#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!





Cleaning the Graffiti in Healthcare

24 07 2013

 I just left the most unusual conference I have ever attended.  First, it was small – 25 people.  Second, it was all women.  Third, it was all senior healthcare leaders who have done amazing things…make that trail-blazing things.  Moreover, I found myself surrounded by women who were journalists at major news outlets, retired military officers from the highest ranks, senior leaders (in some cases the senior most leader!) at major federal and state healthcare agencies, Fortune 500 companies, large health systems, healthcare foundations, national advocacy organizations.   It’s no surprise the name “Amazon warrior” resonated with this group!  Finally, the conference was all about identifying our “living legacy”.   Legacy seems like a strange word when you are living…it’s even stranger when you feel like you haven’t don’t anything yet!  So, how did I get invited you (and I) are wondering?  After all, I was the youngest person in the room, which as an aside, is a very unusual context when you work with students and residents for big chunks of the day.  So, believe it or not, I was invited by in large part due to my… social media presence!  After reviewing the list of participants, the organizers realized something was missing, and that something was someone younger who also had a social media presence.  And whoever said tweeting is a waste of time?

While there is much I could say, one of the group exercises on the last day of the conference is worth sharing and involving others in.  We were asked to examine “broken windows” in healthcare.  A broken window is a symbol of something smaller that is part of the context to a larger problem.  As Malcolm Gladwell popularized in his book, the Tipping Point, New York made a dent in the big problem of crime by tackling smaller problems, such as cleaning off the graffiti from the train every night.  By changing the context, people started to “own” the subway and report crime instead of expect it.  An excellent video summary is here.

So, how does this apply to healthcare?  While there are criticisms of the broken window theory, what a boon it would it be if we could locate something small in healthcare to fix the very large complex problems facing healthcare.   So, our group only had a short amount of time to pursue identifying broken window in healthcare.   While it sounds easy to come up with broken windows, it is much harder than it looks.   Interestingly, the healthcare problems here are so large, that the broken window may not be as simple and elegant as the graffiti example, but represent an easier place to start.  Here are three examples broken windows that we came up with.

  • Media portrayal of healthcare, especially related to resuscitation – By correcting the media portrayal of resuscitation, the public might have fewer unrealistic expectations of life sustaining therapies at the end-of-life, which could result in fewer people opting for futile measures.   By the way, researchers have even studies this (watching episodes of ER for research!) and have demonstrated the problem in a New England Journal article.   Imagine tackling this problem with media tools to demonstrate to people what a “good death” is.
  • Patient gown – While patient-centeredness is the new buzzword in our world, can we really say the system is patient centered?   Take the simple example of the patient gown which represents a loss of control and source of embarrassment to patients.  Could it be that when patients are in the gown, they feel to disempowered to engage in their own healthcare?  Could changing the gown empower patients to take a larger role in their healthcare?   In case you are wondering, there are many stories and efforts that have been undertaken to redesign the hospital gown – my favorite is the collaboration by Bridget Duffy, former Chief Patient Experience Officer at Cleveland Clinic, with fashion designer Donna Karan.
  • The Word Healthcare – It is well accepted that our healthcare system focuses on “healthcare” and not “health”.  Prevention and health promotion takes a back seat to intensive healthcare interventions.  It’s easy to resign that this will never change due to the payment system, or that return on investments in prevention are only realized in the long-term.  But, what if we could change the dialogue by using the word “health” instead of healthcare at every opportunity and juncture.  By changing the dialogue, can we change the context enough to create a change in the system?  I’m not sure, but at this point, I will say it is certainly worth a try.

There could be other examples of graffiti in healthcare.  By continuing the dialogue, hopefully we can locate the most promising levers for change.

–Vineet Arora MD

Special thanks to Dr. Joanne Conroy from the Association of American Medical Colleges for organizing the conference, our facilitators from the leadership consulting group Sunergos, and support from the Robert Wood Johnson Foundation to make it happen.





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)





What Can the Unmatched Seniors Tell Us?

18 03 2013

Yesterday, after the mayhem and jubilation of celebrating a successful match at the Pritzker School of Medicine with our students, I went onto Twitter to follow the #match2013 hashtag to understand what the reactions were.  Most were positive, but one headline caught my attention ‘In Record-Setting ‘Match Day,’ 1,100 Medical Students Don’t Find Residencies.”

It is true this was the largest match because it was “All-in” – programs either were in the match for all their positions (including international medical graduates or IMGs) or they were not.  Obviously, many programs put more positions up for grabs in the Match.  After I reposted this article to Twitter, there were many theories and questions about who these unmatched students were and why  - some of which I have tried to answer to the best of my ability below.  I welcome your input as well.

  • Are these IMGs?  This number is US Senior medical students who have been admitted and graduated from US medical schools but now have no place to go to practice medicine.
  • Does this include those that entered the “scramble” now called SOAP. Technically, those that entered SOAP and were successful would have been counted as “matched” on Friday.   Last year,  815 Us seniors went unmatched after the SOAP.
  • Did they choose to go into competitive specialties? We have to wait for the 2013 NRMP statistics, which will likely address this.  The 2012 data shows that more unmatched seniors did choose to go into competitive fields.  Last year, the % unmatched is much higher for students applying to radiation oncology, dermatology, and competitive surgical fields for example.
  • Did they go unmatched to due to poor strategy or poor academic performance? While poor strategy such as ‘suicide’ ranking only one program is related to the risk of going unmatched, the truth is getting into residency is competitive and there are some who will not match because of poor academic performance. Some even argue that medical schools have little incentive to fail students and a portion of these students should not be graduating to begin with.
  • If they had gone into primary care, would they would have matched?  I hear this myth that program directors in primary care fields only take international medical graduates (IMGs) since not enough US medical graduates apply.   This is due to the largely untested assumption that any US Senior would be preferred to an IMG.  However, I personally know program directors who would definitely take a seasoned and high performing IMG over a below-average US Student.   The reason this is important is the rationale for not lifting the GME cap is that we have 50% of certain fields filled by IMGs and those spots would naturally be filled by US grads. Interestingly, many of these spots happen to be primary care driven fields.   Yet, it is still unclear if US Seniors will displace IMGs for spots in IMG oriented residencies.  It is also unclear if they will be willing to apply to programs that typically cater to IMGs, since they are often not considered as prestigious or geographically desirable to US students.
  • Is this related to the lack of GME spots? Certainly, it is true that more effective career advising may have resulted in applicants being more strategic about their rank list and not reaching for a competitive field.  However, we cannot ignore the supply/demand side of this equation.  At a time when there is a shortage of physicians and a call to increase the number of physicians, the US medical school system by responded to this call.   New medical schools have opened.  Existing medical schools have increased their enrollments.  So, there are now more US Seniors entering the match and there will be even more in the future as new medical schools mature their entering classes to graduating students over the next four years.  Given that the supply of matched candidates includes both foreign-born IMGs and US-born IMGs, there are more candidates than spots.  And while many believe IMGs will be the ones that get “squeezed out” in this shortage situation, again this is an untested assumption.  It is also important to recognize that IMGs often play a significant role in ensuring primary care for rural populations and underserved communities,which are often not geographically desirable by US graduates.

 We are left with a fundamental question:  Do we owe it to our entering medical students who successfully graduate from medical school to have a residency spot?   At a time when we have a shortage of physicians and a call for medical schools to increase in size, should we not expand our residencies?   Unfortunately, GME funding is on the chopping block because of the belief that too much money is being wasted on residency training.  Moreover, hospitals seem less enthusiastic about expanding residencies, as it is not as much of a bargain due to caps on hours residents work, and all the other new accreditation standards for residency training.

There is a potential solution.  The “Training Tomorrow’s Doctors Today Act” by Reps. Aaron Schock (R-Ill.) and Allyson Schwartz (D-Pa.), and the “Resident Physician Shortage Reduction Act of 2013” sponsored by Sens. Bill Nelson (D-Fla.), Charles Schumer (D-N.Y.), and Majority Leader Harry Reid (D-Nev.) would enable training 15,000 more physicians over 5 years.   Moreover, spots would be distributed to programs and specialties in critical shortages, like primary care.

Given the time that it takes to train a physician, now is the time to act to ensure we have the doctors we need for the future.

 –Vineet Arora MD MAPP





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 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.








Follow

Get every new post delivered to your Inbox.

Join 16,212 other followers

%d bloggers like this: