Personal Health

This post is slightly different than my usual, focusing on personal health.  I recently received a wonderful gift for Father’s Day, a pedometer which links via bluetototh with my smartphone.  Given my interest in quality improvement, this has really helped me with measuring exactly how much I am exercising.  What I love about it is the opportunity to compare day to day, and to set and achieve different goals.  Personal accountability is a great thing.
In addition, it has been a privilege to watch my two girls advance in their dance class and learn self-confidence by performing on a stage.  This has prompted me to actually join in as well; I have taken the plunge, and began taking tap dancing lessons (for those that know me, I have two left feet, so this does not come easily to me at all).  I absolutely love this class, despite never having taken any dance lessons ever!!  It is such a great opportunity for me to get away from work (even if for a short time) and focus on myself and my own health, while learning a new skill.  But it provides the added advantage of the girls seeing their father exercise (believe me, this class is a total workout), prompting them to want to exercise more themselves.  I am not even mentioning the opportunity to get to know better the other adults also taking the class with me.
I do believe that we can better counsel our patients about the importance of exercise if we actually exercise ourselves: these are just a few ways that I have done so.  So what do you do to focus on your own health that you talk to your patients about, and what exercise regimens get you jazzed up?

Thoughts on Incoming Intern Orientation

This particular week is the week that the new intern physicians arrived, and become oriented to clinical care. Ours start on June 24 with managing real patients. They are brimming with excitement, but also have a lot to do during the week.

It is interesting to hear from the "old guard" about how it used to be. "My
orientation was 'here is the ER, and here are the bathrooms: now go and see some patients.'" While I certainly would not think that such an orientation is acceptable nowadays, I have to reflect on what exactly we now make the new interns go through.  HIPAA training, ACLS, PALS, NRP, FIT testing, composites, meal cards, explanation of the numerous (not an exaggeration here) computer systems and log-in codes that are necessary are literally just a small part of orientation--and that doesn't even include Handoff training (my personal area of interest).  I mean no disrespect to our hospital administrative personnel by these comments, but am constantly reflecting on what we could do better for our incoming learners.

So what do they actually remember? While as educators we certainly do feel that it is important to have them learn why HIPAA training is critical, or that they have to foster professionalism within the context of social media, I do think that what currently exists truly is an overwhelming mass of "do this, don't do that, you must sign this, you must complete that." So how much do they really retain, when we KNOW that many learners lose interest after a very short time (adult learning theory tells us this)?

Does making interns sign a "I heard this info"-form really help? Does "don't forget to do this" really mean translation of knowledge? Will taking multiple modules online actually help when they won't be back to that particular hospital for 5 months? I'm not so sure.

If anyone has better ways of completing this training in an environment that
promotes retention of information, believe me, I am all ears. I suppose that a similar situation exists in starting other new jobs, and new hires are frustrated. What is so telling is that so many come back later saying "if only I had known that information during orientation, then I wouldn't have done X".

So how long are your orientations, and what do you do to make it educational and fun? Do you feel that the interns complete orientation ready for direct patient care within your system?  Personally, I am looking forward to the "10 things you ought to know about internship"-talk that one of the CURRENT residents is giving later in the week. I would be willing to bet that that is the most useful "orientation" information that the incoming interns will actually get for the entire week, despite months of planning and trying to fit so many “required” things into the week.

I am curious as to any ideas that others have. Believe me, everyone is learning here, and this is after knowing for 10 years exactly what previous trainees have told us about orientation.  I’m sure other educators out there have similar thoughts.  Please let me know your ideas.

Learning from Technology in Education

Yesterday, I had the privilege of attending a conference hosted by my children’s school corporation on the use of tablet computers/iPads in education.  As a medical educator, this absolutely piqued my interest.  In addition, as a parent, I have a big voice in how my children are educated, and want to know how I can help.  As it is now, my children are pretty tablet computer-savvy, and are always asking “Can I borrow your red iPad?” 
This conference was nothing short of incredible!  I learned so much, from how to get organized, to how to use video conferencing, to what apps are helpful for children in 3rd grade.  The keynote speaker was truly inspirational, with a wonderful message that “technology is always changing, but teachers will never be replaced.”  This was so great to hear, as an educator myself.  I also loved seeing teachers from all over Indiana come together to learn for themselves and ultimately for their students.
It is my opinion that the medical education world can learn from what the Center Grove Community School Corporation put on yesterday.  The focus was how to embrace technology in order to connect, create and collaborate.  I saw my kids’ teachers there as well, which was invigorating to see that other educators take an interest in their own personal professional development.
As a take home, I am now jazzed up to learn more about how to use tablet in education, for my own personal learning network (I love the phrase “personal learning network”, which is similar to medicine’s “individualized learning plan”).
To the organizers of the iPossibilities Conference at Center Grove, thank you so much, from one education arena to another.  I have taken away so many great ideas from your conference, both for helping my own children learn, and also for my day-to-day work as a medical educator.  I hope to be able to put on a similar conference within medical education, to demonstrate what is possible.  Our learners deserve nothing less!
[To learn more about the iPossibilities conference hosted by the Center Grove Community School Corporation, which was funded through a grant from the Department of Education, and to see handouts, please click here.]

Graduation and the Cycle of Residency Training

Our residency program and our residents completed graduation ceremonies this past week.  They were wonderful: many faculty attended, and celebrated with the finishing trainees about to embark on future careers and further fellowship training.  I always enjoy seeing how mature the residents are when they finish.
Some are appropriately nervous about what the “real world” of medicine will bring.  Some are giddy with excitement with the opportunity for more training.  Some are excited to be staying here, and some are excited to be moving elsewhere, whether it is a new place, or “back home.”
Regardless of what they eventually do, this is truly the culmination of four years of hard work.  They are ready to be independent practitioners.  They are ready to care for patients to the best of their abilities with no more required supervision.
Congratulations to the Indiana University School of Medicine Med-Peds Residency Class of 2012!  You will go on to do some great things, and will certainly be missed.  We are proud of your wonderful accomplishments, and your outstanding patient care.
Oh, and later this week, the cycle repeats itself, as a new crop of interns (the Class of 2016) begins orientation.  I can’t wait!

Seat Belts: What's The Big Deal?

I wonder how often doctors speak with patients about wearing seat belts.  We all know it is important, and most states have a law requiring that a seat belt should be worn. (click here for information about each state’s seat belt requirements).  In a busy clinical practice, talking about preventive care (such as why wearing seat belts is important for safety) is difficult on top of all of the other things patients want to talk about.  But it is important.
The use of seat belts is one of those habits that most people just do.  You get into the car, you put on your seat belt.  It is that simple.  If we don’t get into an accident, then all is fine.  But what happens when we are unfortunate enough to be involved in an accident?
A recent teenager death from an automobile accident in an Indianapolis suburb hit home to me as a physician who cares for teens.  The teenager who died was not wearing a seat belt.  Over the years, I have also cared for patients who likely would have died were it not for wearing a seat belt.  Their stories are compelling.  In addition, my oldest daughter was in a car crash a few days ago.  She had one minor bruise, but otherwise was unharmed physically.  She was in an age-appropriate booster seat, wearing her seat belt.
It makes me think: why are people choosing to not wear a seat belt?  Seat belts save lives.  So do air bags.  Research clearly demonstrates this.  The use or lack of use of seat belts is a public health issue, which has the potential to impact anyone, regardless of socioeconomic status.
This issue has certainly impacted my family and my practice.  Please, if you get into a car, take the few seconds it takes to click in your seat belt.  As a physician who spends time providing advice to patients, this one is a no-brainer: wear your seat belt when you get into a car—every time, with no exceptions.  It may save your life.

Medical Administrators – Should They Still Care For Patients?

I have been relatively absent from social media for the past week or so.  I have been doing inpatient duties on a general medicine service, and really enjoy working with medical students, interns, residents, pharmacists, and inpatient floor nurses.  It has been a wonderful opportunity to experience the day-to-day activities involved in hospital medicine, and of course, to see and care for patients.
The time on the inpatient service is demanding, both physically and emotionally.  Managing ill patients, long hours caring for complex patients and updating their families leave little time for my other duties in overseeing a CME office and a residency program.  I am trying my best to juggle all of these duties, but for now, the patient care priorities do come first.
As I was arriving one day this week, I saw the chair of another department coming in, and mentioned that I was on service doing inpatient work.  He remarked: “So good to hear that you are continuing this great work, and that you are still actively involved in patient care.  Keep it up!”  That made my day.
So I have been pondering this: should physicians who have major administrative duties and oversee programs, and thus have major time devoted to such activities, still care for patients?  Should they still remain clinically active in order to have “street credibility” with their mostly clinical colleagues? 
I think the answer to this is “yes”.  As busy as it is, I still believe that it keeps me fresh.  It allows me the opportunity to reflect on why I went into medicine in the first place.  It allows me to still remember what it is like to talk with a worried family member about a loved one, to see the gradual changes when a patient improves from hospital admission to discharge.  It allows me to also see the trainees doing what we want them to do: learn to care for patients.
The more I become involved in overseeing administrative programs, the less time I can devote to direct patient care.  But I still really enjoy doing the day-to-day patient care, and working with trainees as they learn the art and science of medicine.  I still haven’t forgotten the old adage by Francis Peabody: “The secret in the care of the patient is in caring for the patient.”

Medical Conferences: What Are Your Take Home Points?

I attended a local conference today sponsored by our Department of Pediatrics and Riley Hospital for Children.  Many of our residency graduates, especially those who live and work locally, return for this meeting.  It really is great to see our graduates and what they are up to.  I enjoy hearing about how they have transitioned to practice, and learning about their own successes and challenges.
This particular year, I was not a presenter, nor did I run any workshop.  I went to this conference strictly to learn.  It was simply wonderful to do so.  The day started off with a dynamic visiting speaker reflecting on the state of well child visits and potential innovations around how to be more effective with these, especially given the changes in medicine that are occurring and will continue to occur.
One might think that this topic is not all that interesting (which the speaker himself even acknowledged).  Plain and simple, I was inspired!  It brought me back to why I chose to go into medicine in the first place: to make a difference. Other extremely well-presented sessions reminded me of things I should be doing when encountering patients with specific conditions.  A lunchtime talk on mentoring solidified a successful day for me (and that was only halfway through the day!).  Other great “high-yield” topics in the afternoon piqued my interest as well.
When some people come back from conferences similar to this one, they realize that while the conference was wonderful, there is still a stack of paperwork that needs to be completed, that there is more work to be done, patients need to be seen, and emails must be answered.  I also have all of those things looming over me.  But I also gained a sense of purpose, connectedness, and excitement for the future of medicine from the conference.  In addition, I learned some new things, was reminded of things I should already know, and also heard about changes coming in the future.
What do you get out of going to conferences besides the acquisition of information?  What other “informal curriculum” things get you jazzed up, and how can conference organizers effectively capture that for other attendees?  I am curious if others see this similarly or differently.

A Medical Educator Joins Social Media: One Year Later

I just realized that yesterday was my one-year “anniversary” for joining Twitter.  Wow, what a ride it has been.  I have learned so much in this short year.  Here are a few take-home points:
1.      If physicians and other health care professionals are not becoming involved in social media, they are missing out on a “place” where many of the patients already are.
2.      Despite #1, there are late adopters who feel that social media is a “waste of time” for physicians.  That is ok.  Forcing them to “do social networking” will not be fruitful.
3.      Social media is a fantastic way to meet other like-minded individuals who have similar interests.  I never would have met a great group of people (some in real life) had I not joined social media.
4.      Patients crave information about their health.  If they want it via social networking routes, we should offer it to them.
5.      There is a lot of mis-information floating around on the internet.  It is a duty of physicians to combat this and provide correct information.  I fail to understand why physicians don’t embrace this more: it is advocacy in the truest sense!
6.      If you decide to join social media, start slow, but start.  It will take a while, like riding a bike is not learned in 15 minutes.
7.      Do not let social media take over your life.  The important things (family, friends, etc.) are still the important things, so don’t lose the priorities.
8.      Push the envelope.  It is time for curricula in social media within medical education to be formally written, and also to be disseminated.  Policies or guidelines are one thing, but curricula are another.
9.      There are many “tools” to make it easier to integrate social media into “what you do”.  Pick one or two, and use them.  It will make the process less overwhelming.
10.   Have fun!  There is some great learning, and in addition there are some fun people out there, and I am a better person for having met them virtually.

For Your Health

Today’s post is a little off the usual theme of Medical Education.  But then again, maybe it isn’t.  Why are those who do medical education involved in teaching others?  Among other things, because they enjoy the love of teaching.  I certainly do.  Today’s post is teaching by doing.
Yesterday, I ran in the Indianapolis “Mini-Marathon”, a 13.1 mile half marathon which is supposedly the largest half-marathon in the United States.  Wow, what an incredible day.  I have run it before, but there was something different about yesterday.
I got there early, after waking up before my alarm woke me up.  I stretched, got my stuff all ready to go (including having my phone with me, as well as gel packs), and was ready to go in my corral early.  I didn't see as many people that I know as I usually do.  It was great to see Dan Fulkerson, one of our Neurosurgeons.  In the corral, just before the start, I found another one of my Riley Hospital colleagues, Dr. Scott Walker, a pediatric anesthesiologist, and met his family.  An incredible sight of the race just before the start is here.
In the past, I have tended to come out too quickly, and I was determined not to do that again.  The first mile was just about where I wanted to be, and the next two were perfect.  I was feeling great at this point, and was on track to meet my goal.
For me, the nemesis has been the race track, which is just before mile #6 until just after mile #8.  I was determined not to slow down on the track.  I made it to the Yard of Bricks at a time which was perfect for me.  I felt really good at this point. 
Then I just plain petered out, along with many other runners.  I walked the water station at the end of the track, and just couldn’t recover.  The heat had gotten to me, and I simply couldn’t go any faster.  My legs were aching, along with my feet.
My GPS timekeeper shows the times from Mile #9 through the end with slower times during each consecutive mile.  This was a bummer, but I think that the lack of long training, and the heat took its toll on me.  But the atmosphere was just incredible.  It was wonderful seeing people running for causes, running for loved ones, running for their own health, or running "just because."  This alone is a reason to run the Mini.
For example, I saw military personnel decked out in full gear, with heavy backbacks, who did the entire race with this gear!  I saw a man who had an obvious stroke but who kept trudging along (actually passing me!).  I saw kids pushing their parents on.  I heard so many words of encouragement and songs from the many bands and cheerleaders along the way.  My favorites: the Circle City Cloggers, and the high school students decked out as Christmas ornaments!
So why have I continued to run the Mini-Marathon?  I am certainly sore afterwards.  It definitely takes a while to train for this (lesson for next time: train a bit longer, focusing on the longer distances).  Is it the thrill of running?  Is it the excitement?  Is it all of these things, plus some unknown factor?
Who knows?  I’m not sure, but I just signed up again for next year!  Here’s to my health and yours!

Interprofessional Education (IPE) – Learning How to Do and Teach It

Last week I had the incredible privilege of attending a workshop on interprofessional education (IPE). Although I believe that I have been inclusive of the views of other heath care professionals, this workshop opened my eyes to new possibilities for how we educate the future health care professionals in all areas.

First of all: kudos to the absolutely amazing people from the Centre (note Canadian spelling here, eh?) for Interprofessional Education at the University of Toronto.  Ivy, Mandy, Lynn and Belinda were just wonderful people to get to know (absolutely some of the friendliest people I’ve ever met).  They truly embody what the world of working together with other backgrounds can and should entail.  Their work is truly inspiring, and is all the more impressive given the limited amount of dedicated time that they have to do it.

Second, it opened my eyes to some awesome people who are already here working for my own institution (Indiana University), whom I had not yet met.  It is fascinating when people work so hard in their own arena and do not know that others with like-minded interests are sometimes literally right around the corner.

Third, it reinforced the belief that no matter what health care field one may work, it is still all about the patient!  I am reminded of this every day in my work, and this workshop cemented that even more.

Fourth, it is exciting to see that my own institution has a plan for how to embed IPE into the curricula of the medical school, the nursing school, the school of social work, the dental school, the school of optometry, the school of rehabilitation sciences, and others (we do not have a school of pharmacy).  There is much work to be done, but we are well on our way.

I was not originally scheduled to go to this, but had the privilege of attending portions of the workshop.  I am so glad that I did, even if I missed some of the sessions for patient care duties.  It has invigorated my interest in what I do in medical education.  And isn't it great to be invigorated every once in a while?

Here are two links on IPE in medical education.

Disseminating the Message

I have had a blast the past few weeks.  I enjoyed a great vacation with my family.  I was privileged to give a Grand Rounds presentation on how doctors can use social media responsibly to improve education and health in general.  What a great opportunity, capped off by several across the country watching the live stream and others live tweeting specific points from the presentation.
Today, a segment on physicians using social media is airing on the radio show Sound Medicine.  I have to say that doing this segment was simply a phenomenal time, and an honor to work with the incredible people from Sound Medicine.  Nora Hiatt, Barbara Lewis, and of course, Dr. Kathy Miller, are complete professionals, who left me wanting to come back as soon as possible to do another show.  The radio show that is Sound Medicine is an example of what is good in medicine, and how we can educate not only other health care professionals but also patients and families.  Click here for more information about Sound Medicine.
So what’s the point of this post?  Disseminate the message.  Make it simple.  Social media can really help medicine and ultimately, patient care.  Doctors should not blindly jump in without a plan, but should definitely consider joining in social media to deliver information, ideally for the betterment of patients.  It is an opportunity to provide factual content to a place where many of the patients currently exist: on the internet, looking up health information.  We have an obligation to our patients to educate them how they want to be educated: let’s make good on that obligation.

The Costs of Health Care – Change Can Occur

Health care is currently undergoing much change.  Unfortunately, the care provided in the United States ranks not as high as expected given the costs.  The US health care system is the most expensive in the world.  Yes, we have amazing medical centers here, and incredible research is done here, with successes seen every day.  But, along with those successes come the harsh reality that care is uneven for the entire population, simply costs too much, and this is affecting our entire country.
Health insurance costs are through the roof.  It costs so much for a family to comfortably cover health insurance costs, as to be prohibitive for many.  Companies are struggling to be able to provide health insurance benefits to their workers and families.  Some patients choose not to have health insurance due to excessive costs.
No one REALLY knows how much specific treatments and diagnostic tests cost (and even then, the costs vary significantly from place to place).  Doctors order things every day, without understanding what the cost is to the patient and to society.  Patients get billed for many different services that they may not even be aware of (e.g., a “facility” charge, a specialist charge, an imaging charge, as well as other costs hidden until the bill arrives).
This is a problem, and it is a massive one.  But rather harping on “what is wrong with health care”, I prefer to take the high road.  I prefer to highlight solutions—and one was just rolled out earlier today.
I am talking about the Choosing Wisely campaign.  This is as good as it gets, and demonstrates that doctors and the organizations which they belong to want to try to fix some of the costs associated with care.  Specifically, this initiative is looking to focus on the “overuse” in medicine that is so common today. 
There are tests that physicians and other health care professionals order on patients which unfortunately have NOT been proven to improve care.  In fact, sometimes these tests lead to more unnecessary tests, without improving outcomes.  It is the outcomes that matter most.
The American Board of Internal Medicine Foundation (or ABIM Foundation, for short) worked with multiple medical organizations to determine 5 tests within each specialty which should NOT be ordered for common issues pertinent to that organization.  In the first roll out, announced today, 9 specialties each discussed 5 tests which should be avoided in specific, common patient care scenarios.  What a fantastic idea!!
While there may be other potential solutions for lowering the costs of health care, the reality is that it still is physicians and other health care professionals who order these tests.  If they can decrease the ordering of unnecessary tests, costs will be reduced, plain and simple.
This is NOT rationing, in my opinion.  It is simply working smarter to do things which are the right thing to do (or to avoid things which are the wrong thing to do).  It means explaining to patients that a CT scan is not necessary for that headache.  It means not ordering an MRI for that patient with low back pain who likely has a low probability of having a rare condition causing that pain.  A simply way of explaining it is "first do no harm"--what I learned on the first day of medical school is still just as important as every other thing I learned.
Please support this cause.  It is really a noble one, and should and will be promoted throughout medicine, whether it involves patients seen by primary care physicians or those seen by specialists.  What I really like is the approach to roll this out not to just the physicians and medical organizations, but to the lay public as well.  It will also be mentioned in Consumer Reports later this year.
Support the Choosing Wisely cause.  It is an example of physicians choosing to put what is right and what they can do right now to improve health care first, and their own pocketbooks second.  I know that I will put it into practice immediately, especially when seeing patients and teaching medical trainees at the point of care.
For a list of the 45 statements from the 9 organizations, click here

Social Media and Disseminating Medical Information

I attended a one-day conference on Social Media yesterday.  It was really fascinating to see how many tools are out there to help measure, improve and monitor a social networking presence (for both persons and for companies).  I have previously mentioned that return on investment is not critical to my presence in social media.  However, this conference opened my eyes to the importance of this, and I now believe it should be absolutely taken into account, especially if one goal is to disseminate information, enhance communication and learn from others.
Some ask why I, as a medical educator physician, have become involved in Social Media.  My reasons have not changed.  I do it because physicians need a presence for social networking, since the majority of patients who use the internet are already looking for medical information online.  Physicians have an obligation to society to disseminate clear, succinct and truthful health care messages to combat online misinformation that is unfortunately too common; what better way than to use social networking to accomplish this?  Let’s meet our patients where they are, which is on social media.  Add to all of this the importance of role modeling the intersection of social media and medicine with learners, all the while maintaining a professional demeanor.
I gave a presentation on social media in medicine and medical education two days prior to this conference, as a Department of Pediatrics Grand Rounds.  This was my first formal scholarly presentation on this topic.  It was simply a blast to be able to present this information to my colleagues.  The conference was very well attended.  Some were skeptical, and a few probably remain skeptical.  Some came up to me later and in emails and asked “How can I get started in social media, for the betterment of my patient care?”  This was the biggest compliment of all (and bigger than more Twitter followers, in my opinion).  It demonstrates that people listen and are willing to learn and try new things, and want to put patient care first and foremost.
Here are a few examples of how social media and mobile technology have the potential to improve patient care:
What are your thoughts on using social media to help improve patient care?

[For those interested in the tweets during the Grand Rounds conference, please see the hashtag #IUPedsGrRounds, with the transcript available here.]

Social Media for Physicians

Social media for physicians: what's all the buzz about?
I've read some great posts on social media in medicine recently.  Here are a few of my own thoughts (in no particular order), after reflecting on some great writing:
1.  Patients--lots of them--are looking online for health information. If doctors are not finding them there, then those patients may be getting information from others who may not have the requisite knowledge, thus increasing the chances of dissemination of mis-information.

2. Yes, doctors understand that they need to be careful and keep privacy in mind. HIPAA has been around for several years now.  Docs get it.  But if they let that hesitancy get in the way, they miss the opportunity to educate.  That is a lost opportunity.

3. The cost of advertising on social media is measured in time.  Yes, it is a doctor's most precious commodity, but it is not like an investment in a many-million-dollar new scanner.  The benefits are definitely worth it. And there is a Return on Investment (not only financial, but also in opportunities for meeting new people and forging new relationships). 

4. Good communication skills should never be forgotten. Yes, doctors still need to know how to communicate with patients one-on-one. But again, patients are already in the social media environment.  Why not meet them there?  See #1.

5. Doctors need to embrace the technology, not just complain about the "new generation" and their obsession with technology (which may not necessarily be true).  The new tools are here to stay.  Either get on the bus or risk being left in the dust.  It's similar to saying "I'm not going to try to improve my practice because I like the old way." That would not fly.  So why are doctors so hesitant to try and taste the water from the social media fountain?

6. We need to role model the balance of this new communication method with "traditional communication" for the trainees.  But did the old way really work?  Unfortunately, the medical profession is less trusted than it has ever been.  Maybe the new generation has ideas for how to remedy this, and some of those ideas will come from social media.  Let's listen and learn!

7. Let's study the impact of social media like we study the impact of the newest drug. Certainly, we know that some drugs work better for some conditions than other drugs.  But what about the impact of a patient education app on real patient outcomes?  Or the impact on physician knowledge and attitudes?  How about a randomized trial of a medical education app to teach murmurs (half the trainees) compared with a simulation mannequin that focuses on teaching murmurs (the other half of the trainees)?

8. It's fun!  I have learned so much from meeting people I never would have met had I not joined Twitter.   Plus, social media is not like email that has to be answered.  If I don't have time today, well, then that is ok.  Some days I may "use" social media a lot, and other days not at all.

9. The opportunity to have conversations with others with similar interests is definitely one worth exploring.  And there are others out there with similar interests, both down the hall, and across the globe.  It is easy to walk 20 feet and ask the colleague down the hall, but what an opportunity to learn from the colleague several thousand miles away!

10. The opportunities to present a clear public health message are undeniable.  Isn't that a responsibility which the medical field should take on and own?

The ACGME's Updated Accreditation System for GME

So the ACGME today just announced a major restructuring to the process of how residency and fellowship training programs are reviewed.    It is called the NAS (Next Accreditation System).  Take home points  from the article, published today online in the New England Journal of Medicine:
1.      Measurement and reporting of outcomes occur through the milestones  (this “grounds the competencies and makes them meaningful”)
2.      Programs submit milestone data on residents every 6 months.
3.      Sponsoring institutions will be responsible for the quality and safety of the environment for learning and patient care.
4.      Programs can be formally reviewed with a “site visit” every 10 years (this is VERY similar to the ACCME, which accredits CME programs, with the “self-study” process).
5.      The accreditation system focuses less on problem identification and more on success of programs in addressing them (this is quality improvement in its purest form, in my opinion).
My personal opinion: I am VERY glad that the ACGME mentioned self-regulation in the article.  If the medical education profession did not regulate itself, then others who likely have no business evaluating medical education would be regulating it.  Kudos to the ACGME, for listening to program directors that the administrative “burden” was overshadowing the education of trainees, which I feel is the reason most program directors chose to do what they do.
I believe that it is wonderful that the ACGME took on this ambitious NAS endeavor.  I look forward to what the next steps will be.  What are your thoughts?

What Is Med-Peds?

Most people understand the specialty of pediatrics: the care of children.  The advocacy group for pediatricians is the AAP, or the American Academy of Pediatrics.  Fewer understand the specialty of internal medicine (“medicine” for short), which is the care of adults.  The specialty society for this group is called the ACP, or American College of Physicians.
I am both of these.  I am both a pediatrician AND an internal medicine doctor (called an “internist”).  The name of the “specialty” given to what I do is called “Med-Peds”.
Med-Peds training is relatively unique, in that it incorporates half of its time (2 years) in internal medicine and the other half (2 years) in pediatrics.  After this training, doctors are eligible to go into practice in internal medicine, OR in pediatrics, OR in both (this last is ideal).  They can also choose more subspecialty training in internal medicine, OR in pediatrics, OR in both.  This flexibility in career options is quite attractive to those who choose our field.
Med-Peds is considered a primary care field.  Obviously, family medicine is a primary care field, as is pediatrics and internal medicine.  But in all of these options, trainees can choose further training.  This article (focus on Table 1) highlights the percentages of each which go into primary care.  Many forget that Med-Peds is a great option for those interested in primary care.  Others consider Med-Peds a great choice for those in medical school who can’t decide what they want to do.  Whether one chooses Med-Peds for any of these options is not critical: they chose it for their own reason, and that is what matters most.
What I have the privilege of doing within Med-Peds is being an educator.  At Indiana University School of Medicine, I oversee a Med-Peds residency program (the largest one in the country), and love the opportunity to train future physicians, no matter what their interests.  Niches within Med-Peds include transitional care (caring for patients as they transition from being a child to being an adult) and global health.  However, it is important to realize that Med-Peds alone as a specialty cannot be solely responsible for transitioning every child with a chronic condition to adulthood, and that other physicians need to be comfortable in thinking about this transition.  One of my Indiana University colleagues and mentors, Dr. Mary Ciccarelli, was involved in writing a document about transitional care, which was recently published, and has been passionate about furthering the concept of transitional care.
Explaining Med-Peds to physicians not familiar with it is difficult enough explaining it to patients is even harder (hence the reason for this post).  Med-Peds is not necessarily an “alternative” to family medicine (for the record, I do not “bash” family medicine as a specialty); the training is very different, yet many in both end up practicing similarly, in a primary care arena.
If you are a medical student, I encourage you to think about Med-Peds as a specialty.  If you are a patient, I encourage you to consider a Med-Peds doctor as your primary care physician.  Here are some quick facts about Med-Peds:
The training is four years total: two in pediatrics and two in internal medicine.
The training allows opportunity to pursue further training in either pediatrics, or internal medicine, or both.
A wonderful organization which promotes Med-Peds is called NMPRA (National Med-Peds Residents’ Association).  This website provides the best explanation of Med-Peds that I have seen.
A wonderful organization which promotes the education of Med-Peds trainees is called MPPDA (Medicine-Pediatrics Program Directors’ Association).  I was honored to serve as the president of this organization from 2010-2011.
Med-Peds is the only “combined” residency which is accredited by the Accreditation Council for Graduate Medical Education (ACGME).
There are currently 77 residency programs in Med-Peds accepting residents in the National Residency Match Program (the “Match”).  We would like to see Med-Peds grow as a field and have more accredited programs.
A blogger who has the same Med-Peds training as myself (and completed his training just as I was beginning mine at Indiana) is Dr. Rob Lamberts.  Here is his current website.
The Med-Peds Section of the American Academy of Pediatrics is the second largest section in the entire Academy.
I would love to hear your comments about the field of Med-Peds.  It is a wonderful specialty, and I am honored to call myself a Med-Peds doctor!

Social Media in Academic Medicine

The inspiration for this post came from a Twitter chat on the theme of Social Media in Academic Medicine on the “meded” chat, on Thursday 2-16-2012

Social media is definitely integrated into today’s culture. So many young people are using social media. In addition, a quicly growing demographic in social media is actually those in their 40s-50s. Despite this impressive growth, social media has not, in my opinion, made its way into mainstream academic medicine yet. Certainly papers have been written on the topic of social media in medical schools, but much of the focus has been on professionalism around using social media, and less on what positives social media can bring to medicine.

With regards to social media in academia, however, the growth is slow. Promotion of faculty in academia on the strength of a portfolio focusing on social media is currently probably not that common. But should it become more common in the future? Will physicians who choose to be engaged in social media for purposes of promoting medical education or medicine consider this as their main “scholarship”? And what about the physician who chooses to blog on medical topics (which can provide quality information on the internet to counteract some questionable medical material that currently exists)? Is that something to put on a dossier? Surely it can attract an audience, and can provide useful information to patients and those interested in health.

Finally, as we talk about the hidden curriculum in medicine often, how should the academic physician who is “laughed at” or “taunted” for tweeting or blogging react when she hears: “You are wasting your time with that social media stuff.” (you can probably ascertain that indeed I have heard this quote more than once)

I have my opinions, and would love to hear yours. I will leave you with a few articles on Social Media in the academic arena.

Professors like social media more than other educational technology

How higher education uses social media

Social Media Footprint for Academics

A doctor's reputation vs a hospital's responsibility: Social Media

Quality Improvement in Medicine and Medical Education

There are fads in medicine (e.g., “Vitamin E can prevent heart disease”, which we now know to NOT be the case), and then there are things that here to stay. The movement of quality improvement (QI) is definitely in the latter category. The importance of quality improvement in medicine cannot be overemphasized, yet there are some who question the utility of QI. There are others who have bought into why quality improvement is critical towards improving patient care. A new arena within medicine of “implementation science”, where putting guidelines into actual practice constitutes success, is emerging. This has even transcended maintenance of certification. Part 4 of the process involves doing a specific quality improvement project aimed at improving one’s performance with regards to patient care. All of the medical specialties in the ABMS have such a requirement. Quality improvement is also embedded into the CME world as well, with Performance Improvement CME, or PI-CME, coming of age as an important aspect of what physicians do. So how does a clinician go about doing quality improvement? My suggestion is to think about something that doesn’t go as smoothly as one would like (in the CME world, this is known as a “practice gap”, which drives why it is important for physicians to continually be educated). Whether it be ordering necessary tests in diabetic patients (e.g., urine for microalbumin, LDL cholesterol levels) or improving throughput in the office, quality improvement principles can guide an approach toward improving “something” (whatever the something may be). Within medical education, quality improvement curricula are now no longer innovative: they are REQUIRED. Residency programs are required to teach quality improvement to trainees, although the ideal way to teach it is not known. The literature in this arena is clearly growing, however, which is exciting, and it is common now at academic medical centers for residents to provide excellent ideas for improvement projects. So why is there push back to looking at improving how one practices? In other words, what can the organizations which lead the QI movement do to achieve front-line clinician buy-in to the importance of the science of improvement? After all, the ultimate outcome is improved patient care outcomes, and who would not support that?

Teaching on Disclosure of Medical Errors

I’ve been a teaching physician for a bit over 10 years now.  One of the great things about teaching learners about medicine is that in doing so, I myself learn something every day.  There are so many things to learn in medicine.  Sure, a lot is “medical content”, but there are so many other things.  How to “connect” with a patient, how to interact with other health care professionals, how to improve adherence: all of these are some of the “softer” sides of medicine—but just as important as the newest drug for managing a particular disease.
Since 2003, I have been privileged to teach quality improvement principles to residents.  While what we were doing was “innovative” in 2003, now it is no longer innovative: it is REQUIRED.  Teaching what I call "the science of improvement" is very exciting to me, and demonstrates how advances in medicine move forward. 
One area within quality improvement that is particularly exciting to teach about is Disclosure of Medical Errors.  What this means is that we realize that errors occur, and rather than hiding them, we (the medical community) should tell patients about these errors.  Literature is now actually supporting the fact that when errors are disclosed, patients/families are LESS likely to be sue physicians, not more likely.
While this is fascinating information to me, the real impetus should not be about getting sued versus avoiding a lawsuit: it should be about doing the right thing for patients.  It has been fascinating to read the literature on this topic, and how it has “pushed the envelope” towards doing the right thing for patients which ultimately improve patient care.  Authors such as Tom Gallagher and Wendy Levinson (from the University of Washington, and the University of Toronto, respectively) have written on this topic for years, and have really advanced the field.
While reading some posts on Twitter today, Mike Moore, a medical student in the Seattle area posted a link to this outstanding TED talk on Disclosing Errors by Dr. Brian Goldman.  Wow.  This is absolutely worth watching, and should be required for medical students and residents (as well as teaching and practicing physicians).
So how should medical schools teach about Disclosure of Medical Errors?  If it isn't happening, it is time to do so.  If it has been integrated, kudos are in order: it is an important tenet of quality improvement to make the care that we provide for patients better—and isn’t that why we are all here anyway?

Social Media and Stages of Change

I am a physician educator, and have been for over 10 years.  I have been involved in teaching residents (GME, or Graduate Medical Education) for 10 years now, and have recently added to that the opportunity to work and learn in the CME (Continuing Medical Education) world.  Both of these areas carefully study ways to best teach medicine and medical concepts to learners.
One concept important for any physician to learn is something called “Stages of Change”.  One key tenet of this model is that people progress through different stages in the journey to change.  Sometimes, it takes a long time to complete this progression. 
The first stage is Precontemplation, in which one has not yet fully acknowledged that a change for a problem behavior is necessary.  In Contemplation, the second stage, acknowledgement has occurred, but the person is not yet ready for the behavior change.  In the next stage, Preparation, the person is ready for the change.  The next stage, Action, involves changing the behavior.  The Maintenance stage is one in which the behavior remains changed.  Sometimes another stage is Relapse, in which the person reverts back to the undesired behavior.
Two classic examples used to teach this in medical school are quitting smoking, or starting an exercise regimen.  However, one can apply the principles of the Stages of Change Model to other areas. 
Obviously, one very hot topic nowadays is physician involvement in social media.  Many physicians are jumping on the bandwagon.  Others, however, are “holding out” for various reasons (many of which include some reference to lack of time).  Personally, I was actually in this second category until May, 2011. 
In May of 2011, my wife mentioned that I should join Twitter.  That turned out to be the beginning of a new era in how I do what I do.  I joined one weekend, and have never looked back.  Now, I have actually been a heavy user of Twitter during medical conference meetings (apparently, I was the highest volume tweeter at the AAMC meeting in November, 2011, and also came back from the ACEHP meeting this past weekend as a high volume tweeter as well.  I’ve joined a few others (LinkedIn, Google+, Doximity, and others), and have learned so much in the process.
One of my plans is to become involved in the scholarly work around the use of social media by physicians, to ultimately help patients.  I had a great opportunity to meet with others at the ACEHP meeting in Orlando about this topic, and think that it will definitely be lots of fun to study this area.
So what does that mean for me?  I went from the Precontemplative stage to the Action stage relatively quickly, regarding my own personal use of social media.  I use it to learn, to teach, and to advocate (Reference 1).  I personally feel it has made me more efficient, not less.  Plus, it has been a lot of fun, and I have met (virtually, and a few in real life) many new people I would otherwise not have had the opportunity to meet.
So where do you fit in to the Stages of Change Model with regards to using Social Media?  Are you still dead set on not joining Social Media (Precontemplative)?  Have you considered joining social media (Contemplative)?  Are you planning on taking the plunge (Preparation)?  Have you joined (Action), but then gave it up (Relapse)? 

Reference 1.  McGowan B. Technology and Medical Education.  Presented at ACEHP PreConference Workshop on January 21, 2012.  Found at: 
Reference 2. Sherman L. Sitting next to me during Reference 1, saying “Do you realize that you bypassed some stages of change?” on January 21, 2012.

Social media policies within medical schools

I have been in multiple discussions in various venues about social media in medical schools recently.  It appears to me as if every conversation ends up focusing on professionalism (or more specifically, unprofessionalism and what students should NOT do).  The conversation then turns to “a policy is necessary so that trainees/students understand what  isn’t ok”.  About a month ago, I wrote this blog here, which touched on this topic. 
While I agree that a policy or a guideline (the IU School of Medicine calls it a guideline) is important, and professionalism should of course be mentioned, I always tend to notice almost no discussion of what good can come from social media in medical education.
Is it that people are scared?  Is it that people are worried about doing something that will come back and haunt them?  Can medical schools be sued over comments made by students or faculty in social media circles?
I am particularly proud of the IU School of Medicine’s social media guideline here (shout-out to my colleague Gabe Bosslet for his direction and leadership in crafting this document). 
My personal opinion is that of course people need to be smart and not post patient information, or anything that might link with a direct patient, in a social media context.  But we sure are missing what great potential is out there.  What about disseminating helpful health information to patients?  What about the opportunity to dispel rumors, false information, and “snake oil cures”?  What about the potential for maintaining quality public health information (on vaccines, for example) for all to see or read?
Below are some interesting posts on the topic of Social Media policies, specifically with regard to health care.  Please let me know your thoughts on this subject, and how we can leverage the good from social media with the concern over unprofessional online behavior.
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