Month: June 2010

ACGME 2010: Cracking the Code, Breaking a Promise, & Hope for the Future

The ACGME has just announced it’s new proposals for duty hours and graduate medical education is stopped in its tracks just as we finish new intern orientations.  Residency educators (including me) are now poring over the small print in the New England Journal tables or the sleek new ACGME website to understand how to create a schedule that complies with the new rules.   

In addition to schedule making, residency educators are all staring at the new program requirements are all trying to “crack the code” in the new requirements, much like Keanu Reeves in the Matrix.  Specifically, program directors want to know what will count as “qualified supervisor”, “fitness to duty”, “strategic napping”, or a “fatigue management strategy” so that programs don’t get the red flag the next time the ACGME site visitor comes knocking.  So far, it sounds like residents can still supervise interns so attendings aren’t being asked to sleepover in their offices…just yet.   This will likely generate some of the discussion for the 45-day public comment period on the proposed requirements.  

One thing is clearly different – interns (first year residents) will only work 16 hours maximum while residents (after internship) can work longer – up to 28 hours (I should say 24+4).  While it makes sense to protect the interns who are least experienced and most sensitive to fatigue, the current culture characterizes internship through the following promise:  if you can “just get through intern year”, then it gets better.   In fact, I think I stated this to many of our graduating medical students and incoming interns this month!   After internship, residents currently look forward to more time for research and elective rotations, working on applications for future job/fellowship, studying for their boards, catching up on paying bills (or moonlighting to pay bills) and reacquainting with their family and friends.  The promise is also more than just hours of life, its about the scut work associated with intern work improving later in residency.  Residents can now go to their educational conferences or operate in the OR and leave their interns behind to doublecheck and triplecheck that the CT’s are done, labs are drawn, medications are adminstered, and patients actually get discharged.  So what happens if this promise is broken?   The rationale for preserving overnight call for residents is that they will get the clinical experience that they need at a time when they are ready and prepared.  However, the escalation of work during training requires all of us to rephrase how we approach discussing internship and residency.   Most importantly, what will the interns and residents think about breaking the promise?

The new rules also include more on handoffs, one of my favorite topics.  While handoffs will undoubtedly be more frequent for interns working 16 hour shifts, programs are also asked to take steps to “minimize transitions of care”.  They also require all residents to be competent in handoff communication and for programs to monitor handoffs so they are structured, effective and safe.   As we’ve discussed before, it’s currently unclear what type of education works best, or how to monitor handoffs.   Given our work in the area, our latest thought is that programs need a “handoff menu” so that different programs can “order” the types of education or evaluation tools (ranging from 5 minute lecture to simulation-based training) that will work best for their residents. 

Given the need to scale up handoff education to all residents, it’s important to make learning about handoffs fun, interactive, and most of all QUICK.  After all, getting time on the GME orientation calendar is not easy when you’re competing against needlesticks and computer training.  So, with the help of a talented recent medical student graduate, we’ve developed a short video to highlight the pitfalls of handoffs and how not to do them for our new intern oriention that generated lots of positive feedback.  (It’s now publicly posted on here as part of a social media contest this week for educational video of the month so please vote by sharing!).  

And just when I thought we were onto something,  two of our creative undergraduate students decided to go one step further with the following “Oh My God” Handoffs Cartoon based on the video which says it all in one page (read clockwise)!  So, with all the fretting about how we will ensure the clinical education and professional development of the millenial generation with the new duty hour limits, we cannot forget to celebrate their incredible unique talents and nurture it for the betterment of medical education and patient care.   Maybe they will figure out the best call schedule for the new rules too.

–Vineet Arora, MD

please email for any information on our Handoff Menu or other tools

Disclosure: I have received funding from the ACGME to reviewthe literature  to help inform the new standards and have also testified to the committee that created the new standards.


Lessons from Commencement for New Interns & Faculty

I just returned from an Alaskan cruise where I spent the week doing lots of things in leiu of work.  One thing I did do was reflect on our commencement speech for our recent medical school graduates.  In contrast to the famous names of former years such as Atul Gawande, Sanjay Gupta, or even President Obama (before he was President), this year’s commencement speaker was one of our own faculty.  The word on the street was that the class was hoping for US. Surgeon General Dr. Regina Benjamin. However, since it was unclear whether she could commit until short notice, they needed a backup speaker in the event she could not come who would not mind being the understudy.  So the class of 2010 had selected University of Chicago Professor and beloved teacher Dr. Scott Stern for this important role.

 While some medical students or parents may have thought they got stiffed on ‘star power’, I can truly say this speech was no runner up — it was a bona fide winner.  Dr. Stern spoke eloquently about the trials and tribulations of medical school, the journey and then his own journey as a teacher.  Unlike the famous name speakers he was following in the footsteps of, Dr. Stern was able to connect with the audience since he knew them and of their journey.  Interestingly, his number one lesson was to maintain balance and try to do those things that make you human so that you can be a better doctor.  I certainly clung to those words as I departed the next day for Alaska.   For it wasn’t just the students he was speaking to, as I looked around, the faculty were all attentively listening and nodding their heads at his every word too.   

So, I return from my short vacation, rested and ready for the daily grind.  This week is a special one too since our new interns start.  As we greet them nationwide during orientations that go over what to do when they get a needlestick injury, forget their computer password, or need new scrubs, we need to remember they will devote their lives to this job and we need to show them they can balance it too.  This is easier said than done, since residents are often at the mercy of their call schedule, can’t easily maneuver to get time off, and are often working late and are sleep deprived.  So, how can we do this?   Well, like teaching all the other fuzzy stuff including the ‘p word’ we explored last time, its about role modeling and personal interaction.  So, here are some tips for any attendings out there who are shepherding the new interns into the hospital this July.

  1. Ask your interns what they do on their day off – make sure they are socializing and have a good support system. 
  2. Ask your interns what they like to do – they are moving to a new location and may not be plugged in to the latest goings on with respect to their interests.  
  3. Share a bit about how you unwind and take the pressure off with your interns.  It will show them that you are a human and more than just the ‘attending’.  On this cruise, I realized that I have a major passion for ping pong to the point where I am looking forward to getting a ping pong table.
  4. Encourage them to take care of themselves.  Going one step further, do they know a dentist in the area?  Do they have a doctor? Have they joined a gym?    
  5. Make sure you take care of yourself too.   This means knowing when to say when and practicing saying no from time to time so you don’t take on too much.  I’m currently practicing this one so I’ll let you know how it goes.

So most of us in residency education wait with baited breath for the annoucement of shorter work hours and the fury that follows regarding residency education and patient care, we need to make sure that it’s not a bad thing to get some rest.

–Vineet Arora, MD

Read more about Dr. Stern and his address here

Professionalism is a dirty word… and why are medicine docs called fleas?

At the recent AAMC meeting on how to integrate quality into teaching hospitals, the question that kept popping up from speaker after speaker was how to address the fact that doctors in teaching hospitals don’t get along.  Unfortunately, all the specialty bashing that takes place prevents the adoption of a team based culture necessary to advance quality and safety.  As one speaker highlighted, how can we really start to address this topic when specialty services are busy blocking the consult or disparaging the internal medicine doctor by calling them a ‘flea.’  I hadn’t heard the term ‘flea’ in a while but many onlookers were nodding in agreement, possibly thinking about the last time they heard someone disparaging the ER for an incomplete workup or a specialist blocking the consult as ‘inappropriate.’  The discussion about quality and safety morphed into every medical educator’s favorite topic, ‘professionalism.’ 

Ironically, while medical educators love discussing professionalism, this word has become despised by medical students.  It has been the subject of the last 2 years of senior class shows at Pritzker.  Why?  Because in response to numerous calls by the AAMC and other groups including the public, Pritzker, like many other schools, have launched a professionalism initiative designed to promote professionalism.  As you can guess, any efforts to ‘teach professionalism’ to students seem preachy and insincere.  So, what’s a medical educator to do?  After years of contemplating this problem with colleagues and experts, we concluded that we first need to identify and reward faculty role models and ensure that our faculty and residents emulate the behaviors that we wish to see in our students.  Apparently, we aren’t alone.  The American Board of Internal Medicine Foundation has awarded 6 grants to variety of organizations to promote professionalism among physicians in practice.  We are fortunate to have received funding through this mechanism to actually address the topic at hand – specialty bashing in teaching hospitals– particularly between hospitalists, primary care physicians, and emergency medicine doctors.  Interestingly, this problem is more prevalent in teaching hospitals.  When our residents rotate at a nearby community hospital, they often comment on how nice the doctors are to each other, even thanking them for consultations!  Of course, unlike the attendings in teaching hospitals on fixed salary, physicians in the community hospital actually make more money for each consultation.  So, aligning financial incentives can actually promote professionalism.

I was at this meeting with one of our 2nd year medical students Marcus Dahlstrom who earned rave reviews for his presentation on student efforts in teaching quality and safety at Pritzker (while I may be biased, you can see his presentation for yourself.)  On the way home, we noted that although professionalism is a dirty word among our students, but that medical educators continue to perseverate on it even at a meeting about quality and safety.  We need a better word and a better way to address these issues.  Because most students are professional, it’s the actions of a few that are remembered by faculty and attributed to all students and their generation. 

On a side note, Marcus also asked me why medicine doctors are called ‘fleas’ since he had not heard that term…yet.   I did not know the answer but here are some potential origins I found – the most useful of sources being

  • Internists can be spotted with a stethoscope around their neck, or a “flea” collar
  • Internists, like fleas, are the last things to leave a dying body
  • They travel in packs on rounds
  • Doctors were very devoted to their plague patients, similar to fleas that were responsible for spreading the deadly disease. 

While I don’t know the exact reason, its interesting that while 3 of the reasons are clearly derogatory, one explanation of ‘fleas’ actually highlights ‘professionalism.’ Ironically, maybe all we have to do to get doctors to stop using this term is to say that it’s part of that dirty p word ‘professionalism.’

–Vineet Arora, MD

Teaching Futuredocs About Death and A Confession

I have a confession to make.  I had never seen someone die until I was an intern.  As the daughter of first generation immigrants, I had little contact with my grandparents who lived in India when their time came.  During medical school, I had a lot of patients but never had a patient die while I was taking care of them.  I was reminded of this last week during three unrelated presentations that all converged around how to ensure that people’s wishes regarding how they want to die are honored.   That is when I had a flashback to my internship – to the first person that I had to pronounce dead.

It was July on a busy inpatient oncology service and month #1 of my intern year.  It was daytime and I got a call from a nurse about a hospice patient who had end stage multiple myeloma who had presumably died, but they needed me to go pronounce the patient dead.  So, I went to the bedside and the husband of the patient was sitting quietly at the bedside.  I introduced myself and thought – okay I’ve never done this before but I’m going to do a physical exam and note the absence of a heart beat, pulse, respirations, and neurologic function and then I would be done.  I started by listening for breath sounds – none and no air movement in the chest.  Then I put my stethoscope on the chest and heard nothing.  That was erie…it dawned upon me that I was in the room with a dead person.  I started to feel hot.  I raised the patient’s eyelids and shone a light into the eyes and again nothing.  At this point, I definitely did not feel like myself and my mind started to race as I was thinking how could I have gotten here without ever being in the room with a dead person?  Fortunately, sensing something was wrong, my attending and co-intern came to my rescue (our resident was off).  My attending escorted me out of the room with her arm around me and said you’re going to be okay and my co-intern brought me an orange juice so I could recover.  I felt so embarrassed. 

How did I get through without medical school without knowing how to pronounce a patient dead or have a family meeting?   Does this happen to medical students today?   Well, the three unrelated presentations I heard last week about how to improve how we train doctors about death and dying convinced me that at least change is on the way. 

  • Training first year medical students to follow a dying patient  First, today’s medical students have a lot more substantive experiences with death and dying then I did.  At a recent morning breakfast meeting of the Academy of Distingished Medical Educators at Pritzker, Dr. Stacie Levine, our fellowship director for geriatrics and our new palliative care program, describe a new longitudinal curriculum for palliative and end of life care for medical students.  In addition, she launched a very new and innovative program for our first year medical students to be trained as hospice volunteers.  Students who chose this option are making home visits and even receiving pages to participate in a “death watch” when the patient they are following dies.  They also reflect on the experience through journaling and discussion.
  •  Improving resident discussion of advance directives with clinic patients  While hospice can be one path to a ‘good’ death, any resident knows that a major barrier to hospice care is that families are not often prepared to make such decisions when their loved one is in duress.  In fact, most residents encounter death through family meetings for patients who were hospitalized with terminal illness or when continued care, usually in the ICU, appeared futile.  These were difficult discussions since often times the patient was unable to participate due to their grave illness and had may or may not have discussed their wishes with their immediate family or next of kin.  This was one reason that the residents, as part of their required ambulatory quality improvement curriculum, chose to improve the documentation of advance directives and identification of a surrogate decision makers for clinic patients that were above 65 years old.  Through earlier identification of surrogates and documentation of advance directive discussion, it is the hope of our residents that these things will be easier when patients are near death.  They have good reason to believe this.  A recent article in the New England Journal of Medicine demonstrated that patients who had prepared advanced directives received care that was strongly associated with their preferences.
  • A new way to discuss end of life preferences with families Lastly, I attended our Department of Medicine Grand Rounds last week which was given by Dr. Dan Sulmasy who happens to be a Medical Ethicist, an Internist, and a Franciscan Friar!  He eloquently described the problems that surrogates face when forced to make decisions for others.  Instead of the familiar concept of ‘substituted judgment’, where the surrogate has to make a decision on behalf of the patient, he argued for a new model which relied on ‘substituted values’ and ‘best judgment.’  Basically, he presented convincing data that shows that surrogates don’t always make the best decisions for patients but they may be able to tell you what the patient valued.  It’s also easier to ask a distraught family member to ‘tell me about your loved one and what they believed in.’  In other words, you will hear the patient story. Once you have a good understanding of the values, then you as the physician can offer the clinical information about the patient including the prognosis and then work with the family member to arrive at the ‘best judgment’ for the patient.  This method still had not been tested but has been highlighted as an alternative to the traditional model. It could also serve as a new way of teaching doctors how to conduct family meetings.  In fact, our fourth year medical students have been learning how to do family meetings through a team simulation through a new Transitions to Internship Course. 

With all of this activity around death and dying in one week culminating in Memorial Day, it was only natural to reflect on my first experience with patient death and how unprepared I felt.  With the focus on death and dying in medical education today, I hope that future doctors will be more prepared for these experiences than I was.

–Vineet Arora, MD