red flag to set downgrade your application compared to others.  Don’t give them a reason.  Medicine is not unlike any other industry in which candidates are interviewed to see if they can get the job done and also represent that organization appropriately.  If a video is posted that showcases a student in a tasteless parody with your school logo or name in the background, a hospital or residency is not going to want to take that risk with you.

What can medical schools do to protect themselves?

Well, for starters, schools can have a social media policy that highlight that do’s and don’ts in this area.  Unfortunately, in a recent study by @kind4kids and @MotherinMedicine, most schools do not so we have room for improvement.   The second thing is that schools can also deliver education, not only on the negatives – or how NOT to use social media, but they can also encourage and role model proper use of social media through disseminating course materials, student press, recruitment and admissions, or communicating with their students.  A recent post on a new student blog actually has a Poll this week asking students if they would want to receive information via social media and the majority say yes.

What can students do to ensure that their digital image is safe?

This question actually came from a student that has the same problem as me – a person with another name who happens to be garnering attention for the wrong reasons – in my case, it’s someone with my same name who is an ophthalmologist and has been accused of blinding patients and has many negative patient testimonials.  So, what can I do – well I initially started on LinkedIn to try to distinguish myself from this person and I also took control of my own digital footprint using a Google Profile to highlight who I am and the links on the web that I want people to see.  (You’ll notice my Facebook profile is NOT on my Google Profile).

The same old adage about Vegas applies here- whatever happens on social media stays on social media.  Therefore, just like the national dialogue on health information technology, its important for medical educators and trainees to engage in a constructive dialogue and establish policies that both set standards and teach others how to meaningfully use social media.

–Vineet Arora, MD





Nature vs. Nurture in Medical Education: The Case of Student Bedside Manner

13 03 2011

Sir William Osler at the bedside

Believe it or not, it’s been a major news week about the soft stuff in medicine, bedside manner.   First, a Time magazine story about a new study showing that patients cared for by physicians with greater empathy had better diabetes control.  That study comes on the heels of an editorial in the New York Times written by a patient (who also happens to be a science journalist and an outstanding writer) with mitral valve prolapse who graciously volunteered herself to be examined by preclinical medical students learning to do the physical exam and lived to vividly document the experience for all of us.  As she eloquently describes, some students seemed like naturals, whereas others were awkward and clunky.   

These articles add more fuel to the fire for the most hotly contested question in medical education – Can you teach these behaviors?  One on side, you have the nature supporters, saying that the role of admissions committees is to screen these behaviors out.  The nurture supporters say that these behaviors can be taught and its medical schools responsibility to do so.  While it is true that some pathologic behaviors need to be screened in admissions, the question for most students is more refined—is it true that some students come in ‘empathetic’ and others are just hopeless oafs that can’t empathize with patients?  Well, it was refreshing to read Number Needed to Treat blog written by a medical student who says the NYT article was eating away at her soul…She nails it by saying the following:

“Almost every single med student I know is, in fact, an affable person. Yet it doesn’t always come through in the exam room.”

Why is this so hard?  Well, it is not easy to learn how to do a physical exam while also forming your bedside manner.  Our students have to pass a national standardized exam that requires doing the over 100 step “head to toe” physical exam.  As a ‘dinosaur’, I never had to take such a test. I’m not even sure what all the steps are but have asked my colleague, Dr. Farnan, who runs our Clinical Skills program for medical students who informed me of all the points and that they are to be memorized.  Let’s be honest- most of our faculty could not do this without referring to a cheat sheet.  If they had to memorize it for a test, they may even come across robotic and unempathetic at first. 

So, what does this mean for students’ bedside manners while they are learning?  Well, mental capacity is finite.  Workload has been well described as a construct that includes the mental and physical challenge of the work.  For complex tasks, it is important to consider how much ‘spare capacity’ one has after the ‘primary task’ is dealt with.  Elegant studies have shown that experienced physicians are BETTER at performing a secondary task than novice physicians when both are doing the same primary task.  Why?  The experienced physicians have more ‘spare capacity’ to deal with the second task.  

So what is the primary and secondary task in interviewing a patient?  Well, the primary task is learning the physical exam and how to take a history.  As we celebrate this week’s residency match, the job of medical school is to produce physicians that can perform these basic functions during residency training.  While our medical students acquire these skills, of course some will be naturals, and therefore have more spare capacity to key in on their bedside manner.  In contrast, others may struggle with basic skills and have difficulty with both.  The majority, however, will first initially put all their mental effort into learning how to do a history and physical, leaving little ‘spare capacity’ for bedside manner.  Is there hope?  Yes, as these students get better at taking a history and physical, they will be more at ease.  This will then free up the necessary spare capacity to be continuously cognizant of their bedside behaviors.  Consistent with this philosophy, one school has had success actively reinforcing bedside manner skills while prerounding during the third year clerkship.

This progression is important, and highlights the learned art of medicine.  This was articulated beautifully by our recent keynote speaker, Dr. Joel Schwab, for the Gold Humanism Society senior student honorees.   On the subject of being humanistic, he said that he THINKS about the landmark article on etiquette-based medicine every time he sees the patient and he follows the 6 steps –

  1. Knock on the Door (wait permission to enter)
  2. Introduce yourself (with name badge on display)
  3. Shake hands (wear glove if needed)
  4. Sit down (smile if appropriate)
  5. Briefly explain your role on the team
  6. Ask the patient how he or she is feeling 

While working at a free clinic last Saturday, I too thought about this article for every patient I saw.  The first year students I was working with came from a variety of medical schools in Chicago and were volunteering their Saturday to do this.  I had no doubt that they all cared about the patients.  But, I did notice that they were taking time to think very hard about the chief complaint, figure out the right questions to ask, and how to present it coherently.  So, the role of medical education is to make sure that doing a history and physical becomes second nature for our students, and that thinking about bedside manner becomes the primary task.

–Vineet Arora, MD





Is Medical Education Oppressive? Expert Failure, Social Media & Other Lessons from AAMC 2010

15 11 2010

I spent the majority of last week at the Association of American Medical Colleges.  This was my first time attending the majority of the meeting and it did not disappoint.  While there is lore that some authors are not good speakers, this was definitely not the case with Malcolm Gladwell. Using vignettes ranging from the Civil War to the downfall of Bears Stern and recent financial crisis, he eloquently described what happens when ‘experts’ fail.  Experts fail due to miscalibration, not incompetence.  Miscalibration results from overconfidence when one perceives they have perfect information.  This is certainly true in medicine, in which overconfidence can lead to diagnostic error through early closure.  

While I was still mulling over expert failure, I attended a very interesting session titled “Flexner, Freedom, and the Way Forward” delivered by Steve Kanter, editor of Academic Medicine and Dean of the University of Pittsburgh. Drawing from the educational pedagogy of Brazilian Paulo Freire, he articulated the need to go from the traditional medical education that is fundamentally oppressive, inhibits critical thinking, and rewards conformity to one that promotes intellectual inquiry, the freedom to explore ideas, and imagination.  Unfortunately, the current “deficit” model focuses on students as the major problem, as opposed to environment or instructional practices, and is characterized by the famous “P=MD” promulgated in medical schools today. The increasing emphasis on student unprofessionalism, with little attention on altering the environment or examining the role models – positive or negative- that students interact with is another example of the deficit model. 

So, how do we move to a generative model, which encourages more imagination, creativity, and freedom?  Interestingly, one of Kanter’s answers was through the cultivation of scholarly projects, something that he has championed at the University of Pittsburgh.  This was particularly interesting given the explosive growth in schools that now offer scholarly concentrations, including our own.   During an early morning breakfast meeting of schools with ‘scholarly concentrations’,  I wondered if we would reach a Gladwell ‘a tipping point’ where medical school ‘majors’ would become commonplace or whether these would remain a niche for select schools.   

In addition to thinking about how to move forward, it’s also important to think about how we ended up with this model if it is not desirable?  Is it possible that expert medical educators failed to recognize the importance of critical thinking?  Well, a more plausible explanation is conformity is actually desirable.  After all, few patients are looking for ‘creative imaginative doctors’ (often synonymous with quackery).  Instead, doctors are rewarded for ‘standard of care’ and following ‘evidence-based standards.’  Although creativity and imagination are not rewarded in medical practice, it is certainly needed in medical education.  On this centennial of the Flexner report, there were plenty of reminders at AAMC that we still have the same problems that plagued medical educators 100 years ago.  Reasons for lack of progress in this area include inertia, lack of funding, and the perverse incentives academic health centers that detract from the teaching mission. 

But, this begs the question, is medical education ready for creativity and freedom?   Interestingly, while the “mHealth” or mobile health summit was showcasing the latest technological innovations and advances just down the road in DC, AAMC sessions on social media and medical education focused on the fears associated with increasing use of social media among medical trainees.  When full-scale institutional bans were mentioned, students highlighted how this may inadvertently result in a backlash, popularizing these technologies or the creation of an underground.  In the words of one student (per @MotherInMedicine) “You trust us to care for patients, but not to post on Facebook.” Interestingly, medical educators weren’t the only group thinking about social media and professionalism.  At the same time, the AMA issued its new guidelines for social media, aimed at helping physicians cultivate a positive professional online presence without jeopardizing the doctor-patient relationship.  While social media use in medical education continues to be debated, the meeting was a powerful reminder that we need to consider the future practice of medicine in training the physicians of tomorrow.  While we cannot ‘see’ exactly what the future holds, ignoring it entirely would certainly be oppressive and an expert failure.

–Vineet Arora, MD





ACGME 2010: Cracking the Code, Breaking a Promise, & Hope for the Future

25 06 2010

The ACGME has just announced it’s new proposals for duty hours and graduate medical education is stopped in its tracks just as we finish new intern orientations.  Residency educators (including me) are now poring over the small print in the New England Journal tables or the sleek new ACGME website to understand how to create a schedule that complies with the new rules.   

In addition to schedule making, residency educators are all staring at the new program requirements are all trying to “crack the code” in the new requirements, much like Keanu Reeves in the Matrix.  Specifically, program directors want to know what will count as “qualified supervisor”, “fitness to duty”, “strategic napping”, or a “fatigue management strategy” so that programs don’t get the red flag the next time the ACGME site visitor comes knocking.  So far, it sounds like residents can still supervise interns so attendings aren’t being asked to sleepover in their offices…just yet.   This will likely generate some of the discussion for the 45-day public comment period on the proposed requirements.  

One thing is clearly different – interns (first year residents) will only work 16 hours maximum while residents (after internship) can work longer – up to 28 hours (I should say 24+4).  While it makes sense to protect the interns who are least experienced and most sensitive to fatigue, the current culture characterizes internship through the following promise:  if you can “just get through intern year”, then it gets better.   In fact, I think I stated this to many of our graduating medical students and incoming interns this month!   After internship, residents currently look forward to more time for research and elective rotations, working on applications for future job/fellowship, studying for their boards, catching up on paying bills (or moonlighting to pay bills) and reacquainting with their family and friends.  The promise is also more than just hours of life, its about the scut work associated with intern work improving later in residency.  Residents can now go to their educational conferences or operate in the OR and leave their interns behind to doublecheck and triplecheck that the CT’s are done, labs are drawn, medications are adminstered, and patients actually get discharged.  So what happens if this promise is broken?   The rationale for preserving overnight call for residents is that they will get the clinical experience that they need at a time when they are ready and prepared.  However, the escalation of work during training requires all of us to rephrase how we approach discussing internship and residency.   Most importantly, what will the interns and residents think about breaking the promise?

The new rules also include more on handoffs, one of my favorite topics.  While handoffs will undoubtedly be more frequent for interns working 16 hour shifts, programs are also asked to take steps to “minimize transitions of care”.  They also require all residents to be competent in handoff communication and for programs to monitor handoffs so they are structured, effective and safe.   As we’ve discussed before, it’s currently unclear what type of education works best, or how to monitor handoffs.   Given our work in the area, our latest thought is that programs need a “handoff menu” so that different programs can “order” the types of education or evaluation tools (ranging from 5 minute lecture to simulation-based training) that will work best for their residents. 

Given the need to scale up handoff education to all residents, it’s important to make learning about handoffs fun, interactive, and most of all QUICK.  After all, getting time on the GME orientation calendar is not easy when you’re competing against needlesticks and computer training.  So, with the help of a talented recent medical student graduate, we’ve developed a short video to highlight the pitfalls of handoffs and how not to do them for our new intern oriention that generated lots of positive feedback.  (It’s now publicly posted on here as part of a social media contest this week for educational video of the month so please vote by sharing!).  

And just when I thought we were onto something,  two of our creative undergraduate students decided to go one step further with the following “Oh My God” Handoffs Cartoon based on the video which says it all in one page (read clockwise)!  So, with all the fretting about how we will ensure the clinical education and professional development of the millenial generation with the new duty hour limits, we cannot forget to celebrate their incredible unique talents and nurture it for the betterment of medical education and patient care.   Maybe they will figure out the best call schedule for the new rules too.

–Vineet Arora, MD

please email patienthandoffs@gmail.com for any information on our Handoff Menu or other tools

Disclosure: I have received funding from the ACGME to reviewthe literature  to help inform the new standards and have also testified to the committee that created the new standards.








Follow

Get every new post delivered to your Inbox.

Join 16,208 other followers

%d bloggers like this: