#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





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!





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








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