#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

Vampires and Urban Legends: Teaching Residents about Healthcare Costs

24 05 2011

This past weekend, I gave a talk at the Committee of Interns and Residents, the largest housestaff union in the United States.  The most inspiring moment of the meeting that I witnessed were the 2 standing ovations earned by Dr. Koffler for advocating for residents to get paid in 1936 (her first paycheck was 15 dollars a month!).   How could I follow that…especially with a talk on how to train cost-conscious physicians?   Those who know my work well may even wonder how I got invited to talk about this.  Well, earlier this December, I wrote on the blog about my holiday wish list for medical education and #2 was a curriculum on cost conscious practice for medical trainees.   In addition to lack of a formal curriculum, there were several other barriers on teaching residents how to practice cost-conscious medicine that I discussed.

  • Faculty are not trained.  The largest barrier of course is that faculty don’t know how to do this.  A study in Journal of Hospital Medicine showed that faculty physicians could not identify what things cost.
  • No one knows what the cost of anything is.  Because each hospital negotiates its own prices with suppliers, it is very difficult for residents to know how much things cost.  In trying to find out how much your hospital charges for various tests, you may end up on a wild goose chase until you find the helpful person who may or may not even be in your state!
  • Bad systems promote costly workarounds.  Most of the time, residents are too concerned that they won’t be able to get a test or worse, it will delay a patient’s discharge.  The system is set up to order the test even if the attending thinks about it.  Some of our own data shows that interns learn during internship to misrepresent tests as urgent to get the job done.
  • Rumors and hospital legends spread quickly.  The highly connected residency program can actually spread rumors about how much things cost or give rise to urban legends when patients actually pay and don’t pay.
  • Underordering, not overordering, is penalized.  Due to the highly litiginous environment, most attendings encourage residents to err on the side of getting a test since the biggest fear we all have is of missing the ‘can’t miss’ diagnosis.  More reasons doctors over-order tests here.

So what can we do to teach residents about cost-conscious practice?  Well here are just a few of the things we can do..

  • Empower residents to find out how much their hospital charges for things.  As I said at the conference, we may need to start a support group for those that start down this daunting path – but it is the first step to understanding how to control costs.  Starting with senior leadership could be helpful – after all, how many C-suite leaders would not want to find out how to teach residents to control their costs? There is also a related movement to improve price transparency for patients.
  • Show residents how much they spend.  At least in the case of daily phlebotomy, a recent study dubbed “Surgical Vampires” (due to the daily blood draws ordered by the surgical interns) highlighted that letting residents know how much things cost actually reduced the cost of lab ordering per patient and resulted in 50,000 dollars saved over 11 weeks!  Studies with electronic health records at the point of care show even greater results!
  • Use unbiased resources that promote better cost-effective decisions.  Specialty societies like the American College of Physicians and the American College of Radiology are now starting to create guidelines that encourage cost-effective practice through more judicious use of imaging or other therapeutic modalities.   The popular 4 dollar list for medications is another example.
  • Incorporate discussions of costs into routine educational conferences.  At Harvard, one chief resident started a Hospital Bill Morning Report for the residents to review what a patient bill is like.  In our medical student lectures on radiology, the costs of the tests are also now discussed.
  • Educate patients that less is sometimes more.  Letting patients know about the risks of overordering tests- specifically workups of incidentalomas and pseudodisease may be helpful in explaining your new approach to cost-conscious medicine.   The pushback from patients may be the fear of rationing,  which is of course irrational since it already occurs.  A helpful summary for patients on high value cost conscious medicine appeared in Annals of Internal Medicine.
As with all things, there is the potential for unintended consequences in teaching cost-conscious medicine.  The most egregious of which would be to hide behind the veil of practicing cost-conscious medicine in order to shirk work and avoid getting an indicated test when needed.   This is especially important to watch out for as burnout sets in late in the academic year.  So, as we resist our inner vampire urge to order blood tests and uncover hospital urban legends and myths about healthcare costs, its equally important not to morph into the haphazard and dangerous cost-cutting monsters that we all fear most.
–Vineet Arora, MD

Healthcare Horrors: Needles, Medical Studentitis & Other Medical Phobias

3 11 2010

Every Halloween, I take note of some of the most infamous Doctor costumes, ranging from the mad scientist who created Frankenstein to Dr. Jekyll and Mr. Hyde.  Even if you don’t dress up as a doctor, there’s enough medical paraphernalia that contributes to costumes including all that medical gauze for the perfect mummy costume, the skeleton head for your porch, or the fake blood for the perfect vampire or zombie.  This does beg the question, what is it about doctors and healthcare that is scary?  As it turns out, fear of doctors and healthcare is very common.  Here is a short rundown of the more common healthcare-associated phobias.

  • Iatrophobia is a fear of doctors.  Interestingly, these phobias are actually types of social phobias in which the afflicted is afraid of interacting with the doctor, discussing their personal illness, or being examined.  Some suggest that ‘white coat syndrome’ or higher blood pressure in the doctor’s office is part of this syndrome.  
  • Dentophobia is the fear of dental care or dental procedures.  Unlike iatrophobia, this is quite common and some sources cite estimates as high as 75% of Americans suffer from some form of ‘dental fear’. Some suggest this is actually a variant of post-traumatic stress disorder due to the pain associated with a prior dental procedure.  Not surprisingly, the dentist’s professional demeanor is also important.  Anyone scared of Willy Wonka’s dentist dad in Tim Burton’s Charlie and the Chocolate factory?
  • Nosocomephobia is fear of going to the hospital, which is either related to fear of death or could also be related to fear of contracting illness or disease (germophobia initially described in JAMA in 1910) and may be a variation on obsessive-compulsive disorder. Of course, it is important to distinguish this pathological fear from normal concern since hospitals are reservoirs for germs and disease and hospital associated infections are on the rise
  • Pharmacophobia is the fear of taking medicine, which is often related to fear of rare side effects due to a medication.  This can sometimes manifest itself as medication ‘noncompliance’, which doctors often assume patients are intentionally not following directions.  It is also often associated with prior adverse drug events.  Perhaps the best known pharmacophobia is currently manifest as the fear of vaccines in which it is not the fear of the needle (see below) but the fear the risks of vaccination like autism or that the flu shot causes the flu.
  • Needle phobia is a very common phobia.  Some estimates say at least 10% of Americans are trypanophobic, and are likely to faint during a needle stick.  This may even be an underestimate since those with needle phobia are not likely to seek medical care.  This is a very serious phobia since needle phobia is characterized by very low blood pressure and shock when presented with needles, and there have been reports of patient deaths.  Unfortunately, people with needle phobia often avoid recommended vaccinations and blood tests, placing them at higher risk of illness.
  • Nosophobia is the fear of contracting disease.  Perhaps the most classic example of this occurs in medical students (typically in their second year) who believe they or others around them are suffering from the symptoms of the diseases they study.  Medicalstudentitis was reported as early as 1964, and it is still alive and well.  One study estimated 80% of students suffered from this and a Facebook support group even claims 1000 members.  Nosophobia can also manifest itself in patients who spend a lot of time online searching for causes of their symptoms.  Cyberchondria is a type of nosophobia the unfounded concern that common symptoms are harbingers of serious disease due to online searching.

While these phobias may sound harmless, exaggerated or silly, it is actually important to identify people with these phobias and help them seek professional treatment early.  Patients with healthcare phobias are likely to avoid seeking care for actual symptoms which places them at higher risk of morbidity and mortality.  Now, that’s a scary thought!

–Vineet Arora, MD


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