Wisdom of the Crowd: Finding the Most Promising Innovations to Teach Value

16 10 2013

Earlier this year, we launched the Teaching Value and Choosing Wisely Competition in conjunction with Costs of Care and the ABIM Foundation.  Why a competition?   Not surprisingly, traditional “literature review” yielded little by way of promising strategies for educators who wished to learn how to teach about value.  However, we had all learned of isolated stories of success, occasionally through attending professional meetings, sometimes via networking with colleagues, or more often through just plain word of mouth.  To help bring these stories of success to the fore, we relied on a crowdsourcing model by launching a competition to engage a larger community of individuals to tell us their story.  Of course, there were moments we wondered if we would get any submissions.  Fortunately, we did not have anything to worry about!  In June, we received 74 submissions, from 14 specialties with innovations and bright ideas that targeted both medical students, residents, faculty and interprofessional learners.

Reviewing each abstract to determine the most promising practices that could be easily scaled up to other institutions was not an easy task.  One interesting struggle was the inherent tradeoff between feasibility and novelty – what was feasible may not have been so novel, while you were left wondering whether the most innovative abstracts would be feasible to implement.  Fortunately, due to the outstanding expert panel of judges, we were able to narrow the field.  While all the submissions were interesting and worthy in their own right, it was clear that there were some that rose to the top.  For example, while every submission included some level of training, the most promising innovations and bright ideas employed methods beyond traditional training- such as a systems fix using electronic health records, a cultural change through valuing restraint, or oversight or feedback mechanisms to ensure trainees get the information they need to assess their practice at the point-of-care.

Perhaps it is not surprising that several of our winners came from innovations or bright ideas developed by trainees or medical students.  After all, the junior learners are on the sharp end of patient care and in the position to see the simplest and most elegant solutions to promote teaching value. Giffin Daughtridge, a  second year medical student at the University of Pennsylvania proposed linking third year medical students to actual patients to not only review their history, but also their actual medical bill.  As emergency medicine residents at NYU, Michelle Lin and Larissa Laskowski were inspired by Hurricane Sandy to develop an easy to use curricular program for her peers.   At Yale, junior faculty Robert Fogerty instigated a friendly competition among medical students, interns, residents and attending physicians to reach the correct diagnosis with the fewest resources possible during morning report style conferences.

The methods employed to achieve success were equally diverse, ranging from repurposing traditional tools to using new methods altogether.  Building on the traditional clinical vignette, Tanner Caverly and Brandon Combs launched the “Do No Harm Project” at the University of Colorado to collect vignettes about value to learn from. This program also informed the launch of “Teachable Moments” section in JAMA Internal Medicine that is now accepting submissions from trainees.  Meanwhile, Amit Pahwa, Lenny Feldman, and Dan Brotman from Johns Hopkins University proposed individualized dashboards that would make lab and imaging use for each trainee available for feedback and benchmarking against their peers.   And Steven Brown and Cheryl O’Malley at Banner Health proposed a local high-value competition that resulted in more than 40 entries from trainees. Drs. Brown and O’Malley plan to implement the most promising ones.

These are just a few of the innovations and bright ideas that were submitted. You can check out the entire list of innovations and bright ideas on the Teaching Value forum.  Our hope is that this is just the start of developing a network of individuals interested in working together to transform medical education by incorporating principles of stewardship.  So, in this case, we recommend that you follow this crowd.

Vineet Arora, MD MAPP  on behalf of the Teaching Value Team members including Chris Moriates, MD, Andy Levy, MD, and Neel Shah MD MPP 

Join us Thursday October 17th at 9pm EST on Twitter for #meded chat where we will discuss the winning innovations and bright ideas!

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 


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