#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

From Astronauts to Attendings: Workload, Duty Hours and July, Oh My!

reposted from Academic Medicine’s blog

Every July, as academic hospitals welcome new interns, a flurry of activity ensues. While learning to care for patients and navigating the complex social territories of their new hospitals, interns also are worrying about “getting out on time” and making sure not to “dump” on their colleagues. This work compression, particularly among interns who are not familiar with the day-to-day operations of wards, can strain the learning environment. With the implementation of resident duty hours regulations, attending physicians are subsequently called to provide more direct patient care. Yet residency is a time for learning on the job, and part of that learning comes from the teaching attendings provide. In our recent study in Academic Medicine, we asked: “So what has happened to time for teaching?”

Given the recent changes in academic medicine, attendings’ workload needs to be examined, especially regarding their role as teachers. Previously, most studies of workload and work compression focused on residents. Moreover, these studies commonly focused on workload as it related to patient census. While patient census is one measure of workload, we all have had the experience of how one very complicated patient can add up to more work than 10 relatively straightforward patients. So, should we instead consider perception of workload rather than actual workload measured by volume?

Borrowing from methods developed at NASA to examine astronauts’ workload, we examined attendings’ perceptions of workload and the relationship of those perceptions to reporting enough time for teaching. In doing so, we found a steep relationship between attendings’ greater perceived workload and time for teaching. Additionally, we analyzed our results with respect to the time of year and to the implementation of duty hours regulations. Implementing duty hours regulations, not unexpectedly, reduced attendings’ time for teaching, but the magnitude of this reduction was humbling.  What was most surprising, however, relates to the time of year, specifically summer, which everyone fears because of the “July effect”.  Interestingly, more teaching occurs during summer than during winter and spring. We also found that attendings’ greater workload during winter and spring was more detrimental to their time for teaching than their workload during summer.

Certainly, having attendings provide more direct care when residents have heavy workloads improves patient safety. However, the cost to residents’ education and subsequent learning and growth is not trivial. Ensuring that teaching on the wards is restored should be a central focus of graduate medical education reform.  Moreover, while winter and spring should be times for continued teaching on advanced topics to ensure professional growth towards achieving competence, for some reason, we fall short. Meanwhile, during summer, attendings may cut back on their own busy clinical practice and/or administrative duties in anticipation of their role as teachers and supervisors. Regardless of the reason, to prepare for future changes to the accreditation system and attendings’ role in documenting progression through milestones, testing and implementing innovative ways of re-balancing workload to restore teaching and learning on the wards is imperative.

–Lisa Roshetsky MD MS and Vineet Arora MD MAPP 

Not Getting Sick in July

Today is July 1^st.  While everyone has heard the old adage about not getting sick in July because of new interns, the truth is that new interns nationwide have started already. Yet, you don’t hear much about the “late June effect?”  So is the July effect overblown or true?  Well, there have been many studies – so many so there was a recent systematic review co-authored by one of my own co-interns a long time ago.    While I am sure it was hard to synthesize the studies of often sub-par quality, the review does state “studies with higher-quality designs and larger sample sizes more often showed increased mortality and decreased efficiency at time of changeover.”  The study I recall best examined over 25 years worth of death records and found a pattern.  In the 240,000 deaths due to medication errors, mortality rates did increase in July, especially in counties with teaching hospitals.  I’m not sure death certificates are accurate as a way of diagnosing cause of death but that’s another story.

While it’s not possible for patients to time their illness, the question becomes what can be done to ensure July is as safe as possible? While there is scant literature on this topic, over the last several years, I have had the privilege of attending in July.  While I ended up attending in June this year before the interns switched, I was reminded of several ways in which July is different and can be made safer.

• July requires more intense supervision.  Residency is a time of graduated supervision.  In June, a few weeks before third year residents graduate, it would be tragic or perhaps a sign of a problem if an attending had to oversee every little decision in the moment.  It would also annoy the senior residents to no end.  The senior residents have matured to the point that they are the team leaders and you are often the advisor and hearing about their decision-making and rationale and providing advice and guidance where needed.  That is certainly not the case in July.  In July, attendings often are hovering (even if they don’t admit it) or “epic-stalking” checking on every lab and medication.  Moreover, greater attending supervision is more commonplace since 2011 due to a huge push by accreditation agencies and in part due to shorter resident duty hours.   The truth is that interns are rarely acting alone and are often working in tandem with a more advanced resident and attending.  While a recent ICU study questions the utility of overnight attending supervision, a systematic review from our group found that enhancing supervision was associated with improved patient outcomes and resident education in a variety of settings.  Faculty can be more formally prepared for their bigger responsibility in July as it will not only require more time, but also more intensity of supervision. While this would include traditional in-person supervision, attendings can be taught to provide formal oversight of care through technology tools, such as the EHR, mobile computing, and yes, even Google Glass.
• The residents are more eager to learn in July.  July is a time when interns and residents want to learn.  They are eager for feedback.  It is much harder to teach interns and residents in June since they have gotten good at their role…and picked up a lot of medical knowledge on the way.  Because of their umpteenth case of a certain disease, they may not find any additional learning in the case.  Of course, there are always more things to teach, but it is just a little harder than in July when your new interns are ready to soak up knowledge like a sponge.  You can also have a big impact on practice patterns before they form and cement best practices.  While some faculty shy away from signing up for July, many I know prefer to do July because of this reason!
• Everyone is new in their role in July. July is a time of transition for all residents, such as senior residents, chief residents, not to mention new attendings.  Moreover, other health professional training programs are turning over too such as pharmacy residents.  One potential solution that has been mentioned is to stagger the start date of various specialties/professions so that not everyone is new in July.  While this is probably not as feasible as it sounds (and it doesn’t sound feasible), it is an interesting idea worth entertaining.
• Anticipate the inefficiency. Because of the turnover in all staff, everything is a little less efficient.  While a little less efficiency may not seem like much, for a resident team, less efficient means likely higher census because of delayed discharges.  These higher patient workloads make caring for existing patients hard, and admitting new patients even harder, and of course all of this is under the pressure of the time clock.  Although not commonplace, I have heard of some programs lower workloads early in the year, anticipating this inefficiency.  Another way is to restructure teams so that there is more ‘redundancy’ on the team to help care for the patients.  Either mechanism seems like something to consider especially for teams that are struggling to get all the work done in time.
• The patients seem to get sickest when the senior resident is off.  In the back of my head, I know this is probably some type of heuristic in which I am overweighting what the days are like when my senior resident is off….  Regardless, for some reason, it does seem like a good practice to anticipate patient illness on those days. And of course, extra supervision and assistance to the intern when the senior resident is a terrific idea.

While these observations may refer to July, just when the residents get accustomed to their role and rotation, its time to switch.  For this reason, it could be that August (and even September) is not that different from July…so while we focus a lot on July, it may be better to prepare for the Summer of Supervision.

Vineet Arora MD