#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’s NEXT in Residency Training: Fighting off the Tick Box Zombies

11 06 2012

This weekend, an interesting article on the curent state of UK residency training crossed my Twitter feed.   Due to restricted residency duty hours in the UK (yes they have a 48 hour work week for residents aka junior doctors), they fear they are graduating “incompetent doctors who are putting patients at risk.”

This debate is not just isolated to the other side of the Pond.  In fact, a recent reports in the New England Journal of Medicine documented that nearly half of residents are OPPOSED to restricted resident duty hours, with another paper in Academic Medicine showing that many internal medicine residents were concerned about limited educational opportunities with duty hours.  Finally, in a recent study that we did with the Association of Program Directors of Internal Medicine and the Association of Program Directors of Surgery published in Academic Medicine, program directors feared specific consequences of duty hours related to faculty morale, patient continuity and resident education.

While I could go on, the reason I started to write this post was NOT to rehash the duty hours debate!  Instead, I wanted to highlight a very specific concern that is mentioned in this UK story.  One of the chief complaints in the UK medical training system is that junior doctors were being passed on the basis of dreaded ‘tick-box forms’.  (You gotta love the Brits for colorful names to what we simply call evaluations).

So now at this point, I feel like I am watching 28 Days Later, where all of London was quarantined and zombies took over.   Will the Tick Box zombies come to the United States and take over our GME system?  Have they already?  I hope not…but let’s face it.  Everyone is wondering what comes NEXT with milestones and GME.

The “Next Accreditation System” or NAS (not to be confused with the rap artist) is about documenting the achievement of specific milestones related to specific “entrustable professional activity” or EPA.  An EPA is “simply the routine professional-life activities of physicians based on their specialty and subspecialty.”  For example, for internal medicine, one of the end of year EPAs is “Manage the care of patients on general internal medicine inpatient ward.”  In this way, EPAs are more granular than the 6 “core competencies” and should in theory be easier to observe and evaluate.  Lastly, for each EPA, there will be a “narrative” that programs can select to describe how competent the resident is in that area.

While program directors and others involved in GME are all learning the new “compet-english” that has been developed, many are also concerned about the burden of evaluation in a system that is already overburdened.  In other words, will the Tick Box zombies attack us stateside?   Well, some of this is up to how the residency educator community responds to the charge.  To prevent tick box zombie attack, program directors must resist the urge to create hundreds of milestone evaluations and add them to existing evaluations.   The key is not to reinvent the wheel but to modify existing evaluations to link them to milestones and EPAs. In some cases, old evaluations that were not helpful should be re-evaluated to see if they are necessary.  Moreover, to prevent tick box zombies from striking, it’s important to design and implement ‘good’ measures of resident performance.  A good measure would adhere to some of the same properties of optimal National Quality Forum quality measures: reliable, valid, linked to meaningful outcomes, feasible to collect, and distinguish between good and bad performance.  When good measures of residency performance do not always exist, there is an opportunity to work together to figure out what they are.   While this is definitely a work in progress, one nice thing is that no one is alone.  In Chicago, a citywide meeting of residency leaders of over 10 programs was held to share how best to do this and learn from each other.   After all, to truly make our NEXT step in GME, we must all work together to prevent the tick box zombie attack.

Vineet Arora MD  

Special hat tip to @keitharmitage for inspiring this post with his tweet : )





Mentoring in Medical Education: Modeling from the Movies

23 04 2012

A big part of medical education is mentoring.  The term ‘mentor’ originates from Homer’s the Odyssey and refers to an advisor.   The role of mentors vary, but generally serve to guide mentees through work, support them during the process, keep them grounded and focused on the task at hand, and provide general moral support.

Over the weekend, at the Pritzker Revisit session on Scholarship and Discovery, our own students stated the number one thing to consider when finding a project was finding a great mentor.  How does one find a great mentor?  Well, our students are encouraged to seek “CAPE” mentors- think Superhero mentors.  The mentor should be Capable, Available, have a Project that is of interest to the student, and Easy to get along with.   Capable means that the mentor has the skills to not only be a good mentor, but also to carry out the task or project at hand.  This may sound like odd, but sometimes faculty are so excited to have a medical student work for them, they may make the false assumption that the medical student will help them with tasks (i.e. statistics) that they themselves don’t know.  Availability is especially important as it is the number one reason our students state they had a less than optimal experience in the summer doing scholarly work is that their mentor was not available.  While availability of all doctors is an issue, the question is often whether faculty make themselves available when they can (i.e. answer student email, take phone calls, meetings).  Setting expectations for when and how to meet can be very important.  Ideally, the mentor has a project that is interesting to the student since if the work is not interesting, it will be even harder to make progress.  Last but not least, the mentor has to be easy to get along with – meaning that their style meshes well with their mentees.  Some people simply do not work well together do to different personality types.  So, I often tell our students to consider that when meeting potential mentors or deciding between two mentors.

As I was thinking about ways to highlight effective mentors, I recalled some classic movies with mentoring relationship.  In relooking at these scenes this weekend, it struck me that there are some interesting reasons why they are good mentors that correlate with our model (well some of them are a stretch but they are still fun to watch!).

  • Yoda in Empire Strike Back encourages Luke Skywalker to not just try, but do.  When Luke fails to resurrect the wing fighter, he does not allow Luke to make excuses but instead demonstrates that he can do it showing that he is CAPABLE.  
  • Mr Miyagi with the Karate Kid mentors through teaching small movements related to everyday house chores “wax on, wax off.”  While he is certainly gruff and challenges Daniel, Mr Miyagi also makes himself AVAILABLE to Daniel at that moment and in the future by saying at the end “Come back tomorrow” to continue the training.  
  • Remus Lupin goes so far to use a “simulated” Death Eater to challenge Harry Potter to learn the Patronus charm (and making all standardized patient experiences seem like a cake walk!).  When Harry fails at first, he is patient and nurturing, stating that he did not expect Harry to get it on the first try.  He also makes suggestions to the technique which turn out to be the key.   Since Harry really needs this charm, this is a PROJECT THAT IS OF INTEREST and Harry ultimately succeeds in casting the spell.  
  • Gandelf in Lord of the Rings provides consolation to Frotto during a moment of despair by highlighting that it his job and also showing that Gandelf is sensitive to Frotto’s needs and EASY TO GET ALONG WITH.   

In addition to these highly acclaimed superhero and superstar CAPE mentors, let me know if you know of other model mentors from the movies.

Vineet Arora MD






What Happens in Vegas Can Be Used to Teach Costs of Care

16 02 2012

Funded with a grant from the American Board of Internal Medicine Foundation,  Costs of Care has partnered with medical educators at Harvard Medical School and the University of Chicago (that would be us!) to start addressing this problem. We are developing a series of web-based medical education videos that use clinical vignettes to illustrate core principles of cost-consideration, including how to communicate with patients about avoiding unnecessary care and reducing overused or misused tests and procedures.  As part of the project launch, we released a new teaser video today called “What if Your Hotel Bill Was Like a Hospital Bill?”. The video is a tongue-in-cheek depiction of the challenges patients face in deciphering medical expenses, and their additional confusion when they learn doctors are not trained to consider costs.  – Excerpt from Costs of Care Press Release by Dr. Neel Shah  

How does this relate to Vegas?

On a recent trip to Las Vegas with my family for the holidays, I was in the Bellagio lobby admiring the Chihuly glass ceiling.  While that was impressive, I was also watching the clerks check in and out the long lines of visitors to the hotel.  The staff explained any charges on the bill, confirmed that the bill agrees with the expectations of the patron and then finalized the transaction, printing a copy on the spot for the traveler before they got in the cab to the airport hailed by the bellman.   What a far cry from hospitals where most of the hospital staff have no idea how much anything costs!  After all, doctors are notoriously bad at considering costs in the doctor-patient relationship, as demonstrated by a great piece by Dr. Peter Ubel on his experience with the cost of his own prescription medications. As Paolo (or Paul who works as our research project manager in his day job) from Hotel Hospital highlights, “our hotel staff specifically focus on the highest quality of care…I doubt that they even know how much anything costs here.”  The rest of the script was easy to write.  Shooting was a lot harder since we had to find a spot in the hospital that looked like a hotel but thanks to some creative camera angles and props from our MergeLab team, we were able to get it done.

Learning about costs of care is critical to taking care of patients.  This was especially poignant during my recent inpatient service block at a nearby community hospital, since I cared for many uninsured patients who paid out of pocket for their medications (not to mention their hospital stay).   Our residents were concerned about one patient who was uninsured and would have difficulty paying for Plavix, a critically important drug after his heart procedure.  Review of his medications also revealed he was recently put on Lexapro, a nongeneric antidepressant (with a sordid history) that was costing him over 100 dollars a month when there is a generic alternative for 4 dollars a month, which would help him afford his Plavix.   When physicians do discuss costs, they also get it wrong and perpetuate a ‘medical urban legend’ like stating that patients have to pay when they leave the hospital against medical advice (this is not true!).   These are just a few of many examples of why teaching students and residents to bring up costs and arming them with tools to address the issue with their future patients is imperative.  Without considering costs of care, we all take a ‘gamble’ that costs of care are not an issue for patients….Of course, the odds are against that.

Stay tuned for more work from our Teaching Value Project from Costs of Care funded by the ABIM Foundation. 

–Vineet Arora, MD, MAPP

Special thanks to our production team and actors: Mark Saathoff , Andy Levy MS4, Kimberly Beiting, Paul Staisiunas, Jeanne Farnan, and Neel Shah!





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

KM3YKUY2DG5Z





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





Reviving Case Reports: Chasing Zebras or Solving Mysteries?

31 08 2010

I am teaching a new course this week entitled “Turning your Clinical Cases into Scholarly Work.”  I hope to draw on my own experiences through the years mentoring students and residents in writing up several clinical cases, but also in making diagnoses.  In preparing for this course, I have also learned quite a bit about the controversy surrounding case reports and the challenges that they face in today’s healthcare system. 

Unfortunately, case reports have fallen out of vogue.  Many journals no longer accept case reports or they have relegated them to the 2nd class ‘online’ only publication since they are often not highly cited and lead to a lower journal impact factor.  Critics of case reports actually say they overemphasize the unusual at the expense of the ordinary and are not evidence-based.  Furthermore, in today’s era of cost consciousness medicine, chasing ‘zebras’ or unique diagnosis is often frowned upon due to the potential for inappropriate or overuse of tests, with the possible unintended consequences of working up incidentilomas

Despite these concerns, case reports have had a major impact on the discovery of new diseases, mechanisms of disease and even drug therapies.  The first cases of AIDS were reported as case reports.  Side effects of drugs are often discovered through case reports and can lead to changes clinical practice (MRI contrast and nephrogenic systemic fibrosis) to prevent harm.  Cases reporting potentially desired side effects can also prompt accidental discovery of new drugs that can change quality of life for many people, as is the case with Viagra

So, how can we promote the art of case reports without creating zebra chasers who drive up healthcare costs?  Well, the key may lie in Sherlock Holmes.  Medicine is often compared to detective work and it is well known that Sherlock Holmes used the power of observation to make informed deduction.  While Holmes was a fictional character, the invention of Sir Arthur Conan Doyle (a doctor turned writer), he was modeled after Dr. Joseph Bell, Doyle’s former physician-mentor.  To get his trainees interested in observation, Dr. Bell used the power of observation to deduce mundane things like occupation and recent activity in passersby.  In essence, the clues to making the diagnosis lie in careful understanding of the patient’s story and observation of the physical cues.    

Unfortunately, the powers of observation are declining these days due to the ease of ordering CT scans without thinking about a patient.  Fear of malpractice also drives the use of diagnostic testing over trusting one’s self.  To make matters worse, diagnostic tests are financially rewarded, while thinking about the right test to order to make the diagnosis is not.  If the art of diagnosis were more handsomely rewarded, more hospitals would actually have a “Department of Diagnostic Medicine” led by their own version of Dr. House (who is based on Holmes incidentally …and Chasing Zebras was considered as a title of the show).  As stated by Rapezzi and colleagues…

Current trend towards mass use of sophisticated diagnostic tools in routine practice—accompanied by a blind faith in technology and predefined diagnostic algorithms—is threatening to kill off the science and art of clinical reasoning. Besides burning a lot of public and private money to make diagnostic work rather superficial, doctors also risk losing the intellectual pleasure that comes from careful diagnostic reasoning.

So, in considering how to revive case reports and the art of diagnosis, its worth revisiting lessons dating back to the old adages that been used to teach generations of doctors before the proliferation of imaging.  While each of these rules has its faults, they represent a return to thinking about the diagnosis.   If only it was only as simple as, “It’s elementary, my dear Watson”…   

Occam’s Razor – “entities must not be multiplied beyond necessity” refers to the thought there is usually one unifying diagnosis.  The term razor is used to highlight shaving away unnecessary assumptions to get to simplest explanation. 

Hickam’s dictum – “Patients can have as many diseases as they well please” The counterfactual to Occam’s razor is credited to John Hickam, MD who highlights that it is statistically more likely for a patient to have several common diseases explaining a constellation of symptoms rather than a rare zebra.  The best example of this is Saint’s triad which consists of gallstones, hiatal hernia, and diverticulosis which don’t have anything to do with each other other than they are often common in patients.

Pasteur’s dictum  – ‘chance favors only the prepared mind’  This refers to the fact that to make the ‘leap’ of discovery, one must have the knowledge & skills to be able to make the connection.  In other words, you cannot find an interesting case if you are not reading and know what to look for.

Sutton’s law- First, consider the obvious.  In other words, conduct the test which will confirm (or rule out) the most likely diagnosis.  This phrase is named for bank robber Willie Sutton, who when asked why he robbed banks supposedly answered “because that’s where the money is.”








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