#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





Eating Chocolate and other lessons from the ABIM Forum

19 08 2013

Every year, the ABIM Foundation convenes a set of thought leaders on American health care to answer the tough questions.   At first glance, this year’s meeting  had the same standard agenda –  talks and discussions followed by networking and informal activities. However, for some reason, this Forum was more exhausting. Perhaps trying to solve the nation’s vexing problems facing health care is fatiguing! So, what were some of the themes that we came away with?

  • Intrinsic motivation is powerful, so can we create it? We heard about the potential dangers of extrinsic motivation through financial reward. Pay-for-performance, after all, is a tool that is only as good as the system is designed, and many designs have not been very effective. I was reminded of an unusual medical education experiment when they started paying residents in pediatrics on a fee-for-service model (yes, residents). The residents saw more patients, and their outcomes even improved with fewer ER visits! But, closer inspection yielded that these residents stacked their clinics with well child visits, who were healthier and did not need to visit the ER. So fee-for-service residency was abandoned. While everyone agreed it was time to move away from fee-for-service medicine, do we really think a change in the payment system creates intrinsic motivation? One health system offered their solution: recruit those that are intrinsically motivated. But, that still leaves us with how does one become intrinsically motivated? The answer likely lies in the last session of the meeting –find and cultivate joy in work. After all, if the work of transformation is enjoyable, people will do it for free.  And for physicians, joy does not come from lowering the GDP, but from treating the patient in front of you.
  • A series of small innovations add up to a larger one.  There were a series of innovators highlighted at the meeting who shared their innovation. While many were sharing large-scale innovations and initiatives like ACGME’s CLER Program, I shared a much smaller scale innovation, a redesigned resident clinic handoff using ideas generated from talking with over 100 patients about their experience. I certainly recognized the scale I was operating on was much smaller than some of the other folks in the room who lead large health plans or organizations. Then, one of the speakers who transformed their culture highlighted that it was a series of small innovations adding up to the larger one that made it doable. Featuring innovations at this meeting is not new, but the discussion of scalability was important. As each innovation was discussed, the question became how was this scalable and could be spread to others. This discussion was particularly salient to our Teaching Value Project team as we hosted a breakfast to not only introduce the project, but also discuss the future and how to spread this innovation…so stay tuned.
  • Organizational culture and leadership matters… a lot. While on the subject of necessary ingredients for innovation, the terms organization and leadership would probably be the biggest if we did a word cloud of what people said at this meeting. It can feel trite, but it’s true…leadership and culture are key. The type of leadership that was highlighted focused on nurturing innovators and supporting people in the work that they do. While they are not afraid to take risks, they are also understand their frontline clinicians and patients. Too bad they also sounded like an endangered species. Not surprisingly, many groups had the same action item – train visionary leaders to lead these healthcare systems of the future.  While we can wait for the new visionary leader to be manufactured, culture always halts people in their tracks. How do you create the culture you want? The recurring theme here was to make sure you had good people. In other words, recruit people for the culture you want, not the on you have. And for a real change, a more radical business approach would be to let go of the “protectionist mentality” where everyone is going to keep their job. Moving to a results-oriented work environment would mean not only recruiting the right people but getting rid of the wrong people. I’m not so sure our academic health systems are ready to do this, but it was refreshing to hear from a business leader that term limits and succession planning were the norm. In this way, organizations are automatically refreshed with new ideas from leaders who were prepared to lead.
  • Eating radishes when you want to eat chocolate is work. To summarize, forcing people to exert willpower to resist what they want to do (eat chocolate) by doing something else (eating radishes) translates into hard work to resist, and less patience for something else. A more complete explanation of this study is here. Sure, this sounds simple, but we do keep piling quality measures and requirements on every physician in the context of a 15 minute office visit. Unfortunately, electronic health records are forcing us to eat more radishes, and this comes at the expense of talking to patients. At least two innovators solved this problem by having someone else eat the radishes, such as a scribe in primary care so that physicians could focus on the joy, spending more time with patients.
  • Ask patients to help design the solution.  While this may sound like a no brainer, its not as easy as it sounds!  This is an unusually high level of patient engagement that most of our organizations are not used to. In one stunning example, a hospital in Sweden redesigned its dialysis center so patients can swipe in whenever they want and self-administer their dialysis. In the innovation I presented, we asked 100 patients in our resident clinic what would make their clinic handoff go smoother when they transitioned PCP’s when their residents graduated.  The answers led us to interventions that we never would have thought of, like honoring the patients with a certificate to recognize their teaching efforts of our residents and a cartoon to facilitate patients learning how the process of the handover occurs and what they should do.

So, what does this mean for future doctors? Well, it starts with recruiting intrinsically motivated individuals and training them to be healthcare leaders who can learn to work alongside patients to generate small innovations that can add up to larger organizational transformation.  And let them eat chocolate … so they too can find the joy in their work.

–Vineet Arora MD





From Astronauts to Attendings: Workload, Duty Hours and July, Oh My!

31 07 2013

reposted from Academic Medicine’s blog

Every July, as academic hospitals welcome new interns, a flurry of activity ensues. While learning to care for patients and navigating the complex social territories of their new hospitals, interns also are worrying about “getting out on time” and making sure not to “dump” on their colleagues. This work compression, particularly among interns who are not familiar with the day-to-day operations of wards, can strain the learning environment. With the implementation of resident duty hours regulations, attending physicians are subsequently called to provide more direct patient care. Yet residency is a time for learning on the job, and part of that learning comes from the teaching attendings provide. In our recent study in Academic Medicine, we asked: “So what has happened to time for teaching?”

Given the recent changes in academic medicine, attendings’ workload needs to be examined, especially regarding their role as teachers. Previously, most studies of workload and work compression focused on residents. Moreover, these studies commonly focused on workload as it related to patient census. While patient census is one measure of workload, we all have had the experience of how one very complicated patient can add up to more work than 10 relatively straightforward patients. So, should we instead consider perception of workload rather than actual workload measured by volume?

Borrowing from methods developed at NASA to examine astronauts’ workload, we examined attendings’ perceptions of workload and the relationship of those perceptions to reporting enough time for teaching. In doing so, we found a steep relationship between attendings’ greater perceived workload and time for teaching. Additionally, we analyzed our results with respect to the time of year and to the implementation of duty hours regulations. Implementing duty hours regulations, not unexpectedly, reduced attendings’ time for teaching, but the magnitude of this reduction was humbling.  What was most surprising, however, relates to the time of year, specifically summer, which everyone fears because of the “July effect”.  Interestingly, more teaching occurs during summer than during winter and spring. We also found that attendings’ greater workload during winter and spring was more detrimental to their time for teaching than their workload during summer.

Certainly, having attendings provide more direct care when residents have heavy workloads improves patient safety. However, the cost to residents’ education and subsequent learning and growth is not trivial. Ensuring that teaching on the wards is restored should be a central focus of graduate medical education reform.  Moreover, while winter and spring should be times for continued teaching on advanced topics to ensure professional growth towards achieving competence, for some reason, we fall short. Meanwhile, during summer, attendings may cut back on their own busy clinical practice and/or administrative duties in anticipation of their role as teachers and supervisors. Regardless of the reason, to prepare for future changes to the accreditation system and attendings’ role in documenting progression through milestones, testing and implementing innovative ways of re-balancing workload to restore teaching and learning on the wards is imperative.

–Lisa Roshetsky MD MS and Vineet Arora MD MAPP 





Not Getting Sick in July

1 07 2013

Today is July 1st.  While everyone has heard the old adage about not getting sick in July because of new interns, the truth is that new interns nationwide have started already. Yet, you don’t hear much about the “late June effect?”  So is the July effect overblown or true?  Well, there have been many studies – so many so there was a recent systematic review co-authored by one of my own co-interns a long time ago.    While I am sure it was hard to synthesize the studies of often sub-par quality, the review does state “studies with higher-quality designs and larger sample sizes more often showed increased mortality and decreased efficiency at time of changeover.”  The study I recall best examined over 25 years worth of death records and found a pattern.  In the 240,000 deaths due to medication errors, mortality rates did increase in July, especially in counties with teaching hospitals.  I’m not sure death certificates are accurate as a way of diagnosing cause of death but that’s another story.

While it’s not possible for patients to time their illness, the question becomes what can be done to ensure July is as safe as possible? While there is scant literature on this topic, over the last several years, I have had the privilege of attending in July.  While I ended up attending in June this year before the interns switched, I was reminded of several ways in which July is different and can be made safer.

  • July requires more intense supervision.  Residency is a time of graduated supervision.  In June, a few weeks before third year residents graduate, it would be tragic or perhaps a sign of a problem if an attending had to oversee every little decision in the moment.  It would also annoy the senior residents to no end.  The senior residents have matured to the point that they are the team leaders and you are often the advisor and hearing about their decision-making and rationale and providing advice and guidance where needed.  That is certainly not the case in July.  In July, attendings often are hovering (even if they don’t admit it) or “epic-stalking” checking on every lab and medication.  Moreover, greater attending supervision is more commonplace since 2011 due to a huge push by accreditation agencies and in part due to shorter resident duty hours.   The truth is that interns are rarely acting alone and are often working in tandem with a more advanced resident and attending.  While a recent ICU study questions the utility of overnight attending supervision, a systematic review from our group found that enhancing supervision was associated with improved patient outcomes and resident education in a variety of settings.  Faculty can be more formally prepared for their bigger responsibility in July as it will not only require more time, but also more intensity of supervision. While this would include traditional in-person supervision, attendings can be taught to provide formal oversight of care through technology tools, such as the EHR, mobile computing, and yes, even Google Glass.
  • The residents are more eager to learn in July.  July is a time when interns and residents want to learn.  They are eager for feedback.  It is much harder to teach interns and residents in June since they have gotten good at their role…and picked up a lot of medical knowledge on the way.  Because of their umpteenth case of a certain disease, they may not find any additional learning in the case.  Of course, there are always more things to teach, but it is just a little harder than in July when your new interns are ready to soak up knowledge like a sponge.  You can also have a big impact on practice patterns before they form and cement best practices.  While some faculty shy away from signing up for July, many I know prefer to do July because of this reason!
  • Everyone is new in their role in July. July is a time of transition for all residents, such as senior residents, chief residents, not to mention new attendings.  Moreover, other health professional training programs are turning over too such as pharmacy residents.  One potential solution that has been mentioned is to stagger the start date of various specialties/professions so that not everyone is new in July.  While this is probably not as feasible as it sounds (and it doesn’t sound feasible), it is an interesting idea worth entertaining.
  • Anticipate the inefficiency. Because of the turnover in all staff, everything is a little less efficient.  While a little less efficiency may not seem like much, for a resident team, less efficient means likely higher census because of delayed discharges.  These higher patient workloads make caring for existing patients hard, and admitting new patients even harder, and of course all of this is under the pressure of the time clock.  Although not commonplace, I have heard of some programs lower workloads early in the year, anticipating this inefficiency.  Another way is to restructure teams so that there is more ‘redundancy’ on the team to help care for the patients.  Either mechanism seems like something to consider especially for teams that are struggling to get all the work done in time.
  • The patients seem to get sickest when the senior resident is off.  In the back of my head, I know this is probably some type of heuristic in which I am overweighting what the days are like when my senior resident is off….  Regardless, for some reason, it does seem like a good practice to anticipate patient illness on those days. And of course, extra supervision and assistance to the intern when the senior resident is a terrific idea.

While these observations may refer to July, just when the residents get accustomed to their role and rotation, its time to switch.  For this reason, it could be that August (and even September) is not that different from July…so while we focus a lot on July, it may be better to prepare for the Summer of Supervision.

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 : )





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





Electronic Health Records, Quality & Safety: Pritzker IHI Open School Recap

13 11 2011

computer hardware,doctors,healthcare,males,medicine,men,PCS,people,people at work,persons,physicians,science,stethoscopes,technology,x-raysA classroom at the University of Chicago’s Pritzker School of Medicine was packed earlier this month with both medical students and students in the Graduate Program in Health Administration and Policy (GPHAP) interested in learning more about the IHI and quality improvement.   Dr. Chad Whelan, a hospitalist and institutional leader on quality improvement, facilitated an open discussion about some of the challenges in using electronic health records to improve quality of care and encourage physicians to practice more evidence based medicine.  Some of the topics covered included the unintended consequences of using electronic records, the benefits of an electronic record from an administrative standpoint, and issues surrounding the quality of documentation.  The meeting was organized by students in Pritzker’s Quality and Safety Track with guidance from Laura Botwinick, Director of GPHAP.   During a lively and interactive question and answer session, here are just a few of the questions that were raised by students and the discussion that ensued.

How interoperable are the record systems?  Why aren’t we using one single interoperable system?  While interoperability is a focus of “meaningful use” that is part of American Recovery and Reinvestment Act of 2009, electronic health records industry is also a marketplace with vendors competing for market share.  Because of that, interoperability may not have been achieved earlier. For larger healthcare systems such as the VA, the implementation of CPRS represents an example of an interoperable system across many hospitals nationwide.   Since academic medical centers often have several teaching hospital affiliates, physicians and trainees have to learn to work in several different systems, some of which may not even talk to each other.  While many urban medical centers have adopted electronic health records, a recent study demonstrated only 17% of hospitals capital investments.

What are the reasons behind the findings in the literature that mortality and errors sometimes increase when an EHR is installed?  Medicine is a complex system and sometimes changing one thing without changing another will yield unexpected outcomes.  Furthermore, if bad processes are automated, errors can happen much more quickly and systematically if they were being made in the first place.  That is why it is important to use QI tools to improve systems before an EHR is laid over them.  For example, during a QI intervention for pressure ulcers, the implementation of EHR for nursing documentation actually led to a decrease in the physician recording of pressure ulcers since they did not know where to access nursing notes.

How much training do practicing physicians get when an EHR is deployed?  Training is definitely part of the EHR implementation strategy.  One commonly used approach is to actively train early adopters who can champion it for the late adapters and laggards. At our hospital, that training included several hours of classroom time PLUS watching online video trainings at home with practice tutorials.  However, as the faculty and others present agreed, the learning curve is steep and learning is an ongoing process.  Anecdotally, there is often “reverse mentoring” with many of the residents who learn on the job are able to teach the attendings tricks of the trade.

What can be done to avoid the cut and paste problems that have emerged?  Interestingly, hospitals often have the choice whether to disable cut and paste or keep it active.  By disabling it however, the ability of EHRs to make doctors more efficient is sacrificed.  However, enabling cut and paste creates the risk that the information is out of date or inaccurate.   While many egregious examples have been described in the literature, there are some novel experiments being tried around the country include trying to use different colors for pasted information or creating patient records like wikis so multiple people are updating.   In a handoff curriculum for residents, we do highlight avoiding CoPaGA syndrome (Copy and Paste Gone Amok) by highlighting that it is allowed to cut and paste but their responsibility is to cut, paste, and update.

Are medical students getting trained on electronic health records?  Most learning at present is orientation to a specific system and on-the-job training.  Principles of effective practice with EHR need to be translated into medical education as it is an important core skill that all medical graduates will need.  While medical informatics is covered by in some form in many medical schools, recent debates highlight that more robust teaching on electronic health records needs to evolve and expand.   Moreover, the EHR can be used to actually advance medical education by providing a record of what types of patients a resident sees and assist in performance evaluation of patient care.

–Anthony Aspesi MS2 (with Laura Botwinick and Vineet Arora)








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