Friday, December 30, 2011

Generational Differences in Medical Education

I read a phenomenal article on tips to educate “Generation Y”.  It brings up the issue: how does one learn?  What I like about the article is that it focuses not just on traditional learning, but also on approaches to professionalism, communication styles, and feedback methods.  What I also like is that it is non-judgmental, and does not make Generation Y out to be “bad” and earlier generations to be good. 
One focus of Generation Y which I have heard often is that they are “tech-savvy”; thus, educators should incorporate technology into their teaching repertoire.  Remember that this is not just traditional didactic teaching (the article mentions this), but also teaching at the bedside, teaching in small group sessions and other venues.  I have personally tried to do this myself, but have realized that sometimes the content of what needs to be taught/learned is overshadowed by the “cool tech toy”.  Take audience response systems (ARS), for example.  As more and more teachers are using them, the systems become second nature to learners; teachers should not use them just because it looks cool to flash a graph on a screen.  Use an ARS if it helps engage the learner, or reinforce concepts difficult to grasp.
Contrast that idea with this post on the “older generation” being tech-savvy and actually being more likely to integrate technology into their care of patients.   As another example, several medical schools have provided their students with iPads, and have made learning with the use of an iPad part of the curriculum.  The decision to make this leap forward to embrace technology in the educational realm likely came from an “older generation” physician. 
So how do you think medical educators can best help Generation Y learn?  What strategies can best optimize learning for the ultimate goal of improved patient care?  I am particularly interested in what Gen Y folks think.  One parting thought that the focus should be about the learner, and ultimately all about the patient!

Saturday, December 17, 2011

Maintenance of Certification

Board certification as a marker of competence of the medical knowledge necessary in each medical field has been touted for a long time.  Residency programs stress the importance of passing “the boards”, and provide education to residents in the form of didactics that are commonly geared not only to clinical care, but also towards this examination and the skills needed to pass it.
What does it mean to be board certified?  The official term is “Diplomate of the American Board of ___” (depending on one’s specialty).  What it means is that the physician has completed training in her/his area of expertise, and has passed the initial certifying examination (or set of written and oral examinations, for some specialties).  Currently, this certification expires after a certain time period (ten years, for example).
In the past, physicians had to sit for and pass a “recertification” examination, although now the process has changed significantly.  Physicians are now required to demonstrate a valid license to practice medicine, complete an appropriate set of practice questions to demonstrate lifelong learning, pass another certifying examination, and also complete a performance or quality improvement project.  Together, these four parts are known as “Maintenance of Certification”.  An excellent explanation of this process, from the American Board of Pediatrics, is noted here.
There are some physicians who feel that this process to “recertify” is onerous, and not necessary.  There are others who feel it is absolutely essential to demonstrate a minimum standard within the specialty.  I personally fall into this second category.  There are a select few who “grandfathered” in, meaning that their original board certificate was lifelong, thus indicating that they were never required to recertify if they so choose.  This “grandfathering” process is not done anymore in any of the specialties, but there are obviously those who still hold such certificates.
An interesting point-counterpoint as to “should someone who is grandfathered go through maintenance of certification” has been noted.  Those in favor of pushing for everyone to recertify cite this article and others, which showed that those who maintained their certification provided improved processes of care for certain populations than those who did not maintain the certification. 
The American Board of Medical Specialties is soon making public the information around whether a diplomate is undergoing or has undergone maintenance of certification.   I applaud this reason, as I believe that patients deserve to know whether their physician has or has not met this “minimum standard”.  Others do not feel the same, citing multiple reasons why maintenance of certification is onerous, costly, and takes time away from direct patient care.
What do you think?  Should maintenance of certification be public information for all to see, or not?  Should we push physicians who have not maintained their certifications to do so, or to not be permitted to practice their craft?

Tuesday, December 13, 2011

Physicians, Academia and Social Media: Where’s the Beef?

I am relatively new to Social Media.  About 7 months ago, I began on Twitter.  In my work as a medical educator at an academic medical center, it has been a challenge to “disseminate” my interest in social media to my academic colleagues.  There are those who have been great supporters and mentors, such as Dr. Mike McKenna (AKA @IronSalsa, if you are on Twitter), who has given presentations at academic medical meetings, and also Grand Rounds, on Social Media in pediatrics.  On the other side of the coin, others have given me “the look”, as if to say “Why are you wasting your time with social media when there are other things to do?”
This is certainly a valid question, and one to consider if one isn’t yet a believer in the power of social media, or is at least questioning the impact of social media in medicine.  So, I thought that I would find some great posts which discuss this issue.  The question I will leave you with is this: how do those currently utilizing social media convert the academic naysayers?

Saturday, December 10, 2011

The Intersection of Social Media with Medical Students and Residents

The impact of social media on our current society is unmistakable.   This extends of course to the health care field as well, with a majority of adults seeking information about health care online and through social media venues.  Which brings me to how to consider trainees.  The overwhelming majority of medical students and residents are younger than their teachers, and are plugged in more than any previous generation.  They “live and breathe” in the world of social networking everyday.
Some medical educators have recommended for students to avoid involvement in social media.  “The risks are too great” is what is often said, citing examples of unprofessional behavior by trainees.  Certainly there are instances when students or residents acted in an unprofessional manner with their use of social media. 
But what about the positives?  What about opportunities to learn and have social media and medical education go hand in hand?  What about opportunities to help patients with the use of social media? 
Social media “policies” by academic medical centers or medical schools point out the “don’t do this, don’t do that”, but let’s also focus on what the trainees CAN do.  Let’s consider how we can IMPROVE our current health care system and ultimately the care of patients with innovative uses of social media and social networking, such as this amazing site from Webicina.
I really like this “policy” explanation by the Canadian Medical Association, which has a positive outlook on the use of social media for physicians. A wonderful article by a colleague of mine at the Indiana University School of Medicine, Dr. Gabe Bosslet, highlights both the positives and the potential negative ramifications from social media use by medical students (Dr. Bosslet also was instrumental in writing our medical school’s Social Media guidelines).
What’s your take?  Should we recommend trainees avoid the use of social media, fearing repercussions, or should we embrace these new technologies and try to work with (and learn from) trainees, in whom social networking is already playing a major role?

Saturday, December 3, 2011

Twitter and Tweeting During Medical Conferences

I have recently read several different blogs or articles about using Twitter in medical conference meetings.  In fact, I recently returned from the AAMC meeting in Denver, in which apparently I tweeted more than anyone else from within the meeting (some people actually keep statistics on how many times a single person tweets during the time of a meeting; apparently this is relatively simple information to find).
Given lots of interest in this topic recently, I thought I would share what I have learned about this topic with others who may be considering whether to tweet during a conference.  Here are a few links on different aspects of the interplay between Twitter and Medical Conferences.  Most provide the potential positives that can come from Tweeting a meeting, but I have also included views on the other side of the fence that discuss pitfalls.

This discusses finally meeting people you have been Tweeting with but have never met.

This blog discusses some of the negatives of providing a Twitter feed at a meeting, especially if a presenter isn’t quite prepared to give the presentation

This discusses issues related to embargoes within meetings.

This post describes how to optimize your presentation and presents tips and points to avoid as a presenter at a medical meeting.

This straightforward post explains how to tweet by using the hashtag.

This article from 2009 provides an excellent explanation of using Twitter at conferences, including before, during and after the conference.  The authors actually did a study as well, and provide some nice results.

This is an excellent set of suggestions for those who organize conferences, with ideas for how to set up Twitter to make the conference successful.

This blog provides theories of how Twitter can be used at conferences, including “as a conversation starter”, “as an influence generator”, “as a goodwill creator”, and other suggestions.  A wonderful explanation of what these different categories can mean as well.

This blog provides some of the potential pitfalls to using Twitter Feeds at meetings.

This blog explains general content on what it means to Tweet during a medical meeting.

I hope that these links are helpful to get a sense of what it means to use Twitter at medical meetings.  There are many other opinions written on this topic, and I am sure many more will be written.  Have you tweeted during a meeting, and if so, what have you learned from doing so?

Saturday, November 26, 2011

Continuing Medical Education and Lifelong Learning

How do you continue to learn when you are in practice and are very busy?  This is an important tenet for the field of continuing medical education, which itself is undergoing constant change.
Many years ago, the methods for achieving required accredited CME were straightforward.  It was common for physicians in practice to attend a medical conference, whether or not it was of interest or applicable to the specialty of the physician.  In such venues, the primary mode of education was didactic.  Nowadays, the possibilities to achieve CME credits are quite numerous, and involve varied methods besides the traditional “lecture”, especially via the internet.  One which has garnered increasing interest recently, in light of maintenance of certification, is performance improvement CME, known as “PI-CME”. 
As an example of the importance of lifelong learning, today I just updated my Epocrates account, and signed up for free CME through this company.  The case-based vignettes were very similar to what would be seen in practice, in my opinion.  The material was presented in an excellent format, review questions were very well written, and feedback was provided, all through the internet from the comfort of my living room recliner. 
Different states have different requirements for a minimum number of accredited CME.  Recall that most affiliations with hospitals, in addition to state licensure, require a minimum amount of required CME accreditation, usually on the order of 50 hours every two years.
Regardless of the number of hours, the key is that physicians be able to identify their own learning needs, and should develop some sort of rationale for how to stay current in their chosen fields.  A great example of an online CME on the topic of Social Media and LifeLong Learning, by Dr. Neil Mehta, can be found here. How are you doing at keeping up in your area of expertise?  Specifically, what strategies can we instill in learners in residency and medical school to cement the importance of lifelong learning so critical to the success of today’s health care professionals?  Please free free to comment on this post: I'm interested in hearing the opinions of others, including those in training, and those who have completed formal training but are still learning.

Sunday, November 20, 2011

Blogging for Medical Professionals

I have recently hit a “6-Month Anniversary” on Twitter.  It has been a true learning experience.  My foray into blogging is even newer, and I am by no means an expert.  In fact, I am just getting started in the Blogosphere. 
What does one Blog about? [Yes, I do realize this Blog is about Blogging; akin to the Seinfeld sitcom episode describing a Coffee Table book about Coffee Tables]

In looking at Blogging for Medical Professionals, it is interesting to note different approaches.  Here are a few:

So what’s my take?  Blog if you want to.  Blog if you get something out of it.  Blog to disseminate information.  Blog for social reasons.  Blog if it helps you with your return on investment.  Just remember to have fun!

Wednesday, November 9, 2011

Reflections on Six Months of Social Media in Medical Education

It has been a wild ride over the past six months.  I have had the opportunity to meet many new people through Twitter over the course of these six months.  I have learned many more things about how to use Social Media to improve education.  Below are a few thoughts.
1.       Social Media is not a bad thing.  It is about a new way of communication.  This is a good thing.  Several generations (particularly my own) are hesitant to jump into Social Media for fear of “doing something wrong”, especially those in medicine.  This is unfortunate.  Yes, there are clearly limits to what should and what should not be done on Social Media, especially with regard to patients.  But there is nothing wrong with communicating with other people. 
2.       Social Media has made me more efficient, not less.  Depending on whom one chooses to follow, it is interesting to learn about new information so quickly.  I encourage those hesitant to start in Social Media to “just try it”.
3.       There are some very intelligent people on Twitter who have great things to say about medical education.   This should be shared, not suppressed.  People like @RyanMadanickMD , @FutureDocs , @daniellenjones , @Neil_Mehta , and many others provide great insights into medical education, from many different points of view.
4.       Twitter chats take some getting used to, but are definitely great at learning and sharing information with others.  Different medical hashtags provide opportunity to share and learn from many others with similar interests.   This site is great at learning about those different hashtags.

Examples of great links which I found from people I follow on Twitter, about Social Media in Medical Education (in no particular order):

Please comment if you have any others on the topic.

Thank you to all of my Twitter friends/followers for your great ideas/links/thoughts on using Twitter for Medical Education.  Keep up the great Tweets!

Saturday, October 29, 2011

Advocacy in Medical Education

Doctors spend a long time in training.  In the United States, this involves 4 years of medical school, and usually 3-7 years in residency (4 for my specialty of Medicine-Pediatrics, or “Med-Peds”).  Those that pursue fellowship spend even more time learning their craft.  It is truly a privilege to be able to care for patients.  However, in today’s environment, doctors need to know so much more.  Motivational interviewing, managing obesity, and other skills are critical for physicians to do the best for their patients.  Today’s medical students and residents have a lot on their plates to learn, and with the duty hour changes, it is even more of a challenge.
Our government is at a crossroads right now.  Our country’s spending is truly out of control, for many reasons.  Health care costs a lot of money, and it seems to be getting even more expensive year after year.  Doctors don’t know how much things actually cost.  Insurance costs more and more for less and less nowadays.  Given the current state of medicine, it is time that doctors become advocates for their patients in different ways.  They’ve been doing it all along (for example, writing letters to insurance companies stating why a patient needs a medicine not on formulary).  But shouldn’t we be advocates at a larger level, such as in Washington?  Shouldn’t we be telling our stories and those of our patients to our constituents?
What is the reason for this lack of advocacy at a national level?  Is it because we are not teaching advocacy?  The American Academy of Pediatrics has intense advocacy efforts in Washington to advocate for the care and health of children, as does the American College of Physicians for adults.  It is interesting: pediatric training requires learning about advocacy within the community (see page 26 of this link).  Internal medicine training, however does not require formal learning about advocacy.  It should, in my opinion.  Some programs offer curricula in advocacy, and do it well.  There are certainly wonderful venues within internal medicine that focus on advocacy in the care of adults: the ACP, SGIM and AAIM are three such organizations, but awareness by trainees in these areas is limited.
What can we do to help medical trainees advocate for patients nationally?  First, have residents learn about advocacy efforts and how they can get involved.  Second, mentor residents who have an interest in advocacy, which includes giving them the opportunity to go to national meetings that have an advocacy focus.  The CATCH grants through the AAP, or ACP’s Leadership Day are wonderful examples.  Third, physicians need to be stewards related to costs of care, and education on the costs of care must become front and center, not just as a “formal curriculum”, but rather in the day-to-day care of patients.  This means talking about costs while we care for patients, not in isolation.
Let’s inform the "Super-committee" about the issues that are important for doctors-in-training and patients.  First,  GME is a public good (I've been Tweeting this for several weeks now, and heard the same quote from Bob Doherty at the Indiana ACP meeting yesterday as well).  Second, continued funding of GME should not be dropped, whether the funding comes from the federal government or distributed among other payers.  Third, doctors need to be given time to spend with patients, not complete more paperwork.  Fourth, please reward and support training in the primary care fields, which has been shown to improve care and lower costs.  And lastly, and probably most importantly, let doctors who sacrifice so much to be given the privilege of caring for patients be able to actually care for patients, as quoted by Dr. Francis Peabody many years ago: “ … for the secret of the care of the patient is in caring for the patient.”

Wednesday, October 26, 2011

Lifelong Learning: what does it mean to you?

I read a wonderful brief article today about lifelong learning in medicine, specifically in the field of pediatrics.  Our medical school adopted a competency-based curriculum many years ago, and one of the nine competencies is lifelong learning.  But what does this mean?
To me, it means that as physicians, we should never stop trying to learn.  Medicine is changing so rapidly, that the skill of how to learn is as important as the skill of knowing what to do for patients at any given time.  The skill of knowing how to get information is also an essential trait for physicians, and this has definitely changed from not too long ago.  When I did my residency training (1994-1998), we were expected to get “the textbook”, and read it [eventually].  Nowadays, there are way too many textbooks, in addition to online resources, journals, social media outlets and many other sources.
Some people believe that the knowledge stops once someone receives the medical degree.  Nothing could be further from the truth.  Others believe that the knowledge is done after residency training.  This is also false, in my opinion.  This is why there really is a continuum between UME (undergraduate medical education, AKA “medical school”), GME (residency training) and CME (continuing medical education).  The same lifelong learning skills one learns in medical school apply 15 years after completing residency.
But how do we continue to learn?  What is the drive to help us learn?  Is it just knowing?  Is it the feeling of being able to answer questions?  Is it the effect on patient outcomes that drives us to always learn?  I am not sure that there is a correct answer to this for everyone; rather, each person has her/his own answer to these questions.
Whichever is your personal answer, please remember that the zest for more knowledge is a wonderful trait, and is essential for good doctoring in today's era of medicine.  It can make us reflect on how to improve the care we provide for our patients, and will ultimately make our patients better off.

Sunday, October 2, 2011

The Costs of Medical Care

Medical care costs a lot of money.  Most patients do not understand how much care actually cost.  For that matter, most doctors do not understand how much the care that they provide actually costs.  Recently, I participated in a Twitter-chat (#meded, on Thursday nights, 9 pm EST) on issues around the costs of care and how it should be stressed more often than it is.  Several take-home points are worth expanding upon, and other thoughts came to mind after participating in this wonderful online discussion.
Doctors and doctors-in-training should be educated on the costs of the care that they provide.  This is becoming more important given the issues at hand regarding the economy; the percentage of the GDP which is attributed to health care continues to increase.  This increase is not sustainable.
There are others who are making strides to educate health care professionals about the costs of care; here is one such group:
Our medical system in the United States is costing way too much money, yet many feel that reimbursement should be higher than it is.  While I personally understand the views from each side, I do feel that we can lower costs and improve quality, but it will take a team effort to be able to accomplish this laudable goal.
Prevention still costs less than subsequent treatment.  Money invested in prevention is money well spent.
Administrative costs (including time) seem to be taking up more and more of physicians’ time.  Burdensome paperwork requirements are what frustrate many physicians and take them away from what they are trained to do best: care for patients.  Administrative issues might be what drives many away from continuing in the noble profession of medicine.
Doctors are still paid very well in our society compared with other professions.   While some are paid less (e.g. primary care physicians such as myself), they still are paid quite well.
Something ought to be done about the costs of medical care.  As we still need to provide adequate care to all, the million-dollar question is “what”?

Sunday, September 18, 2011

Love Education and Like Education

I am a Program Director for a Residency.  That means that I oversee the training of physician residents training in my field: from what material they are educated on, to how they are educated.  There are certain rules that must be followed, such as providing a minimum amount of vacation per year, designing models for appropriate supervision, how they document the number of patients they see, and the duty hour rules. 
I just finished a half-month of duty on the inpatient ward service.  I always enjoy this time, as it gets me back to why I went into medicine in the first place: to care for patients.  I was able to see firsthand how residents and students are taking histories, are interacting with patients and colleagues, and are performing physical examinations.  In addition, I feel privileged to teach “this is how one can think like a doctor.”
Suffice it to say: I “love” education.  Most of us who have part of our salary dedicated to education (all program directors must have this) would likely get lumped into this “Love Education” bucket.  Others in this category would include clerkship directors (those physicians who oversee required rotations for 3rd year or 4th year medical students), fellowship directors for subspecialties, and Deans of Student Affairs, to name just a few.  These types of physicians still constitute a small percentage of the entire faculty.
The majority of the faculty I would lump into the other bucket: “Like Education”.  These are physicians who primarily see patients and/or direct programs, or are involved in research.  Their jobs include primarily seeing patients in either the inpatient or the outpatient settings.  They may also direct certain clinical programs (e.g., Medical Director of the Cystic Fibrosis program, Director of Outpatient Dialysis Program).  In other words, they are not directly responsible for the oversight of education of residents or students, but have a key role in providing that education, by hosting students or residents in the venues where they care for patients.  They are the ones doing the majority of the actual day-to-day teaching.  They may be (and usually are) phenomenal teachers, and certainly enjoy interacting with residents or medical students. 
Here is my concern: we are losing more “Like Education”-doctors to the reality of the ever-increasing requirements such as the duty hours. 
“Well, I’m just too busy now to take a resident; gotta see more patients, you know.” 
“I enjoy having students in the office, but they slow me down, and thus I can’t see as many patients” 
“I would love to host a medical student now, but unfortunately, just cannot do so, as the documentation requirements just keep going up and up.” 
These are NOT bad people: they like educating our future physicians, but external forces (whatever they are) prevent them from being able to continue their “like” of educating the future physicians.
My concern is that these are the physicians who really make a difference for the training, who really are the ones that the trainees see interacting with patients, and who mentor the trainees.  I hope that the regulatory requirements will eventually hit a tipping point, and can eventually be lessened, so that we will have enough doctors who like educating future doctors to actually do so. 
The “Love Education” physicians will continue to educate no matter what (mostly because it is part of their job).  It is the “Like Education” physicians that need encouragement to continue to be great educators.  Let’s continue to support “Like Education” physicians, in order to keep training alive and well.  They are a necessary component of education, are truly the backbone of what is needed to educate physician trainees, and should be rewarded as such.

Saturday, September 3, 2011

Tough Love and Administrative Professionalism

When doctors and other health care personnel care for patients, it is important to establish a relationship in which the patient feels comfortable in opening up about his/her health.  This can include sensitive discussions, such as the sexual history, the use of illegal substances, and mental health issues.
When certain conditions are due to patient’s “lifestyle”, then it is the doctor’s duty to discuss lifestyle modification.  This may include, for example, counseling on smoking cessation, eating a healthy diet, exercise, practicing safe sex, refraining from harmful substances such as cocaine, and other discussions.  The medical professional may use motivational interviewing as one method to deliver these difficult conversations.
How far do we need to go, though?  For patients with peripheral vascular disease who continue to smoke, when we know that the ONE thing that will help the patient as much as any other intervention is smoking cessation, what are we obligated to tell our patients, and how do we say it without alienating the patient?  Do we discuss how much personal responsibility the patients need to take? 
The same concepts are true when we are working with learners who are struggling in some dimension of their training.  Sometimes it is a medical student who is chronically late for clinic, but we know who is otherwise excellent with regards to patient communication, and spends that extra time so many patients crave.  How do we say that the student needs to be on time, when we know that she is probably taking time with other patients in a different setting?  Which patient is “more important” and how do we relay that to the learner?
What do we say to the resident who never completes his administrative duties, such as completing duty hour forms, logging their required number of patients, or turning in vacation requests on time?  What is the tough love there?  I have found that those same residents who struggle with “administrative professionalism” are also the ones who, after they graduate, will then suddenly call, email, or even page me, needing credentialing papers done immediately, “because if you don’t do them by the end of today, then I can’t start working”.  Is there a version of tough love for those discussions? 
I am a firm believer that what is “most important” is the care of the patient.  I know that Francis Peabody, who stated The secret of the care of the patient is in caring for the patient,  never had to deal with EMRs, competencies, clinical documentation improvement programs, credentialing papers, milestone documentation, RRC site visits, or other administrative duties which come part and parcel with being a medical educator.  But the times have changed.
With this piece, I realize that I raise more questions than answers.  What are your thoughts on this topic?

Saturday, August 27, 2011

Teaching in the New Duty Hour Environment

I have been a teaching doctor for over 10 years.  It has been an incredibly rewarding experience, helping shape the physicians of tomorrow.  “Back in the day” we used to teach in the hospital inpatient setting several months a year, in addition to having a “clinic” or “office”, where we saw outpatients and developed long-lasting healing relationships as primary care physicians.
Now  those days are few and far between.  The opportunities for those to teach in both inpatient and outpatient venues have diminished.  Mostly, the frenetic pace of the inpatient environment is simply taxing (physically and emotionally), and that in and of itself makes it difficult to “be on wards” so much (for the non-hopsitalists) and also maintain a cohesive, outpatient practice.
I always get jazzed up when I start a new inpatient tour of duty, and I usually do so earlier in the year, when new interns and medical students are still early in the training period.  It is great to see the interest learners have in performing certain components of the physical exam, to mentor them through tougher situations, such as telling patients a difficult diagnosis, and to observe learners improve literally in front of one’s eyes.
With the new duty hours, however, the time for teaching has clearly gone down.  Documentation requirements have become more stringent throughout the years, necessitating more time in front of a computer and less time with patients and learners.  Nevertheless, I do feel that today’s learners are just as dedicated as those of previous generations to the provision of high-quality, excellent patient care.  In addition, the duty hour restrictions were thrust upon them, not the other way around.
The teaching docs of the future need to figure out how to integrate “snippets of learning” into a busy day.  Handoffs will become one of the most important skills of today’s trainees (they probably already are).  Learners need to remember that “teaching moments” will probably not occur as a “60-minute chalkboard lecture on abnormal liver tests” as much as in the past, but rather integrated into the care of the patients (and isn’t that the best way to learn anyway?).  Communication skills will need to be stressed, and bedside rounding (in pediatrics, known as “Family-Centered Rounds”, with nurses, pharmacists, other health care professionals and families all together at the same time) will be critical to evaluate how learners interact directly with patients.
I have confidence that today’s learners will learn the necessary skills to continue to provide the best care for patients, and also maintain a semblance of a life outside of medicine.  Something tells me that they already know how to figure out the “work-life balance” better than my generation.