Wednesday, December 24, 2014

Reflections in Medicine and Medical Education 2014

2014 has been a tumultuous year, especially in medicine.  Frustrations with electronic health record systems, the Ebola virus, reactions to the Ebola virus, response to the new MOC requirements, burnout, and many others all contributed to the complexities that exist in medicine.  In medical education, questions like "what do the milestones really mean?" are common thoughts emanating from educators.  I'm not even touching Entrustable Professional Activities either!

Our school also passed a new conflict of interest policy.  I was privileged to lead this effort in 2014, and, despite unanimous approval of the policy in less than a year, I continue to get more questions "what about my situation?  Is that ok?"

In short, it is a tough time to be in medicine, no doubt.  Increased fear of being sued, decreased reimbursement, more regulatory requirements, and the uncertainty of exactly where medicine is going make for challenging times.

So how do people cope with this?  

Some choose to go "nose to the grindstone" and work harder.
Some decide to "call it quits" and leave medicine.
Some opt to "fight back", through advocacy in the form of blogs saying "enough is enough".
Some take a step back and say "at least I have a job and job security".
Some are put off by the "it's a job" phrasing, opting for "it's a profession, and unfortunately it is slowly eroding".

I know that resiliency is a helpful trait to handle all the changes, but still, I don't have all the answers.  I strongly believe that in the end, what I do matters, to learners, to patients, and to future learners and patients.  What trainees do matters.  What doctors and other healthcare professionals do matters.

That, coupled with blessings of continued good health, allows me a little peace in a hectic world moving at a frenetic pace.  Just try to search for your own similar peace.

Happy Holidays to All!


Friday, November 28, 2014

Conflict of Interest: Managing Scandal

I have had the privilege of chairing the Industry Relations Conflict of Interest Committee at the Indiana University School of Medicine, the medical school where I work, over the past year.  I have learned a lot about interactions of academic physicians with industry, and have certainly heard differing opinions on the topic.  Our policies were recently approved (unanimously, I might add!) by all of the pertinent committees, and already, many faculty have had comments and questions about specifics of the policy.

One common theme that we have also heard is that “regulatory agencies and administrative bodies” have hurt the field of medicine.  I certainly understand the additional burdens of what it takes to practice medicine, and how those burdens can actually damage the patient-physician relationship.  However, when one looks at why conflict of interest policies are put in place, one needn’t look very far to see why it is necessary.

Here is a prime example.  The Journal of Patient Safety had to deal with this recent example with its own editor.  Dr. Charles Denham, the [now] former editor of the journal, failed to disclose his own financial conflicts of interest with organizations which paid him.  This impacted recommendations he made with respect to clinical guidelines that center around optimizing patient safety.

What is interesting to me is that sometimes, how one handles a scandal can be as important as the scandal itself.  Covering it up, hiding it, or trying to sweep it under the rug are all examples of ways that don’t work.  It is amazing that it is this same sense of “doing the right thing” that parents try to teach their children.  What impressed me in this example is how the journal chose to address this.  The journal has opted to tighten its own policies and processes around conflict of interest, for authors, editors and others who make decisions about articles within the journal.  They even published an article describing what they plan to do. 

For anyone wondering how to handle a scandal, THIS is how to handle a scandal.  Admit the wrongdoing, describe what steps need to be taken for the better, and, simply, apologize.  As written in this NPR piece, “airing the dirty laundry”, while painful, is a necessary step.  

I applaud Dr. Albert Wu, Dr. David Bates and the journal editors for demonstrating the right way to manage this situation.  I think this is a great learning experience for the patient safety movement, for editors, and for all physicians who interact with industry.  Conflicts of interest are complex, but it all comes back to the fact that there is a public trust that must be put front and center.  If we violate that trust, then we have done a disservice to the profession, to ourselves, and, most importantly, to our patients.

Wednesday, November 19, 2014

Randomized Controlled Trials, Social Media and "Intention to Tweet"

I have to hand it to cardiologists: for years they have created the most innovative and fun names for trials that are conducted.  As a generalist, I still remember the DIG trial from way back when, or the RALES trial, sometimes referencing names of trials when discussed medications for common conditions such as heart failure.  As therapy evolves, we get a PARADIGM-HF shift, some might say!

Today, I was sent a tweet about a fascinating trial, the “Intention to Tweet” trial (hats off again to our cardiology colleagues: TNOTY (Trial Name of the Year).  This trial was a randomized trial of social media to see the impact of social media on views of articles within one journal, Circulation.  In the intervention group, they tweeted out links to half of the articles, and a link to the Facebook page.  In the control group, no tweets were sent.  Kudos to Lee Aase for a wonderful review of what was done in the study, and what it might mean for the future. 

Essentially, what the authors found was that there was no difference in clicks between the articles which had tweets sent/Facebook page links, and those which did not.  Some might refer to this as a “negative trial”.  I think that, in medicine, we need to see results of “negative trials” that show something was ineffective or not better than “usual care”, just like we need to see results that demonstrate a positive effect of an intervention.

But here is the clincher for this: I have seen several tweets from physicians and other scientists who are meaningful users of social media who are questioning the results or the design of the trial.  Some might interpret this as a “defeat” for social media.  

Looking on the Altmetrics page for this particular article, however, paints a different picture.  Recall that this article was announced and sent out TODAY (11/19/14) as an early release article.  The Altmetrics description for this article puts it at the 92nd percentile of all articles within this Circulation journal.  It is in the 94th percentile for all articles of a similar age.  94th percentile!  That is pretty awesome!  Compared with other articles of a similar age in this journal Circulation, it ranks 2nd, in the 85th percentile.  Again, this article came out TODAY.

So here is the kicker.  This article on social media, based on these Altmetrics data, has “gone viral” on social media (at least compared with other articles from this same journal), and is ranked quite favorably in one metric used to gauge social media impact (that metric being “Altmetrics”).  I think that suggests exactly the opposite of what the conclusion did (meaning that dissemination of THIS ARTICLE via social media made it quite a favorable article), which could be interpreted as "social media does have an impact on readership of journal articles.  See this screenshot from Altmetrics from 10:30 pm EST on 11/19/14.

I applaud the authors for developing such a trial and Circulation for having social media editors in the first place.  Those of us who “believe” in the power of social media to teach, to learn and to advocate appreciate the scientific principles which went into creating this trial.  I do agree with one sentence in the conclusion that “further research is necessary to understand and quantify the ways in which social media can increase the impact of research”.  

This article is a wonderful first step towards understanding these concepts, and provides a meaningful way to understand how to consider the impact.  As a social media editor for a journal myself (JCEHP), I plan to reference this article and use it in descriptions of how social media can impact journals, and ultimately, patient health and outcomes.

Friday, November 7, 2014

Medical Education: What Matters

So I've been in Chicago for the past few days at the inaugural Association of American Medical Colleges (AAMC) Medical Education meeting and the Society for Academic CME (SACME) meeting.  What a showcase of incredible learning opportunities!  Here are just a few of my take home thoughts and reflections from the past few days.

1. Healthcare in the U.S. has real problems, and medical education can really contribute to fixing this. We need to start calling ourselves healthcare learning systems. Medical education matters!

2. Getting one's message out to others (whether in the form of an abstract for a future presentation, or in a manuscript for a peer-reviewed publication) means that one has to be mindful of words.  Words matter!

3. Technology can be used to improve communication and healthcare, but we must be careful that technology in and of itself is not a solution.  People matter!

4. Seeing old friends and meeting new people create a wonderful community of learners, and together we can tackle problems better as a group than as individuals. Connections matter!

I still have another day of learning here, and lots more people to meet!  Thank you to the organizers for a wonderful meeting!

[for the record, I wrote and posted this piece while on the "L" headed to the meeting]

Sunday, September 7, 2014

Connecting from Afar: 2014 Stanford MedX

The 2014 Stanford MedX conference is going on this weekend at Stanford.  I was not able to attend (mostly due to time pressures and the fact that there are other medical meetings which I am attending this week).  In fact, I’m headed to Washington DC in a few days, where, along with Kathy Chretien and Ryan Madanick, I’ll be giving a presentation at Academic Internal Medicine Week to internal medicine educators about how to effectively use social media. 

The MedX conference sounds like a phenomenal meeting for participants to learn about the intersection of medicine and emerging technology, where the patient voice and experience was highlighted.   An announcement was even made that for the 2015 conference next year, the meeting will feature medical education as a theme.

Many people whom I respect and follow on social media networks are at the 2014 MedX conference currently, both presenting and sharing content.  There is even a live stream from the main hall that can be viewed by anyone, whether in attendance or not.  That is really cool.  I was able to view this live stream for a short while yesterday and contribute to the meeting from afar via intermittent tweets.

The Friday event had over 13,000 tweets, which is amazing.  This morning, I am still trying to catch up on some of the tweets from both Friday and Saturday.  One of the sessions which was not streamed live, but tweeted heavily, featured technology and social media within medical education.  Several well-known “tech enthusiasts” within medicine were presenting sessions there, including Bryan Vartabedian and Warren Wiechmann.  I feel somewhat knowledgable about the topic, as these two icons were the keynote speakers at our first two “Mobile Computing in Medical Education” conferences the past two years.  Other influencers like Susannah Fox and Wendy Sue Swanson, whom I still have not met in person, are influencing the crucial conversations that abound at such vibrant meetings. 

I’ve written several posts about tweeting medical meetings in the past, and am fascinated with this as a way to disseminate information to others.  It is innovative that MedX is live streaming the main stage for anyone, regardless of whether s/he registered or not.  What a great way to connect with others who could not be present this weekend in California!  Kudos to Larry Chu and others at Stanford for a great meeting and for the ability of non-participants (a better term may be “indirect participants”) to connect.  Sorry I could not be there in person, but I’m certainly there in spirit!

I realize this post is not doing justice to the many other wonderful people contributing to MedX and from whom I am gaining innumerable insights.  Thanks to all for your presentations and your tweets!

Friday, September 5, 2014

Curbside Consultation and Hallway Conversations

“Curbside consultation” is an interesting term in medicine.  There has been an increasing interest in this term in the recent medical literature, specifically as it relates to patient care in medicine.  I myself have often pondered how much one learns from curbside consults.  I know that some specialists may frown upon them because of the potential for some to document recommendations in the chart without a “formal” consultation.  As a primary care physician, I enjoy the camaraderie associated with a curbside consult, and in turn, try to help my colleagues out when they ask me a quick question.

The other day, I was on the way from my administrative office to my clinical office where I see patients.  Just outside the parking lot, I saw a colleague I had been meaning to call but just hadn’t gotten around to actually contacting.  In a five-minute conversation, I was able to get so much more helpful information about the topic at hand, and helped my colleague in understanding a concept with which he was not familiar.  For the record, this actual conversation took place on the sidewalk, right next to the curb.  If there was anything that was truly “curbside”, this was it!

I wonder how much one can actually “learn” from a curbside consult?  In my example described above, I can honestly say that the “worth” of that curbside consult is much more than that of a one-hour “lecture” on the same topic by an expert.  I’d be willing to say that my colleague felt the same.

The same concept can be applied to “hallway conversations” at regional and national meetings: the energy disseminated from a brief conversation with a colleague is itself a wonderful opportunity for learning for all (including disseminating to others who may not be a part of the conversation).  So the next question becomes this: “If it is so helpful, how do we value curbside consults/hallway conversations?”  I don’t know the answer, but it is certainly worth exploring.  Yet one more thing ripe for future study!

Special Thanks go to Dr. Peter Schwartz, my colleague referenced above.

Sunday, August 31, 2014

Clinical Practice Guidelines, Autism, and Ordering of Tests

I just returned recently from giving a presentation to the Institute of Medicine (IOM) on the topic of emerging technology in medical education (more specifically, on graduate and continuing education in the health professions).  The overall theme of the IOM Roundtable discussion was to examine practical approaches to improving genetics education in these groups.  I am a primary care physician, and by no means an expert in genetics or genomics.  My involvement in the meeting centered around using emerging technology within education of health care professionals. 

It was a fantastic one-day conference, and I had the opportunity to meet some very wonderful people; not only fellow educators but also true experts in the field of genetics and genomics education.  The discussions included how genetic providers can best partner with primary care physicians on ordering of tests that will help patients.  We also talked about primary care physicians referring appropriate patients to geneticists for further evaluation.  One of my take home points was that I should be considering genetic conditions more often than I am.  Consider that objective achieved, IOM!

So I recently received this advertisement card in the mail, by Quest Diagnostics.  On one side “Their future is in your hands.”  On the other, a pitch to use the ClariSure brand of chromosomal microarray analysis. 

I have never ordered one of these tests.  I probably need to refer more patients to a genetics clinic, for sure, and not just for patients in whom I am entertaining a diagnosis of autism.

But this phrase right on the pretty glossy paper caught my attention: “Chromosomal Microarray Analysis is recommended as a first tier test for autism spectrum disorders and developmental delay by ACMG” (the American College of Medical Genetics).  Wow, I thought!  That could be considered a pretty bold statement.  Remember, this was sent to me, a primary care doctor, who sees patients with autism, screens pediatric patients at well child visits for it, and refers where appropriate.  The statement above does NOT say “for diagnosis”, “when/if referring to genetics”, or anything like that.  It says “recommended as a first tier test for autism …”.  How should a pediatrician reading this pamphlet sent directly to them interpret that?

I pulled the ACMG guidelines, entitled “Clinical genetics evaluation in identifying the etiology of autism spectrum disorders: 2013 guideline revisions”. In that guideline, Table 4 is titled the following: “Template for the clinical genetic diagnostic evaluation of autism spectrum disorder”.  Indeed, chromosomal microarray is listed as a first-tier test.  But let’s go back to the title of Table 4 and read it more carefully: “… for the clinical genetic diagnostic evaluation of autism spectrum disorder”.  It does NOT say “for pediatricians and primary care providers” anywhere in this table.  I don’t really know too many primary care pediatricians who are ordering this test, but maybe I am insulated.  I am not a clinical geneticist.  So why is this pamphlet being sent to me, a pediatrician?

When I am not sure about something, I like to “go to the literature”.  So I looked for guidelines or a policy by the group with which I affiliate as a pediatrician: the American Academy of Pediatrics (AAP).  I do not recall the AAP recommending chromosomal microarray testing the last time I looked.  The AAP does indeed recommend Screening for Autism, in a guideline from 2007: “Identification and evaluation of children with autism spectrum disorders”, with a simplified algorithm found here, on page 2).  Basically, routine screening in EVERY PATIENT at 18 months for autism spectrum disorders is what pediatricians should be doing.  There is even a code for screening (it’s 96110, for anyone interested!)  I know this algorithm well. 

We are actively working to improve screening for autism in the state of Indiana, and colleagues at my institution have some preliminary data that demonstrate a lowering of the mean age of diagnosis of autism in certain communities by quite a bit (the lower the age, the earlier the patient can be referred to an autism specialist).  Maybe in the future, ordering of a chromosomal microarray analysis will be part of a general pediatrician’s armamentarium, but I’m not sure it is right now.

Is it just me, or should I be bothered by this pamphlet which I received from Quest Diagnostics?  Again, the wording on the pamphlet sent to me, a primary care doctor, at my home address, recommends “chromosomal microarray analysis is recommended as a first-tier test …”.  I struggle with the wording, which omits “by clinical genetics”.  I am not saying that geneticists should not order this test; they probably should.  I am saying that sending this pamphlet to pediatricians, who see scores of patients who may have positive screening tests for autism, seems a bit bold.

Pediatricians should refer patients they are concerned may have autism spectrum disorders to a specialist.  Their concern may arise from a gestalt, or from a formal screening test, such as the M-CHAT-Revised. If this screening test (which costs only time to complete) is positive, a referral to a specialist and a community early intervention service resource is indicated.  One such specialist is a clinical geneticist; another might be a behavioral/developmental pediatrician or a child neurologist.  In addition, each state has its own individual process for early intervention service referral.

People wonder why the costs of health care are so ridiculously high.  I agree with this sentiment: costs are too high!  I do believe that we should be referring patients and interacting more with our genetics colleagues about patients with whom we might be considering certain diagnoses, such as autism spectrum disorders.  But I wonder if general pediatricians are the right audience for such an advertisement for a specific diagnostic test.  I certainly can see this pamphlet sent to the offices of clinical geneticists.

I think the point of the IOM meeting recently was to improve the education of primary care physicians.  IOM: consider your goal achieved, with this primary care doc (me), at least.  I wonder how many of my primary care colleagues are now ordering this chromosomal microarray test in patients who have a positive (abnormal) screening test, versus just referring.  Something tells me that chromosomal microarray analysis is not a cheap test either.  But that’s a discussion for a future blog.

Saturday, August 23, 2014

Residency, Success, Team Sports and Being a Member of a Team

In a recent medical education twitter chat, other medical educators and I were discussing success being tied to previous experience playing a team sport.  It stemmed from this article, which suggested that success in residency (otolaryngology) may be more likely if one played a team sport earlier.  This is a fascinating observation, and one that I hadn’t thought of when interviewing applicants.  Others commented that there may be bias since in early schooling, boys are more likely to be members of team sports than girls.

It is interesting that residency program directors really struggle with trying to find the magic bullet that will determine success.  What does “success” really mean?  For program directors, I suppose it could mean having a resident who performed very well clinically, who was not a rabble rouser and thus “caused no trouble”, and who received excellent evaluations throughout training.  It could mean impeccable surgical outcomes for procedurally-related fields (although there are other factors besides a resident involvement in surgery that might affect surgical outcomes).  It could also mean getting a job and starting a practice after residency, or securing a fellowship after residency training.  I really don’t think there is ONE thing that defines this success. 

There may be success on a test (such as passing a board examination): that has been studied.  The old adage: “past performance predicts future performance” is true with regards to tests, in my opinion.  How this translates for programs directors is that those students who performed well on USMLE Step 1 and/or Step 2 are more likely to pass the board examinations after residency.  While this is only one aspect of “being a doctor” (using competency language, it would be the competency of medical knowledge), residency programs are indeed being evaluated on this measure of board pass rate.

There may be success regarding professionalism. Some might take the reverse approach.  When one is unprofessional, what factors predict that unprofessional behavior? This has been studied by Dr. M Papadakis, and basically, past “unprofessional” behavior in medical school predicts future disciplinary action by state medical boards. 

There may be success in securing a match position.  Many educators have published on this, such as this from plastic surgery

I have heard many references over the years that medicine is a “team sport”.  No one takes care of a patient by only herself/himself.  We really need a team to help patients optimize their health.  I believe that the field of geriatrics models this very well, and has described training on working in multidisciplinary teams.  The importance of teams in medicine has also been outlined for patient-centered medical homes, such that teamwork competencies need to be defined.

One of my mentors (a female) has mentioned “I love seeing applicants who were Eagle Scouts”.  I have heard others who get excited seeing certain extracurricular activities, such as volunteerism, on a written application.  Like others, I certainly enjoy reading some things on an application more than others, but I really haven’t found any one thing that predicts success. 

To me, it is not just the application that is important. The application gets you in the door [for the job interview], but the interview gets you the job.  As for defining success: well, we in medical education have a long way to go before we are able to pinpoint that one down.

Sunday, August 17, 2014

Tweeting the (Medical) Meeting

I am currently in the airport on the last leg of a brief trip to present to the Institute of Medicine about using emerging technology in medical education. I am very pleased that the IOM has agreed to use a second screen to showcase a live Twitter feed during the meeting.  I have used this “second screen” option for several presentations over the past few years; it is done as an attempt to demonstrate live the content that is being highlighted: an opportunity for communication and discussion within medical education in a unique format.
I have written about this in the past.  However, this piece from a few days ago cautioned folks who do tweet the meetings.  Dr. Bryan Vartabedian wrote this phenomenal piece on “tweeting the meeting” earlier today.  I concur 100% with his eloquent, succinct statements that really get into “what it is all about” at such meetings.

I hope the demonstration tomorrow goes well.  If interested, please follow the hashtag highlighting this meeting: #IOMgenomics.  My part is “Innovative Models of Education: Using Technology Appropriately in Medical Education” and starts around 9:45 am EST on 8/18/14.  As always, feel free to follow the #meded chat as well.

Friday, August 15, 2014

Open Payments: Impact on the Noble Profession of Medicine

This blog is a follow up to my previous post dated August 4, 2014 on the Open Payments website related to the Sunshine Act.  In that post, I mentioned the opportunity for physicians to review their own data (as submitted by industry manufacturers) and, if said data were not correct, to formally dispute that data.  However, the website went down after errors were discovered in the submitted data.
Since that time, physicians have been very frustrated that the site was down.  I have had very intelligent faculty members (including a chair of a department) contact me to help with figuring out the process.  Fortunately, the site just opened up yesterday, 8/14/14, and again, physicians could review their own data.  

The Wall Street Journal detailed a piece yesterday mentioning the site as back up and operational, and that the review period to submit disputes would be extended by the number of days that the site was down.  That would make a quick turnaround time for the correction period to be completed before September 30, 2014, the day that that the site was to be officially open to the public.  CMS itself came out with a statement today describing identification of “the problem”, and instituted a system fix to prevent similar errors.  The WSJ followed up today with an updated post highlighting CMS’ position to stick to the September 30, 2014 deadline.

Here is the kicker: CMS will actually withhold approximately 1/3 of the data from the site, due to “intermingled data”, according to a piece earlier today from Charles Ornstein of ProPublica.  “Intermingled data” translated into the fact that physicians were being linked to medical license numbers of NPI numbers that were not theirs.  I cannot fathom how this is possible, as each physician is provided with a unique NPI number.  CMS itself even has an explanation of the NPI number here:  and anyone can look up an individual physician’s NPI number here or here.

If a physician has received no monies from industry, here is what the site will show (in full disclosure, this is the applicable portion of the screenshot from my own log-in):

So where do we go from here?  First, the word needs to get out to physicians that the site is back up, and they should register and review their own data.  The unfortunate problem is that the process is quite complex, and likely takes at least two hours of time to complete all the necessary steps to be able to view the screen above.  A nice explanation of the old timeline and the revised timeline for the dispute period is found in this post

I am all for disclosure and full transparency, but this registration and review process is overly burdensome for physicians, in my opinion.  We need to spend more of our time with our patients, and less time completing administrative duties (translated as “paperwork”, or in today’s current EMR-heavy environment: “computer work”).  The Open Payments system as it currently stands clearly falls into the burdensome “computer work” bucket, and I hope that the process can be simplified in future iterations.  Physicians and other health care providers need to advocate for what makes the profession a noble one: the patient-physician relationship, not time spent trying to comprehend flawed information from a flawed computer system.

Monday, August 4, 2014

The Sunshine Act and Open Payments

Today was a busy day for news about the Sunshine Act and Open Payments. I was asked to present pertinent information about the Sunshine Act to some of the leadership of the medical school where I work, the Indiana University School of Medicine, about this topic.  Essentially, the Physician Payment Sunshine Act (PPSA, shortened to “Sunshine Act”) came out of the Affordable Care Act, and requires that manufacturers of drugs and medical devices (which I'll call “industry”) collect, track and report all payments and financial relationships with physicians and teaching hospitals.  This system was designed to establish a transparent national disclosure system.

As a result, the Center for Medicare and Medicaid Services, or CMS, was tasked with creating a website that provided information about these relationships so that the public can make informed decisions.  That website is known as “Open Payments”.   

As of the time of this writing, for approximately the next three weeks, the “Dispute” period  is still open, whereby individual physicians can register on the website, and review their own data.  If one feels there is a discrepancy, then s/he can file a dispute that industry companies will need to review, and ultimately reconcile.
For my presentation today, I carefully made detailed slides for the leadership to share with the faculty.  I decided today to add in some screen shots of what the report looks like to an individual doctor.  To my dismay, this was the screen I found.

Intrigued with the word "portlet", I sent a request to the CMS Help Desk.  I was pleased with the response time of just a few hours.  This was the response:

[The] portal is down for maintenance at this time.  There is no ETA at this point, but we are working to get this resolved as soon as possible.  We apologize for any inconvenience and Thank you for your understanding.
For further questions please feel free to contact the open payments help desk at 1-855-326-8366.  We are open Monday - Friday from 7:30 am to 6:30 pm CST, excluding Federal holidays.

Thank you,

Open Payments

I wondered what the issue could be.  It turns out that earlier today, this piece was posted by ProPublica.  
How timely! 

I really do hope for two big fixes.  First, that examples like this one here (which generated the ProPublica story) are rare.  The registration to gain access to one’s Open Payments information is complex and cumbersome (the User Guide is unfortunately not much simpler, at 359 pages in length), which one might assume means that CMS is really trying to make sure that someone who logs in is indeed who s/he said s/he is.  Second, that the website can be opened back up very soon. Time is slowly ticking away in the Dispute period.

I am all for transparency, but if a system is going to be put in place to “provide the public with information to make informed decisions”, the information in that system needs to be a) relatively easy to access, and b) correct first and foremost.  It would make sense to me that at the least, industry use the NPI numbers (each physician is assigned a unique number for ONLY that physician and no one else) to insure that physicians with similar names are not mixed up.

-For information about the Sunshine Act and the Open Payments process, see this from the AAMC. 
 -For a step-by-step process about how to register, review, and potentially dispute one’s data, see this from Stanford, along with this FAQ.
 -For a very recent survey of industry and of physicians (85% of whom stated they would like to review their own data BEFORE its submitted to CMS; 7% actually have reviewed their data, however), see this.

By the way, the presentation went fine.  Faculty leaders had great questions.  The take home discussion from many who have already gone through the process: allot two hours for the entire process of registering, waiting for clearance, and potentially for disputing any data that one feels is incorrect.

Fellow doctors, please take the time to review the process and your own data.  After all, we are curious about the details.

Tuesday, July 29, 2014

GME Funding: A New Recommendation and Discussion

Today, the Institute of Medicine (IOM) presented a recommendation report on the future of GME funding to meet the health care needs of the population.  

In this report, the IOM experts suggested a 35% drop in the amount of current payments to teaching hospitals for GME.  Among other things, five principles for reform were described: accountability, meeting the needs of the public, innovation, stability in the funding, and aligning education and clinical care.  They also discussed the creation of a GME Policy Council within HHS to help develop a strategic plan for a physician workforce, and phasing out direct and indirect medical education in favor of a global operational fund.

Other constituencies quickly provided comments voicing their concern over the IOM’s specific recommendations.  The AAMC’s comments were titled “IOM’s Vision of GME Will Not Meet Real-World Patient Needs”, and stated: “ …the IOM’s proposal to radically overhaul GME and make major cuts to patient care would threaten the world’s best training programs for health professionals and jeopardize patients, particularly those who are the most medical vulnerable.”  

In addition, the American Hospital Association noted: “Today’s report on GME is the wrong prescription for training tomorrow’s physicians.  We are especially disappointed that the report proposes phasing out the current Medicare GME funding provided to hospitals and offering it to other entities that do not treat Medicare patients.”  

So what do I think?  This is a very complex issue, first of all.  I do believe that GME funding needs to change because, fundamentally, we (the health care system and the training of future physicians within that system) need to meet the future health care needs of the population.  I believe that we do need more physicians, not fewer.  While reform is likely important, it is costly to educate residents.  Just look at colleges, and how much it costs to educate undergraduate students.  The same is true for residents.

So where do we go from here?  I am not sure, but as a residency educator, I hope that today’s recommendations do not jeopardize the fine training program that I have the privilege of overseeing and other outstanding educators across the country also oversee.  I hope that educators who do the day-to-day work to train the physicians of tomorrow are listened to.  I hope that residents who are currently in the training programs can have their voices heard too.  Let’s advocate for GME to continue to train competent residents who will leave and be ready for independent practice, and for funding that can accomplish that.  After all, THAT is why we are here, to provide much needed health care to the patients.  In all of the discussions and counterarguments, that needs to be the essential core.  As Francis Peabody stated in JAMA in 1927: “The secret in caring for the patient is to care for the patient.” 

Sunday, July 20, 2014

GME Funding

A recent post from the NY Times discusses the issue of the physician workforce of the future.  I believe it accurately describes some of the concerns about GME training.  Yes, GME training is indeed the bottleneck by which new physicians come into the workforce.  Yes, we need new physicians (and other health care professionals) to care for an aging population.  We especially need primary care physicians for this, but we also need general surgeons, many types of subspecialists, and we need physicians to go into underserved areas, particularly rural areas.

There are bills that, if passed, could help fund more GME slots.  Dr. Atul Grover from the AAMCdescribes them well here in this post.  Residency programs accredited by the ACGME take new graduates from medical school, and appropriately train them to go out and practice medicine independently.  I also personally disagree with a proposal from Missouri that advocates for "assistantphysicians".  Simply put, these graduates need adequate training (a minimum of 3-4 years for most residency programs, with some like neurosurgery taking as long as 7-8 years), and that is what GME provides.

Please advocate for future GME funding: it is the best way to begin to create a physician workforce that will help care for our society.

Saturday, July 5, 2014

Scholarship, Emerging Technology and Medical Education

Those who know me know my interest in emerging technology in medicine and medical education continues to flourish.  I am always looking for ways that technology can help drive medical education.  Specifically, social media has the capability of disseminating information to a much greater number of learners than in the past via traditional formats.  One such example is this great video by the AAMC on using wearable technologies in medical education, featuring Dr. Warren Wiechmann.

In discussing this within my academic environment, conversations almost always come back to scholarship, specifically, publishing in peer-reviewed journals.  Articles on the use of social media in medicine are sparse, but are beginning to crop up in mainstream medical journals.  Leaders such as Dr. Terry Kind are really demonstrating the impact via a scholarly approach.

It is with excitement that I read some recent articles (this and this) by some innovators in emergency medicine that can get physicians started using online resources and thinking about peer review with respect to blogs.  Simply put, these articles are phenomenal!  It is exciting to see that journal editors are beginning to see the impact of technology and social media for their readers.  

With this blog, I am excited to announce a new opportunity for me: as social media editor for the Journal of Continuing Education in the Health Professions (@JCEHP).  I thank JCEHP's senior editor, Curt Olson, for his vision to allow me to become involved in growing the journal's reach by utilizing social media, specifically twitter.  In the coming year, we will work on creating and disseminating information via a blog for readers to provide comments on articles of interest, and will push content out to those interested via online social networks.

There are great ways of using social media for the betterment of medicine and medical education.  One such way we have been utilizing at the Indiana University School of Medicine is to tweet our Pediatrics Grand Rounds (follow on Wednesday mornings, 8 am EST, at #iupedsgrrounds), which we've been doing for several years now.  But how do we show (in a peer-reviewed journal) the impact of this activity?  Many specialties have written about tweeting national conferences (including Oncology, Surgery, Nephrology and Urology, to name a few).  

So how can we demonstrate this impact in the JCEHP journal?  By including a presence within social media, we hope to start a conversation on how social media can provide an impact within medical education.  It's a start, but we have to start somewhere.  I'm excited to be a small part of this journey, both at my institution and at JCEHP.

Wednesday, June 4, 2014


This last week, our institution hosted the 2nd annual Mobile Computing in Medical Education conference.  Our keynote speaker, Dr. Bryan Vartabedian from Baylor, spoke eloquently about the “public physician”, and what literacies the physician of the future may need in order to succeed.  Audience members asked about how emergency medicine providers such as Dr. Zubin Damania (AKA ZDoggMD) seem to be ahead of the curve on social media and blogging.  Bryan himself later blogged about it here

In addition, Dr. Aaron Carroll, one of my IUSM pediatric faculty colleagues, blogs often on a variety of health care topics in today’s society.  Here is one of his recent blogs. 

Reading these helped me reflect about my own blogging and how I could do better. So what is the “secret sauce of success” related to blogging in health care?  From the examples above, it seems so simple.

Tip #1: You have to have something to write about.
Tip #1.5: If you can include a reference or a link, it adds some credibility.
Tip #2: You have to keep it short and sweet.

So here’s my attempt to take my own advice.

From #1, today’s blog is about blogging. 
From #1.5, see this reference.
From #2, I need to end this blog very soon.

If you have something to say, say it; the fewer words, the better.  Thanks for reading.

Saturday, March 1, 2014

Burnout and Resiliency in Medicine

I have not blogged in a while; there are many reasons for this, including many things going on in my life as well as with my work as a medical educator and administrator.  The weather here in the Midwest has also been challenging this winter (and another storm headed this way over the next 24 hours) which likely has contributed to my lack of blogging.

Nevertheless, I really enjoy what I do and find meaning in my work.  In fact, a timely discussion with residents during a teaching clinic highlighting this really hit home.  We were talking about burnout and ways to combat it.  The practice of medicine is hard: helping improve the health of our patients is a privilege which brings great responsibility.  This can, however, impact physicians’ own lives in various ways.

Social media itself (in the form of blogging) can be a great tool to ease burnout in medicine.  See this recent blog on this very topic. 

Can burnout be prevented?  What about resiliency in medicine?  Does one's resiliency lessen the potential impact of burnout?  Our institution is proud to host the FIRM (Finding Inspiration and Resilience in Medicine) conference on April 25, 2014.  This conference is being organized by medical students, which really demonstrates how our future generation is paving the way for the necessary changes to the way medicine can and will be practiced.  At that conference, one of our own faculty who wrote a recent post on this topic will be featured. 

So what steps do you take to prevent burnout?  How can you develop the resilience necessary to stay on top of your game and be the best you can be for patients and for yourself/your family?  Some have described interventions during training that impact burnout.  These curricular efforts should be applauded, and are one step towards an improved culture in medicine that helps everyone: patients and health care professionals alike. 

Wednesday, January 15, 2014

CPR, High Value Care, and MedPeds

What a whirlwind of a day today.  Lots of productive meetings, and some incredible learning along the way.  I have two “A-HA” learning moments from today.

The first was our Pediatrics Grand Rounds at Riley Hospital for Children.  Our PICU physicians set up a truly innovative Grand Rounds to have a discussion about the topic of “Do Everything?” regarding pediatric patients in the ICU.  It was co-hosted by a nurse researcher at our Ethics Center who has studied "Moral Distress", and a PICU nurse who provided an amazing perspective to the discussion.  It featured two role playing scenarios in how health care professionals speak with families of terminally ill children about CPR.  It was a great way to engage the audience to think about how families understand outcomes from CPR.  A critical learning point of this topic, common to many regarding patient-physician communication, is to avoid overly complex medical terminology, or jargon, when speaking with families.  In addition to talking about using language that matters, we discussed this paper from 1996, in which the authors evaluated the rate of successful CPR on television shows and compared it to the actual rate of survival in real patients.
This blog here is a recent update to that piece with a great infographic comparing the rates on specific shows.  The other great part was that this grand rounds was totally packed: not an open seat in the room!  For a CME person like myself, it is nice to see that so many participants were able to benefit from this presentation.  My tweets from today (1/15/14) convey much of the content of this educational session, for those with further interest on this topic.

Secondly, I am proud to announce that we piloted our first “High Value Care” curriculum to our MedPeds residents today.  The ABIM Foundation has been leading the charge on this, with the creation of the Choosing Wisely campaign.  Luckily, we did not have to reinvent the wheel, and were able to utilize this amazing high value care teaching resource from the ACP which was recently rolled out.  The residents were as engaged in this discussion as they have ever been.  I think this phrase captures their sentiments: “We want to be part of the solution to the costs of health care crisis and not just order tests indiscriminately”.  I couldn’t have been more proud!

For those interested in finding and using ready-made resources to teach cost-conscious care to residents or students, I can say that we were able to easily complete one of the five current modules with 8 formal multiple choice questions in less than one hour, with ample opportunity for robust in-depth discussion of some of the points.  We elaborated on clinical decision making in the context of cost conscious care.  Kudos to Dr. Daisy Smith of the ACP for creating these online modules that educators can use “off the shelf” right away in their training programs.  One does not even need to be an ACP member to gain access to these modules!

Looking back on these two topics noted above, I now see that they are a perfect example of the variety of training in MedPeds: both a Pediatric topic and an Internal Medicine topic in the same day!  Hooray for MedPeds!  I only hope that other days can be as “educationally productive and rewarding” as today was for me.