#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





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





Love Letters for Med Students Follow-Up

27 01 2013

futuredocs:

For any students wondering what to do if they write or receive love letters from residency programs, here is an oldie but goodie to help. Since this post, we conducted a 7 school study in 2010 of graduates that showed that almost one-fifth reported feeling assured by a program they would match there but did not despite ranking that program first. Nearly one-fourth said they changed their rank order list based on communications with programs. The conclusion “Students should be advised to interpret any comments made by programs cautiously.” And of course be mindful that the 2013 Rank order list certification deadline is Feb 20th at 8pm Central Time. Good luck!

 

Vineet Arora MD

Originally posted on FutureDocs:

While Valentine’s Day is coming soon, a different sort of ‘love letter’ may be sent or received by senior medical students.  As recruitment season draws to a close, residency programs and applicants may be busy exchanging notes of interest, affectionately dubbed “love letters” by scores of medical students and on StudentDoctor.net.

What do these love letters mean?  Some students have asked us whether it is a Match Violation to get or send a love letter.  Others have worried they did not send enough or what type of language they should use.  Well, here are some quick tips on how to approach this somewhat awkward situation.

  1. Is it a Match Violation? It is not a Match Violation for a program or a student to express interest in the other.  However, these statements of interest cannot be binding (i.e. we will only rank you highly if you rank us #1).  If there is any part of it…

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Where are the Lollipop Men in Healthcare?

9 04 2012

I recently watched Dr. Atul Gawande on video describe how what American healthcare needs is pit crews and not cowboys.  This sentiment is also memorialized in his thought-provoking writings for the New Yorker.

Interestingly, Dr. Gawande is not the first person I have heard to suggest such a thing.  A colleague named Dr. Ken Catchpole actually studied Formula 1 pit crews and used the information to guide improvements in pediatric anesthesia handoffs.  His observations were astounding and really highlighted how the culture of medicine is different from Formula 1. In Formula 1, pit crews have a ‘fanatical’ approach to training that relies on repitition.   In healthcare, the first time we often do something is “on the fly”.  Moreover, on-the-job training usually means ‘checking the box’ by attending an annual patient safety lecture.   Perhaps the most important was the role of the “lollipop man” in pit crews.   And yes, even thought it’s a funny name, it’s a critical job.   As shown in the video, the Lollipop man is responsible for signaling and coordinating to the driver the major steps of the pit stop.  When it is safe to step on the gas, the Lollipop man will signal to the driver.  Sounds like a thing so perhaps it can be automated.  Wrong.  When Ferrari tried replacing the Lollipop man with a stop light that signaled the driver, the confusion created (does amber mean stop or go?) led to a driver leaving the pit with his gas still connected.  Quickly after this incident, Ferrari announced it would go back to the tried and trusted Lollipop “hu”man.

So, who are the Lollipop men (or women) in healthcare?  Turns out that Dr. Catchpole and his team observed that it was often unclear who was leading the handoff process that they were observing in healthcare.  With team training and system reengineering, Dr. Catchpole’s team was able to reorganize the pediatric handover so there was a Lollipop man (anesthesiologist) at the helm.

While these handoffs represent a critical element of healthcare communication in a focused area, it is symbolic of a larger problem in healthcare – we are still missing “Lollipop men” to coordinate healthcare for patients across multiple sites and specialties.  This is even more critical on the 2-year anniversary of healthcare reform and this month’s match results. At a time when we need to cultivate and train more “Lollipop men” to coordinate care for patients, we have had stable numbers of students who enter primary care fields.   And like the lessons from the Ferrari team, it is doubtful that a computer (even Watson who is now working in medicine apparently) will be able to do the job of a Lollipop man.

So, how can we recruit more Lollipop men?  While it is tempting to blame the rise or fall of various specialties and market forces, it is important to recognize that being this is a difficult job to do when the Lollipop is broken or even nonexistent.  Without the tools to execute the critical coordination that Lollipop men rely on, they cannot do their job.  So, the first order of business to ensure that the Lollipop, or an infrastructure to coordinate care for patients through their race that is their healthcare journey, exists.  As the Supreme Court debates the future of the Accountable Care Act, there is no greater time to highlight the importance of the Lollipop.

–Vineet Arora MD





How Technology is Changing Medical Education: Match and Residency Training

20 03 2011

This past week was the biggest week in medical education, which culminates in the Residency Match.   It also marked the swsx festival in Austin, featuring the best of technology and entertainment.  So this post is dedicated to commemorating these two seemingly unrelated yet simultaneous events.  The generation that matched are the doctors of the future who are extreme technophiles and not afraid to use it in medicine.  They may even make their career decisions based on them.  On the interview trail, they will often ask whether the program has an electronic health record.   So, as senior students embark into their residency, it seems only fitting to explore how technology is changing medical education.  Since there is a lot to say, I’ll write a follow up on how it is affecting preclinical education but the focus is on the match and residency training here.

Technology and the Match   During the 2011 residency match, social media was in full force, and the internet was atweeting as medical students, schools, and educators were espousing the #MatchDay and #MatchDay2011 hashtags.  Several medical schools actually embraced social media to actively announce where their students were going via Twitter, dedicated blogs, or Flickr (yes Eastern Virgina students wear costumes!).  As students celebrated by announcing where they were going, faculty (including myself) could welcome them into their own program.  Current interns could rejoice that they were that much closer to the end of their grueling internship, except that they were still going to be on call overnight, while the newly matched have restricted duty hours.

Students often wonder about the size and capability of the mega-computer that runs the algorithm that produces the matches.  Unfortunately, this year’s match was marred by a serious computer crash during the precious hours of the Scramble highlighting the worst case scenarios when we depend on technology.  The computer crash also does not bode well for the implementation of next year’s Managed Scramble which will increase the numbers of aspiring residents who will use the Electronic Residency Application Service to apply to programs in the post-Match mayhem that is the Scramble.  In addition, the current debate over the “All -in” plan will require heavier technological capability as international medical graduates will be required to enter the Match (unlike US Seniors, they can accept positions outside of the Match). 

Technology and Residency Training  Technology certainly increases our capability in monitoring resident duty hours and collect evalutions through Learning Management Systems like New Innovations or e-Value.  However, the implementation of electronic health records actually increases time to do work in many cases, which may make it harder to comply with duty hours.  Although decision support can improve quality of care, others worry that overreliance on decision support may result in physicians who subscribe to cookbook medicine and worse, can’t operate without technology.  For example, one program director stated that she was going to resort to a ‘blue book’ exam for residents to demonstrate how to do admission orders using the classic mneumonic ADC VAN DISMAL.

More interestingly, just like email and internet has made it possible to conduct business 24/7, the remote access of electronic health records makes it possible to work from home, after you leave the hospital.  This may come in the form of ‘epicstalking’ as our attendings and residents refer to it – the process of ‘following a patient’ by looking at the labs and studies through virtually logging in to the hospital’s electronic health record “Epic” from home, long after departing the hospital.  Attendings can use epicstalking to ensure that the hospitalized patients are receiving the therapies that are indicated and that the residents are presenting all the information (in essence a form of supervision).  However, residents often epicstalk to try to check to see what is going on with the patient they have handed off and gone home, a time when they should be resting.   With shorter hours, will more work be transferred home?  It is possible, and how this time will be counted in residency duty hours is still anyone’s guess.

In the meantime, maybe a consult to the supersmart Watson can help us tackle these problems? 

Also, stay tuned for part 2 which will look at technology and medical student education.

–Vineet Arora, MD





Love Letters for Medical Students

29 01 2011

While Valentine’s Day is coming soon, a different sort of ‘love letter’ may be sent or received by senior medical students.  As recruitment season draws to a close, residency programs and applicants may be busy exchanging notes of interest, affectionately dubbed “love letters” by scores of medical students and on StudentDoctor.net.

What do these love letters mean?  Some students have asked us whether it is a Match Violation to get or send a love letter.  Others have worried they did not send enough or what type of language they should use.  Well, here are some quick tips on how to approach this somewhat awkward situation.

  1. Is it a Match Violation? It is not a Match Violation for a program or a student to express interest in the other.  However, these statements of interest cannot be binding (i.e. we will only rank you highly if you rank us #1).  If there is any part of it that is binding, then it would escalate to the level of a Match Violation.  Read more about what constitutes a violation here.
  2. “Rank highly” vs. “Rank #1”? –  It is poor form to send more than 1 program a “I will rank you #1” note.  There are 2strategies that most students will use- The first is to select the #1 program to send a “rank #1” letter to and then to send “rank highly” to the next 2-3 programs on the list.  Since some believe that “rank highly” has become the code for “I love you but not enough,”  the alternative is to be coy and not let any program you will rank them #1, but use language like “I could see myself there” or “I would be honored to train there.”
  3. “Rank to match” statements from the program – It is possible that programs could call or email to alert you that they are ‘ranking you to match.’  While you may feel elated, this does NOT mean that you should pack up your belongings and move.  This also does NOT mean that you should cut programs from your list since are secured a spot.  What this DOES mean is that they are interested in you and have likely placed you in a position on their rank list where they THINK on an average year you could match there.  Because the Match is very tricky and the competitiveness for an individual program can change year to year, “ranked to match” in one year may mean “out of luck” in another year.  So our advice is to not put a lot of stock into these statements and still preserve the breadth and depth on your list that you will need to secure a position.  Remember the length of your Rank List is one of the best predictors of whether you will match or not.
  4. What about programs that I don’t send letters to? Will they think I hate them? –Absolutely not.  The letters can serve as a signal in the game that you are interested but just because you don’t send a letter does not mean that you can’t end up at that program.  Programs are maximizing their ability to get the best candidates regardless of this communication.   It would be extremely unusual for a program to strike someone from their list if they don’t receive a letter.  Likewise, if you are not very competitive for a program, your letter is not going to be the dealbreaker to move you in to the rankable range.  Remember, the letter is really a statement of interest that may help a little, but not a lot.
  5. Email vs. Paper – During the recruitment season, paper thank you cards can be a nice touch if sent in a timely fashion.  However, the post-recruitment love letter should probably be an e-mail given the occasional snafu in snail-mail especially in large hospitals.  The nice thing about the email is that it can be immediately forwarded to the members of the recruitment committee or others.  In terms of who to send the love letter to, it is usually sent to the program director unless someone else was clearly the lead recruitment person for the day (an associate program director or a faculty member).  As always, try to personalize the letter to highlight the things you enjoyed about the program that day.
  6. There is no ‘right’ answer – As with our other career advising posts regarding the Match, there is no right answer here.  Since everyone’s case is different, the best thing may be to consult with a faculty member from your field who has been advising you on the process.

Alas, in spite of all the love you may get or feel, the irony is that the key to a successful residency match is not to fall in love.   Remember, you are not in a relationship with any program yet.  Since anything is possible, you need to keep an open mind.  Try to group your list in tiers.  Consider that you would be happy at any of the programs in your ‘top tier’  to avoid being dead set on one place.  Visit last year’s archived post if you need more help creating a rank list or checking it twice.  Lastly, don’t forget to certify your list.

Happy Match List Making!

–Vineet Arora, MD and Shalini Reddy, MD





Blog ‘Paper’ Anniversary: Reflections & Top Posts of 2010

3 01 2011

It’s been one year of blogging or our ‘paper’ anniversary here on FutureDocs! 

I was reminded of this milestone with the receipt of the WordPress blog ‘report card’ below.   While I was excited to learn about the clean bill of health and intrigued by metrics related to shipping containers, I’m not going to lie.   It can be very challenging to stay fresh, write creatively, and keep up with posting while holding down an academic career.          

However, one thing I have learned (and confirmed by @MotherInMed who helped me get started) was that if you are inspired, the post will write itself (like this one).  Therefore, it is critical to pay attention to those moments you are inspired.  This gives rise to a somewhat startling personal observation– blogging can acutally improve your attention span and focus.  Sounds crazy, I know… But, unlike social media sites which can be highly distracting (Twitter or Facebook addicts anyone?), I find that I often pay closer attention to my surroundings so that I don’t miss the inspirational moment around the corner that I can share.   For example, in lieu of walking around aimlessly at medical conferences (a risk at any conference especially in medicine), I found myself taking notes and immediately reflecting on sessions to distill the most salient points, such as the oppressive nature of medical education or expert failure highlighted at the recent Association of American Medical Colleges.

In examining the report card below, the top posts on this blog are both predictable and surprising.  With the explosion of interest in technology and plenty of technophiles in the blogosphere, it is no surprise that posts about Twitter myths for docs and whether the iPad lives up to it’s hype on the wards are at the top.   The other 2 posts relate to career advising, which was a welcome surprise.  They also do reaffirm the need to continue to provide solid career advice to medical trainees, no matter how mundane (like what to wear to the hospital).   In addition to technology and career advising, I’ve enjoyed the ability to highlight various advocacy issues relating to medical education like healthcare reform, resident duty hours, the Match, and women in medicine.  Lastly, I must admit that I do enjoy writing for pure fun — like the posts on movies in medicine or healthcare phobias.   

Special thanks to uber medbloggers KevinMD and medrants who occasionally cross post or reference these posts and all those who subscribe and comment.   I was especially honored to be included in KevinMD’s top 10 posts of the year for this post on shadowing (which curiously did not make the WordPress list below).  

So here’s to more inspirational and informative moments of 2011, both in life and on the blogosphere.

–Vineet Arora, MD

***Blog Report Card From WordPress:

Fortunately, the stats helper monkeys at WordPress.com mulled over how this blog did in 2010, and sent me the following high level summary of its overall blog health:

Healthy blog!

The Blog-Health-o-Meter™ reads Wow.

Crunchy numbers

This blog was viewed about 20,000 times in 2010. If each view were a shipping container, your blog would have filled about 4 fully loaded ships.

In 2010, there were 30 new posts, not bad for the first year!  The busiest day of the year was March 5th with 304 views. The most popular post that day was Top Twitter Myths & Tips.

Where did they come from?

The top referring sites in 2010 were twitter.com, kevinmd.com, Google Reader, medrants.com, and facebook.com.

Attractions in 2010

These are the posts and pages that got the most views in 2010.

Top Twitter Myths & Tips February 2010
6 comments

Attending Rounds with the iPad – Hype or Hindrance? August 2010
13 comments

What Not to Wear: Hospital Edition May 2010
4 comments

Personal Statement Do’s and Don’ts July 2010
4 comments

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