#AAMC13 #BeyondFlexner: Tweeting Back to the Future

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


Twitter to Tenure: 7 ways social media advances my career

As part of our SGIM Social Media Workshop “From Twitter to Tenure” our workshop lineup of ‘twitterati’ will be posting each day this week about how social media affected their career.   So yesterday was @AlexSmithMD on GeriPal.   Here is the schedule for the week:  Monday – me (@FutureDocs) here on FuturedocsTuesday – Bob Centor (@medrants) on DB’s Medical RantsWednesday – Kathy Chretien (@MotherinMed) on Mother’s in MedicineThursday – Eric Widera (@ewidera) on GeriPal (and hope to see you in Phoenix for our workshop!)

For the Twitter to Tenure workshop at this year’s Society of General Internal Medicine Meeting, I was asked to think about how social media enhanced my career.  This may sound ridiculous at first- after all, social media is a big waste of time right? Wrong as some of you have discovered.  Social media has opened doors for me by connecting me to a variety of people I would not have met.  Here is just a brief list of the ways social media has impacted my academic career.

  • Media interviews – I was interviewed by Dr Pauline Chen through the New York Times who located me through – you guessed it Twitter!  She actually approached me for the interview by direct messaging me through Twitter.  She was following me and noticed my interests in handoffs on my Google profile which is linked to my Twitter account.  She was also very encouraging when I started the blog which was exciting!
  • Workshop presentations– I presented a workshop on social media in medical education (#SMIME as we like to call it), at 2 major medical meetings with 3 others (including @MotherInMed who encouraged me to start a blog and also is my copresenter at SGIM).  The idea was borne on Twitter…and the first time I actually met one of the workshop presenters (who I knew on Twitter) was at the workshop.
  • Acquired new skills  – My workshop co-presenter who I only knew through Twitter ended up being Carrie Saarinen, an instructional technologist (a very cool job and every school needs one!).  She is an amazing resource and taught me how to do a wiki.  After my period of ‘lurking’, I started my own ‘course’ wiki  dedicated to helping students do research and scholarly work which we are launching in a week.
  • Lecture invitations – Several of my lecture invitations come through social media.  Most notably, I was invited to speak for an AMSA webinar on handoffs and also speak to the Committee of Interns and Residents on teaching trainees about cost conscious medicine.  Both invitations started with a reference to finding me through Twitter or the blog.
  • Committee invitations – I am now on the SGIM communications task force as a result of my interest in social media.  Our most recent effort was a piece about ‘tweeting the meeting’ with @medrants and an older piece focused on the top Twitter Myths and Tips.
  • Grant opportunities – I recently submitted a grant with an organization that I learned of on Twitter – Initially, I had contacted Neel Shah from Costs of Care asking him if they had a curriculum on healthcare costs.  They did not, but were interested in writing a grant to develop a curriculum so they brought my team on board and we submitted together (fingers crossed).
  • Dissemination – One of the defining features of scholarship (the currency of promotion in academic medical centers) is that it has to be shared.   Well, social media is one of the most powerful ways to share information.   In a recent example, we entered a social media contest media video contest on the media sharing site Slideshare.  Using social media, we were able to obtain the most number of ‘shares’ on Facebook on Twitter which led to the most number of views and ultimately won ‘Best Professional Video.’  To date, this video, has received over 13,000 views, which I was able to highlight as a form of ‘dissemination’ in a recent meeting with our Chairman about medical education scholarship.    While digital scholarship is still under investigation with vocal critics and enthusiastic proponents debating the value of digital scholarship in academia, digital scholarship does appear to have a place for spreading nontraditional media that cannot be shared via peer review.

Part of being a good citizen on social media is giving back.  I try to give back when I can through helping anyone who contacts me for something specific – so I have read personal statements, reviewed websites, and offered input to others who are interested in my perspective on their work.  I can’t always keep up since I have a day job and alas, this is an extracurricular activity.  The good news is a tweet is only 140 characters  – so like the blue bird, I can keep it short but sweet.

–Vineet Arora, MD

Useless Charts & Fresh Eyes in Handoffs

Last month, I was a speaker for AMSA on their patient safety webinar. This was the brainchild of Aliye Runyan, a fourth year medical student at University of Miami and her colleagues, to expand the patient safety taught to medical students.  They are not alone.  The IHI Open School also virally spreads patient safety training where traditional med schools failed.

My topic was handoffs – and they asked me to talk about it.  I wondered what could I tell mostly preclinical medical students, some of whom may not have even entered the clinical arena about handoffs.  Would what I say be over their head and irrelevant if they had no clinical context?  I was also hoping there were some fourth years on the call who could offer their experience doing handoffs as subinterns.

But, I forgot the importance of fresh eyes, a concept that is sometimes used to describe the one positive aspect of a handoff, that sometimes the best insights come from someone who is not well acquainted with the case.  I had a lot of fresh eyes (and mostly ears) on the call.  In the vibrant Q&A that followed (and continued via email), one of the things the medical students brought up asked me about something I said is sometimes bad in the signouts- TMI? or Too much information.  This often happens when the signout is used to help the primary team track the patient and it loses its function for the receiver.  In hospitals with electronic health records, TMI is often a symptom of “CoPaGA” syndrome, or Copy and Paste Gone Amock.

But, this led to the most interesting debate of the night- why has the medical chart become so useless that people feel they need to use the signout this way?  I was asked to think about this question again later in a meeting with our Epic staff who are working to create an automatic signout system for our residents – they really wanted to know why we needed a separate system.  Since our residents have iPads, why couldn’t they just look at the record?

I had to think about that one.  I said that the chart is a document that is an archive that is most helpful for those people that know the patient.  It is also one large medical bill.  And yes, Dr. Verghese makes excellent points about the iPatient, but the truth of the matter is that the medical record is not all that helpful when you don’t know a patient and you have to make a quick on-the-spot decision.  So, this is why we can’t ask busy residents to pause to look in the electronic health record to answer the clinical question of the moment when they don’t know the patient.  The information there is overwhelming.  Our chief resident had a better answer.  The night resident needs the Cliff notes to answer the question since they weren’t assigned (and don’t have time at that moment) to read the full text.

Of course, handoffs are more than just the written information.   A handoff also has to include a verbal interactive component.  As the implementation of shorter duty hours is looming, so too is a requirement that all residency programs make sure their residents are ‘competent in handoff communications.’   I was asked about this by Dr. Bob Wachter in an interview that was just released on AHRQ Web M&M last week (disclosure – I am on the editorial board).  Because programs are looking for a way to meet this requirement, I have racked quite a bit of frequent flyer miles visiting residency programs.  But, after I give a talk, I know that they may talk about it for a bit if I’m lucky. Once, I actually witnessed residents putting some of the principles I taught them into action shortly after I spoke at their resident report.  However, these moments are isolated and as you can guess, education by itself will not translate into practice change (we could talk to the handwashing people all day about that!).   So, like handwashing, a monitoring plan is also needed and yes, that is also part of the new requirement- that programs actively monitor resident handoffs.

So as we head into July 2011, here’s to more fresh eyes…

–Vineet Arora, MD

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 patienthandoffs@gmail.com 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.

Hospitalist Haters: Can We Bury the Hatchet?

Yes, it is true they are still out there.  They believe that students and residents are choosing hospital medicine over primary care so hospitalists are to be blamed for the primary care shortage.  They also believe that the rise of hospital medicine has made primary care less attractive.  Then, there is the salient argument that care transitions are more inherent and vulnerable due to hospitalists.   Of course this hatred is not new.  As a resident, I remember watching Larry Wellikson, CEO of the Society of Hospital Medicine, back in 2002 publicly berated by some very smart people at a conference calling the organization a “SHaM.”  Ironically, this was a conference on how to ‘Revitalize Internal Medicine.’  Given the dramatic rise of hospital medicine since then, it is still surprising when the hatred reemerges in the public domain. It appeared in a recent issue of the Annals of Internal Medicine.  I just returned from the Society of Hospital Medicine conference, and learned there are now 30,000 hospitalists.  Hospitalists are here to stay – so what to do?  Well, let’s explore these myths one by one.

Is the declining interest in primary care due to hospital medicine? While I am very concerned about the lack of interest in primary care, the answer to this question is no.  If hospitalists did not exist, there would still be declining interest in primary care among medical students and residents.  The decline in entry into primary care among medical residents is largely explained by the rising interest in subspecialty medicine, in which 2/3 of internal medicine residency graduates intend to enter.  This choice is largely driven by the financial disparity between high paying subspecialties and you guessed it, primary care physicians.  In fact, hospitalists are losing candidates left and right to subspecialty fellowships also!  As a result, most residents are not deciding between hospitalist and primary care- but between one of them and pursuing a fellowship.  Is it all financial?  Well, I personally believe that residents are also uncomfortable with knowing ‘a little about a lot’ and desire a focused area of practice in the ever expanding domain of medical knowledge.  And, who could blame them?  As a hospitalist, I feel that way often- this is something we need to prepare our residency graduates for – caring for the undifferentiated patient – whether it be in the outpatient or inpatient settings.

It is important to note that the primary care problem starts much earlier than residency!  A widely cited report shows that only 2% of graduates are interested in entering general internal medicine, and less than 20% overall in primary care fields.  The biggest competition is the “ROAD” – Radiology Ophthalmology Anesthesiology or Dermatology – or any other competitive specialty that is lifestyle oriented – meaning high pay with controllable hours.  For any nonmedical person in the world, who would not pick the high paying job with controllable hours?  This is why we need to reduce the disparity between physician specialties in the US and ensure that both primary care and hospital medicine are seen as viable and yes, glamorous careers. 

Has hospital medicine made primary care less attractive? For the sake of argument, let’s imagine the answer is yes – what would that mean? It would mean that a busy primary care physician would desire to go to the hospital to follow their patients early in the morning before clinic and after clinic to round.  They would constantly get pages from the nurses during the day even though they were off premises.  The hospital would require that the primary care physician participate in the latest quality improvement project to improve CMS metrics.  While this may still be possible in more rural areas with less acute patients, the reality is that hospitalized patients today are sicker than ever before.  Hospitals and frankly the government are demanding that physicians are in house to help meet their quality metrics improve patient safety as opposed to rounding on an as needed basis.

 A new analysis shows that the probability of hospitalization for a patient who was cared for by a primary care physician fell before the hospitalist movement started.  Hospitalists emerged as a way to make it easier for primary care physicians to work in the office and not go through the trouble of going on rounds.  So in other words, hospitalists appear to be helping primary care physicians since not many of their patients are in the hospital.  Not surprisingly, a survey demonstrated that 2/3 of primary care physicians thought hospitalists were in fact a good idea.

Do patients prefer seeing their own doctor in the hospital? This question was recently put forth by GlassHospital.  While they may long for the early days of that type of continuity, most patients and their families want to see a doctor immediately when their family member is sick.  Poignant stories from patient safety advocates (Sorrel King, Helen Haskell and others) highlight the need for emergent evaluation by a physician when their loved one is ill.  They can’t wait until clinic ends.  Care by hospitalist is also cheaper and associated with better outcomes, certainly something desirable in healthcare.  Lastly, there is some data from our group that suggests that roughly 1/4 of patients prefer their PCP to see them in the hospital, 1/4 prefer their hospital doctor, and the remaining have no preference.  Patients are also not willing to pay for their primary care physician to see them.   

Are hospitalists responsible for suboptimal care transitions? Well, this is the great sticking point for hospital medicine.  In that same survey where 2/3 of PCPs liked hospitalists, only 1/3 felt they received timely communication about a patients discharge.  A recent review in JAMA supports this assertion. Since that time, however, hospitalists have realized this problem and have adopted care transitions as part of their core mission.  Care transitions are a core competency of hospital medicine.  With funding from the Hartford Foundation, the Society of Hospital Medicine has launched Project BOOST – Better Outcomes for Older Adults Safe Transitions which has been implemented nationwide and in a consortium of hospitals in Michigan and is about to go live in California.  So, while this is the one area that continues to be “unfinished business” in hospital medicine, it is also the area where the greatest progress and improvements for patient safety are being made.

So, can hospitalist haters bury the hatchet?

I hope so.  After all, hospitalists need primary care physicians.  This year, when I’ve been on service, I’ve noted that a primary care physician who accepts new patients is an endangered species.  As a result, I have begged some of my colleagues or other members in the community to follow some of these complex patients.  Since the patients have to leave the hospital when they are medically clear even if their follow-up is spotty, I continue to sign home health orders, receive pages from patients to field their questions, and field questions from subspecialists who are seeing the patient in follow up.  As a result, I have a handful of patients who actually identify me as their physician when they go to an ER in our community.  While I am suddenly reminded of the great pride it is to be known as someone’s doctor, I know that what we all really need is a good primary care physician.

Vineet Arora, MD


Resident Duty Hours: Time for a Wake Up Call?

Anyone affiliated with a teaching hospital knows that the controversy regarding resident work hours is heating up again.  It’s been over 5 years since the ACGME limited resident hours to 80 hours per week with a maximum of 30 consecutive hours.  While this may not sound like ‘reform’, as someone who trained prior to these rules, it is definitely a change. 

More recently, the Institute of Medicine issued a report titled, “Resident Duty Hours: Enhancing Sleep, Supervision & Safety” which recommended cutting hours of resident physicians even more to 16 hours per shift OR a 5 hour ‘mandated’ nap in the current 30 hour system.  The report cites literature from sleep science demonstrating the perils of resident fatigue.  These recommendations have ignited a renewed furor – with groups on both sides of the fence.  For example, the AMA student section recently passed a resolution against the ‘nap’ stating that it would hurt continuity of care.  Other medical societies have highlighted the current issues complying with the 2003 ACGME duty hours and the enormous cost of implementing the IOM recommendations.  The cost of 1.6 billion would be cost-neutral to society if we expected an 11% reduction in preventable adverse events.  As a result of this report, the ACGME has convened a task force to issue new duty hour recommendations in 2011.

As physicians debate these positions, public support for further limits is growing.  Recently, 40 patient advocacy groups, including Public Citizen, have signed a petition urging the ACGME to adopt the IOM recommendations and others to sign the petition at a website cleverly named wakeupdoctor.org.  The website states “Missing: A Patient Perspective on the Need to Reduce Resident Work Hours” and explains the problem “You’ve seen them on Scrubs, ER and Grey’s Anatomy — deeply fatigued interns and residents. But truth is stranger than fiction.” The website does cite evidence that sleep deprived residents make mistakes and the recent IOM report.  Interestingly, the safety risks regarding handoffs are not mentioned. 

With shorter hours, there will be an increase in handoffs, with associated risks for patients.  The IOM report acknowledged handoffs were risky, but highlighted that duty hour reforms should not be hampered due to concerns regarding handoffs.  The IOM did recommend that all trainees receive education on how to perform handoffs.  Unfortunately, it is unclear how to train residents to do handoffs and what improvements actually result in better outcomes. 

Of course, no one wants a tired doctor.  But, the more relevant question is whether you prefer a tired doctor that knows you or a well rested doctor that doesn’t know you? Acknowledging the tradeoff makes it harder to answer.  My answer – it depends.  For a simple procedure, I would choose the well-rested resident (the one that’s most experienced in fact).  But, for a more complex decision where familiarity with the patient matters, I prefer the resident who may be tired, but knows me better.  Of course residents can’t work 24/7 (like they did when they were truly lived in the hospital hence ‘resident’) so handoffs will occur and limits on hours are needed.  But, to arrive at the best solution, we must present this debate in a more informed way for the public.     

Since I’ve explored duty hours in my research, here are my thoughts on some of the common questions I am asked about this topic:

1) Will reductions in hours lead to more well rested residents?   Reductions in hours will lead to some improvement in sleep, but sleep is often deprioritized because residents (like most people) have limited free time and sleep is competing with socializing, family obligations, and other general living life things.

 2) Can we mandate residents take naps (for 5h!)?  No, you can’t force anyone to sleep.  But, you can mandate break time.  Breaks are used in other long shift industries.  Unfortunately, residents are unwilling to use a break or nap if they still have high workloads or are concerned about handoffs.

 3) How can we improve patient safety during handoffs?   This is unclear, but it is clear that the process is fairly haphazard currently so that certainly investments can be made (i.e. formal training etc) so residents feel more capable in conducting handoffs.  More work is needed to know how to train residents in handoffs and also whether handoff improvements actually result in improved safety.

 4) Why not just get rid of extended shifts (longer than 24h)?   This question is interesting and it rests on whether there is really an educational value for residents following patients through the course of disease – and does that experience translate into better decision making in the future.  We don’t know currently since outcomes of residents graduated under duty hours vs. those without duty hours have not been compared since we are just starting to graduate trainees entirely trained under duty hours.  There are anecdotal reports that current resident graduates are less prepared to practice independently after duty hours.

 5) If Europe can have shorter hours for their doctors in training, why is it so controversial here?   Actually, the European Working Time Directive mandates a 48 hour work week for ALL workers, not just physicians.  This includes everyone, highlighting a major cultural difference between the US and Europe.  Junior doctors (what they call residents) were not granted an exception.  Moreover, the leaders of major European medical societies have opposed this regulation and have cited detrimental effects on resident experience.  Reports have also emerged that junior doctors are lying about their actual hours. 

 6) Why can’t we just extend training?  Extending residency training is not a popular option with students.  Unlike Europe where medical education is publicly funded, the average graduating medical student has well over $150,000 in debt.  In fact, due to concerns of a doctor shortage, most specialty societies are advocating for shortening the length of training in the United States.