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








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