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.