#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





Cleaning the Graffiti in Healthcare

24 07 2013

 I just left the most unusual conference I have ever attended.  First, it was small – 25 people.  Second, it was all women.  Third, it was all senior healthcare leaders who have done amazing things…make that trail-blazing things.  Moreover, I found myself surrounded by women who were journalists at major news outlets, retired military officers from the highest ranks, senior leaders (in some cases the senior most leader!) at major federal and state healthcare agencies, Fortune 500 companies, large health systems, healthcare foundations, national advocacy organizations.   It’s no surprise the name “Amazon warrior” resonated with this group!  Finally, the conference was all about identifying our “living legacy”.   Legacy seems like a strange word when you are living…it’s even stranger when you feel like you haven’t don’t anything yet!  So, how did I get invited you (and I) are wondering?  After all, I was the youngest person in the room, which as an aside, is a very unusual context when you work with students and residents for big chunks of the day.  So, believe it or not, I was invited by in large part due to my… social media presence!  After reviewing the list of participants, the organizers realized something was missing, and that something was someone younger who also had a social media presence.  And whoever said tweeting is a waste of time?

While there is much I could say, one of the group exercises on the last day of the conference is worth sharing and involving others in.  We were asked to examine “broken windows” in healthcare.  A broken window is a symbol of something smaller that is part of the context to a larger problem.  As Malcolm Gladwell popularized in his book, the Tipping Point, New York made a dent in the big problem of crime by tackling smaller problems, such as cleaning off the graffiti from the train every night.  By changing the context, people started to “own” the subway and report crime instead of expect it.  An excellent video summary is here.

So, how does this apply to healthcare?  While there are criticisms of the broken window theory, what a boon it would it be if we could locate something small in healthcare to fix the very large complex problems facing healthcare.   So, our group only had a short amount of time to pursue identifying broken window in healthcare.   While it sounds easy to come up with broken windows, it is much harder than it looks.   Interestingly, the healthcare problems here are so large, that the broken window may not be as simple and elegant as the graffiti example, but represent an easier place to start.  Here are three examples broken windows that we came up with.

  • Media portrayal of healthcare, especially related to resuscitation – By correcting the media portrayal of resuscitation, the public might have fewer unrealistic expectations of life sustaining therapies at the end-of-life, which could result in fewer people opting for futile measures.   By the way, researchers have even studies this (watching episodes of ER for research!) and have demonstrated the problem in a New England Journal article.   Imagine tackling this problem with media tools to demonstrate to people what a “good death” is.
  • Patient gown – While patient-centeredness is the new buzzword in our world, can we really say the system is patient centered?   Take the simple example of the patient gown which represents a loss of control and source of embarrassment to patients.  Could it be that when patients are in the gown, they feel to disempowered to engage in their own healthcare?  Could changing the gown empower patients to take a larger role in their healthcare?   In case you are wondering, there are many stories and efforts that have been undertaken to redesign the hospital gown – my favorite is the collaboration by Bridget Duffy, former Chief Patient Experience Officer at Cleveland Clinic, with fashion designer Donna Karan.
  • The Word Healthcare – It is well accepted that our healthcare system focuses on “healthcare” and not “health”.  Prevention and health promotion takes a back seat to intensive healthcare interventions.  It’s easy to resign that this will never change due to the payment system, or that return on investments in prevention are only realized in the long-term.  But, what if we could change the dialogue by using the word “health” instead of healthcare at every opportunity and juncture.  By changing the dialogue, can we change the context enough to create a change in the system?  I’m not sure, but at this point, I will say it is certainly worth a try.

There could be other examples of graffiti in healthcare.  By continuing the dialogue, hopefully we can locate the most promising levers for change.

–Vineet Arora MD

Special thanks to Dr. Joanne Conroy from the Association of American Medical Colleges for organizing the conference, our facilitators from the leadership consulting group Sunergos, and support from the Robert Wood Johnson Foundation to make it happen.





Making the Most of the iPad Mini on Medicine Rounds

20 12 2012

On my birthday several weeks ago, I was lucky to get an iPad Mini from my husband. I already have an iPad and have shared my experience. In fact, we gave all of our residents iPads (one of them contacted Steve Jobs and got a response), and documented an improvement in efficiency on the wards. So why the Mini? What is all the fuss? Well, after finishing 2 weeks on service, I can finally tell you why the Mini is the new must-have for doctors and future doctors.

  1. It fits in your white coat! Yes, while there were entrepeneurs who started creating the iCoat, the truth is who wants to wear a coat with a huge pocket on the side? This means that you also don’t need to wear the “strap’ that we require our residents to wear for the iPad since we did not yet invest in the iCoat.
  2. You can hold it in one hand! This for me is the best part and very underappreciated point in the blogs and reviews I have read. This means you can tough the screen with one hand while you are palming it with the other. I don’t even have the largest hands so I would say it definitely was just at the reach of my palm grasp but I can imagine it would be perfect for my male colleagues.
  3. It fits in your purse! While the female docs may find palming the iPad mini not as easy as the men, never fear…since this one is for the ladies. Many female doctors are always on a quest to find the right handbag/workbag combination. Owning an iPad always meant buying boxy “folio” type purses or shoving it to barely fit in a handbag. The mini is the PERFECT size for a medium size handbag – hobo or satchel. This means that you can go from day to night without carrying your “work bag” to the restaurant. And for the men out there, you can always get a “murse” this holiday season. I hear that they are making a big splash.
  4. You’ll carry it more. Number 1 through 3 really boil down to the fact that it is hard to carry the iPad. Because it is so easy to carry, you won’t find yourself without access to the electronic health record or paging directory. You may be more apt to show patients their images or X-rays or look something up because it is not as hard to use.
  5. You’ll make friends. Basically the minute I brought out the Mini, everyone…nurses, social workers, residents, students, and yes patients were interested in seeing it – “Mini envy” as my students called it. It’s a conversation starter that can improve collegiality and teamwork. When I visited floors that I did not usually work on (overflow patients), I met a nurse who asked me about the Mini – and the next day, she came to our rescue when we were trying to decipher the timing of a patient’s medication and a potential new allergy.
  6. It is more discrete to use at a conference (once everyone stops staring). The Mini is smaller so a bit more stealth in terms of answering a text page or checking a lab while you are sitting in case conference, and you can easily stash it back in your purse as noted above.

Some things to think about. The Mini is not without its pitfalls – many of which are predictable due to its size and interface.

  1. For the visually challenged, it can be hard to see. Sure… you can always “magnify” things with the correct gestures. But, if you are in your Citrix Client looking at your electronic health record, it may not be so easy to magnify and you may have to hold it up closer to your face which can be awkward. Maybe I just need to get my vision tested? Either way, something to be aware of.
  2. Easy to lose. As part of the residency program project, the nice thing about the iPad with strap is you an see it on the resident and its harder to walk off with. The Mini could disappear in a snap. Could someone even “pick-pocket” a doctor coat? Very possible.
  3. It is not a complete substitute for a workstation or pen and paper. This is not unique to the Mini. There is a reason that mobile tablet computing is not a complete substitute for a workstation – the lack of a keyboard. As a result, some our residents carry “paper notes” with their iPad – the paper notes are to take notes of the to-do list that is created on rounds -nothing like checking all those boxes off as an intern. The iPad does not replace that so readily – and while there others thinking about this space, its worth noting that the preference for pen and paper to organize one’s thoughts is very strong. I have to admit, watching the catchy commercial for the Windows Surface, there is still something so appealing about an external keyboard.

So what is the verdict for the Mini? Well, as we say in medicine, the risks of the Mini are outweighed by its benefits making it the perfect prescription for all the physicians or physicians to be in your life. And there’s still a few shopping days left before Christmas…

Happy Holidays!

Vineet Arora MD





Time to Fight Horrors of Healthcare Costs by Taking Charge of Teaching Value

31 10 2012

This Halloween, several creative costumes have emerged from the zingers of the Presidential debates – Big Bird costumes are selling out like hotcakes. For a more do it yourself look, here’s a recipe for Binders full of women.  The debate over the best way to contain healthcare costs have also been a central part of the debates, and yet medical bills do not seem to make popular costumes. Maybe that is because that unaffordability of healthcare is too horrifying for ironic humor – even on Halloween.

As we head into the election, patients are increasingly being terrorized by runaway healthcare costs.  Americans outspend our peers two to one and still seem to be worse off. We overtest and overtreat to the point of absurdity.   According to a recent report, “The U.S. did 100 MRI tests and 265 CT tests for every 1000 people in 2010 — more than twice the average in other OECD countries.”  The causes are multifactorial but the solutions can’t be left to presidents and policymakers alone. An important part of the responsibility rests with healthcare professionals and the educators who train them.

Experts in health professions education and economics have lamented the poor state of education on healthcare costs.  Over 60% of U.S. medical graduates describe their medical economics training as “inadequate.”  Not only are medical trainees unaware of the costs of the tests that they order, they are rarely positioned to understand the downstream financial harms medical bills can have on patients.  More recently, Medicare, the largest funder of residency training in the United States, is concerned that we are not producing the physicians to practice cost-conscious medicine in an era of diminished resources.

We have been scared in the dark too long and this Halloween the time has come to Take Charge.

Join us now at http://teachingvalue.org/takecharge

About Teaching Value: the Costs of Care Teaching Value Project is an initiative of Costs of Care that is funded by the ABIM Foundation.  Our team is comprised of medical educators and trainees who believe it is time to transform the American healthcare system by empowering cost-conscious caregivers to deflate medical bills and protect patients’ wallets.  Our web-based video modules are designed to be easy to access for anyone anywhere and provide a starting point for tackling this problem. It’s time to emerge from the darkness and do our part to tame the terror of healthcare costs.





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!





Transforming Medical Education: Trust, Time, Teams & Technology

28 11 2011

This past Thanksgiving, I was able to reflect on the always jam-packed and inspiring Association of American Medical Colleges 2011 Meeting that took place earlier this month in Denver.  The theme of the meeting was transformation.  It was certainly an interesting theme with the undertones of economic recession and the GME funding crisis- and that was before the failure of the Supercommittee to reach a resolution.  So, how does medical education need to transform?  In more ways than one, it turns out.  So here are just 4 that were the recurring themes of the meeting and being a fan of alliteration, they all begin with “T”.

  • Trust – it was clear that we need to restore the Americans people trust in physicians and in the medical education process.  While students enter medicine to make a difference, something that they see in their journey to becoming a physician makes them jaded and they sometimes lose sight of their initial intention. Is it debt, burnout, role models…Or likely some combination of the 3? It does not matter, because we have to restore their faith in teaching– yes teaching.  Teaching is the heart and soul of our medical education and it is sometimes the easiest to lose in an academic health center focused on NIH dollars or US news world report rankings.  In addition to teaching our students, it is time to teach another constituency, our patients and Congress about the critical need for medical education.   And in fact, advocacy is something we need to be teaching our own trainees so they can engage in the dialogue regarding the future of healthcare.
  • Time- perhaps the most radical proposal advanced was by Victor Fuchs who suggested that we radically redesign medical school to have medical students specialize 2 years after medical school and enter specific pathways like they do in many other countries and in other fields.  I’m all for shortening dwell time for our medical trainees, but I am not so sure that young people are ready to make a serious commitment about what they want to do at such an early age.  There has to be a middle ground since at the same time, one of the most well attended sessions was “who cares about the 4th year of medical school?” which included many insightful comments about the need for reflection and consolidation of core skills.  So, clearly not all time is easily tossed to the waste side.
  • Teams- given the projected shortage of over 90,000 physicians by 2020, it is important to reorganize care into teams.  While there is a lot of controversy about what to call nurses who have PhDs, that was not the focus of the meeting. It was about how can you encourage everyone to practice to their highest level of certification.  Team based competences have actually been developed by several groups and have been advanced by many schools with inter professional learning.  One difficulty we face at home is that we don’t have allied health professions, but we are brainstorming how to involve actual nurses and pharmacists in training medical students.
  • Technology -there was a lot of discussion about technology to boost medical education.  There was even a technology in medical education abstract session moderated by @motherinmedicine and including podcasts, iPads, and social media in medicine.  Perhaps the most interesting speaker was Chuck Friedman at the University of Michigan who is the former technology czar of the US and eloquently highlighted the need for moving medical education from wrote memorization to a distributed knowledge where the most important information future physicians will need to know is not what the information is off the top of their head BUT how to access information.  He went so far to say testing would move to “unassisted testing” followed by “cloud-supported testing” which would then merge into a pass or fail based on performance on both.  I know all of us who certified or recertified recently would welcome assistance from the cloud- it is after all the closest approximation to real medicine.  However, my hands down favorite moment of this session was when someone astutely asked what about these physicians when the power goes out or when the computer system fries.  His response was simple and so spot on… “Dont get me started on the state of IT in our teaching hospitals”.
So, while we just celebrated a holiday and accompanying ritual to give thanks, it is now time for medical educators to transcend the traditional status quo and instead test novel techniques to transform medical training — not only to restore public trust but so we can also train the trainees who will treat us in the future.
–Vineet Arora MD




Rising Above the Sea of MacBooks: “Edu-tainment” and Other Tips

12 09 2011

Although Steve Jobs has stepped down as CEO of Apple, his legacy for physicians-in-training is very palpable. Or should that be visual – As I looked into the auditorium of eager and bright incoming medical students this Summer, I saw a bunch of Apple’s staring back at me – sleek, silver and unmistakably MacBooks.  This is the millennial generation so why would I be surprised?  Maybe because it is more ever-present than before this year.  Could it be that the entering class of 2015 had more millenials?  Actually, another hypothesis has also been put forth that is equally if not more plausible…our medical school auditoriums were installed with new desks and chairs.  While these were well received, the desks served as an inviting surface just beckoning for the MacBooks to be placed there.    As a result, you’re never sure if you’re competing with Facebook, the worldwide internet, or even email messages that appear more interesting than your class.   Since lecture capture technology has made it possible for people to view lectures from home, it’s important to make attending lecture in person worthwhile.  Well, here are some tips for medical educators who ‘lecture’ in this new age.

1.  Engage in “edu-tainment” – As Scott Litin at Mayo refers to it, “edu-tainment” is the goal – entertainment via education.  How does one incorporate entertainment into lecture style?  Well, the easiest way is through humor.  This is difficult since not everyone is funny by nature so it may be that you have to inject humor in odd ways.

2. Play games – Games are inherently fun and interactive can stimulate a lot of learning and discussion.  While you may be thinking about computer games, easy games can often stimulate learning.  One of our research ethics faculty played 20 questions with the group of students to teach about landmark research ethics cases.

3. Turn into a talk show – There is nothing more boring than watching the same person for an hour give a talk.  It is much more interesting to watch a panel of people tell a story about themselves – whether it be a patient, another physician, or another student.  I still remember medical school lectures with invited guests that had this talk show appeal due to the lack of power point and focus on the story.  While I’m not suggesting a Jerry Springer approach, who doesn’t love Oprah – at least Chicago has several role models to choose from.

4. Showcase video – Video is one of my favorite teaching tricks.  One well made video can communicate a thousand research articles.  In our week of Scholarship and Discovery, our faculty used videos from Xtranormal (no it was not the famous orthopedics vs anesthesia) but a similar one.  One faculty who could not attend taped a welcome introduction, and another used a clip from “Off the Map” which is now off the air but is still an effective reminder of how NOT to perceive global health.

5. Use audience response – Use of Turning Point clickers can result in instant feedback and engagement with students as they see the results of their poll immediately. It also tells you how many people who up to class!  The only problem is that passing out the clickers and collecting them can be rather time consuming.  So, another possibility is to issue them at the start of class which is done in some colleges and used as a way to count attendance (until a brilliant undergrad brings in a bunch of clickers to class to vote for their lazier friends!).  Here Steve Jobs can help again – Turning Point has audience response systems for iPhones and iPads that can be used and automatically identify people- but it would require that everyone have a smartphone and purchase a license to the software.

6. Refer to the internet– Given that students are on the computer, you can take advantage of it and ask them to visit internet resources in class by showing them urls or web pages that are of use.  Sometimes you may actually refer to your own course website like we do.

7. Provide fancy color handouts – While handouts may sound like they have gone by the waste side, there is nothing like a fancy color brochure or handout to create a “buzz”.  It’s almost like a souvenir of their hard journey to class that day.  If you ever want to provide someone with a ‘leave behind’ that looks important, lamination is key.  A color laminated leave-behind is even better.  Pocket cards are some of my favorites.

Is there any guarantee these tips will work?  Of course not.  But, what’s the harm in trying?  While some professional schools have gone so far as to block wireless in lecture halls, the truth is that current medicine is augmented with the help of computers and online resources- so we should figure out how medical education can be too.

–Vineet Arora, MD








Follow

Get every new post delivered to your Inbox.

Join 16,210 other followers

%d bloggers like this: