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





Becoming a Medical School Memory Champion via Cartooning

11 06 2011

Congratulations to all of our MS2 who recently took the dreaded USMLE 1 Exam!  Unfortunately, much of medical school is about memorization – and believe it or not, there is a science to memorization.  I learned this from one of our students—who describes her experience meeting a ‘memory champion’ and picked his brain for some memory tricks for Step 1 including cartoon images.   As I’ll be speaking at the upcoming Comics in Medicine conference here in Chicago this weekend, it seemed fitting to describe her journey.

Right around the time I was beginning an epic five-week studying stint to prepare for STEP 1 of the Boards, Joshua Foer happened to be a guest on The Colbert Report (my go-to 20 minute study break).  Joshua Foer is this ridiculously young and talented journalist who won the US Memory Championships (yes this exists).  If his name sounds familiar you may be thinking of Jonathan Foer, his equally talented older brother who is also a writer.

Anyway, Joshua Foer was promoting his recently released book “Moonwalking with Einstein:  The Art and Science of Remembering Everything.” The book is about memory and his adventures in the world of memory competitions. Apparently there is a small group of people who get together each year and have memory competitions which consist of several memory “events” including faces of strangers, poetry, random words, numbers, binary digits, stacks of cards, etc.  Participants wear noise cancelling headphones and blinders (think sunglasses with two little holes drilled out) to reduce distractors as much as possible.  After attending the US competition as a journalist he wound up being tutored by and English memory master and winning the completion the next year (the US memory scene is not very developed, the Germans are much more serious).

Foer stressed that memory champions are not born with extraordinary powers of memory. They training themselves to use some established memory techniques and are constantly developing new ways on remembering things. This intrigued me since I wondered if I could use some of these techniques to master the overwhelming volume of facts needed for the Boards.  I started reading his book and loved it. It’s very pop-science quick read.   When chatting with one of my best friends who was studying for the Bar, she says, “Oh Josh Foer is giving a talk at this spot in Echo Park this weekend, let’s go pick his brain for ideas.”  (I studied in LA).

So we went… and I managed to get up the nerve to ask him for any advice.  In the most bizarre coincidence, he tells me that his wife is a also second year medical student studying for the boards (bet she’ll do just fine!).   Since visual mnemonics are big in the memory world, he explained that when making a visual aid, the funnier, scarier, raunchier, and stranger it is, the easier it is to remember. He recommended trying to enrich the image with as much detail as possible. He also explained that, though these images help you remember, thinking up good ones takes a lot of creative energy and can be exhausting. That’s one of the things you work on developing when training for a memory championship – the capacity to conjure up rich, creative images really quickly.  He signed my First Aid for the Boards, and I went home and started using that idea by making cartoons (a la Micro Made Ridiculously Simple).

He was right…creative effort is draining.  Sometimes, it took forever to think of something that would stick – but the stuff I made cartoons for is in the vault! Here is an example of a visual aid I made myself for a mucopolysccharidosis, Hurlers. In this image there is a gargoyle (Hurler’s causes gargoylism) hurling a ball (Hurler’s).  He has a dark spleen and liver (spleno- and hepatomegaly) and rain clouds for eyes (clouded corneas). He is also panting and gasping because of airway obstruction.  What I love about this picture is that if I can remember one part of the image (one thing about Hurler’s) the rest of the image (the rest of the facts) come back to me. The other nice thing I noticed is that on a lot of Boards questions you narrow it down to two answers, but it’s been a while since you looked at that material and you are 70% sure you picked the right answer. If I made a picture like this I was sure, clouded cornea’s goes with Hurler’s, not the related Hunter’s disease.  I used some other techniques from the book: the “memory palace” for biochemical pathways; the “major system” to remember lab values.   While memory tricks don’t lend itself to everything, it was really helpful for stuff that is difficult to reason through (lysosomal storage diseases, embryology).

–Gabrielle Schaefer, MS2

Thanks to Gabrielle for describing her experience!  And who said doodling in class never got you anywhere?





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





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





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.








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