Saturday, May 23, 2015

Using Technology for Lifelong Learning in Medicine

I think that in the current age of “everything at one’s fingertips”, in the form of mobile devices like smartphones and tablets, the concept of lifelong learning has never been more important.  How does a physician “keep up”?  What are the skills that are important for physicians to have?  Dr. Vartabedian has written extensively on the subject of the digital literacy that is needed for today’s physicians.  Curating, collating, and how to find what one needs are skills that need to be taught, not only to students and residents, but also to practicing clinicians.

Given the plethora of sources available, I am seeing trainees more and more asking “what should I read/study?”  This is interesting, since there never have been more resources available than in today’s age.  I’d like to give just a few examples of tools that I find incredibly helpful.

[Full disclosure, I have no financial conflicts with any of these tools mentioned.  My spouse is an emergency physician in community practice.]

Browzine.  I use this resource on a mobile tablet through my institutional library subscription.  It allows opportunity to get full text articles from most of the journals with which our library has a subscription.  It is also great to review table of contents quickly, with fast linking to the full text if I want to read more.

NEJM Knowledge+. This resource is a way to review content for internal medicine (and family medicine) through adaptive learning, which is very unique.  I think of it as “smart testing”, whereby one inputs both answers to multiple choice questions, as well as her/his confidence in the answer provided.  Here is a link to an explanation on this type of learning.  I have used my own account to choose questions for residents during education conferences, and the engagement from the residents has been quite impressive.  There is also an opportunity to purchase an account for an entire residency program.

ALiEM: this is a compendium by emergency medicine specialists which is an incredible resource for those interested in this field.  It includes posts on staying healthy, links to apps pertinent to caring for patients in an emergency setting, resources for teaching in emergency medicine, as well as learning emergency medicine.    I especially like the videos describing procedures in the ED setting.  For those interested in improving their educator skills, the MEdiC links are incredibly helpful.

Twitter: there is an incredible community of practice related to medical educators on Twitter.  I learn so much from folks I have met, and also many I have yet to meet in real life.  A Thursday evening, 9 pm EDT Twitter chat on medical education topics is a great opportunity to start learning from others.  For literature on this topic, see these two articles: one on using Twitter as a learning tool, and one on social media for lifelong learning


I am curious what other online resources and technology that others are using for their own lifelong learning.  

Wednesday, May 13, 2015

Lifelong Learning in Medicine

Physicians and other health care providers are incredibly busy.  The administrative burdens have never been greater, they must learn to “keep up” in their respective area of practice, and caring for patients is a complex set of skills that takes time to achieve proficiency.  Recently, there has been a flurry of conversation in medical education about lifelong learning, including this piece on the interplay of social media and lifelong learning.  Most would agree that lifelong learning (whether self-directed or otherwise) is an important skill.  In fact, we teach this early on in medical school, and continue to stress the importance of lifelong learning during residency training and again in practice.

This post by Dr. John Mandrola on the NEJM Knowledge+ blog really hits home with respect to lifelong learning for practicing clinicians.  I really appreciate the last point about finding one’s own strategy for lifelong learning.  I struggle with optimal formats for “teaching” people to have a strategy.  Some excel at this skill, and others really need to work at it.  I think that maybe modeling it to trainees could have an effect (“Someday, I want to be like Dr. X; she is always striving to learn, even after 20 years in practice”). 


I do believe that given the rate of change in medicine, it is paramount that physicians consider the important of lifelong learning.  After all, our patients will ultimately benefit from our efforts to be lifelong learners and to stay current in our practice of medicine.

Sunday, March 1, 2015

Residency (GME) Positions: Addressing the Nation's Healthcare Needs

I’ll start this post with full disclosure: I am a medical educator, and have spent a good portion of my professional life educating trainees (residents) to prepare for independent practice.  My specialty is combined internal medicine-pediatrics, or “Med-Peds” for short, and my personal clinical practice is primary care for the underserved.

I have been very interested in what the future health care environment will look like, and thus follow updates from agencies that comment on the future of health care, as well as the supply of physicians and other health care providers.

There are some facts about which very few disagree, and there are others where interpretations are very different.  We do know that many new medical schools have opened up within the past few years, and also that many existing medical schools have increased matriculation. 

From this, it would seem as if the supply of physicians to care for future generations is being addressed.  But remember that, to be a physician practicing independently, one must graduate medical school, and also complete residency training.  It is this part, the percentage of residency training positions, which has NOT increased as much as the medical school matriculation.  The actual number of positions has increased, but not at the same rate as medical school graduates (see Figure 1).  In short, the “bottleneck” for US students to become practicing physicians is indeed US residency positions, known as GME, or graduate medical education.  The National Residency Match Program (NRMP) does state that there are enough GME positions for all US graduates, but there are other graduates (from international medical schools) applying for these same positions.

This was a busy week for such projections.  The AAMC came out with a roadmap earlier this week describing plans for how to address this situation.  The Commonwealth Fund, however, delivered another interpretation of the situation, stating that the current healthcare situation can handle the influx of new patients as a result of the Affordable Care Act.  This follows on the heels of the IOM report last year addressing the GME issue and recommending no additional funding for new residency positions, among other things. 

So who is correct?  I admit my biases on this topic, in that a) I am an educator, and attend the AAMC meetings, and b) I practice in a state where even the Commonwealth Fund writes that there are fewer primary care docs.  For the record, our Med-Peds residency program is the largest one in the country, and has been for at least 20 years.  About 40-45% of our graduates choose primary care as their ultimate specialty, higher than either hospital medicine or further fellowship subspecialty training.  This percentage of graduates choosing primary care was higher in the 1990s.

I’m curious what readers of this blog think about the situation.  Is there a doctor shortage, and is there a shortage of primary care physicians?  Will patients be able to get access to health care given the influx of new patients into the health care system?  What else should be done besides the roadmap outlined by the AAMC?


Thanks for reading; I’m curious to hear differing opinions.

Saturday, February 21, 2015

Storytelling, Narrative Medicine and the Digital Age

Narrative medicine and reflective exercises have been a very important tool in the education of medical professionals.  With social media's integration into the fabric of society, it is important for today's trainees to understand the implications of public storytelling on one's professional persona.  This recent editorial and article on the topic in the journal Academic Medicine this month describe the divide between digital natives and digital immigrants, and how each might have different viewpoints of how storytelling is disseminated.

And then here is another recent piece in the Atlantic about the topic, in which the author reflects on her writing about a patient experience and whether it should or should not be published.

I don’t claim to have any of the answers for this myself.  What is the correct approach to disseminating storytelling or narratives about patient encounters?  Do others learn from it or not?  Some pioneers are addressing this situation directly.  Dr. Bryan Vartabedian, who has spoken at our institution about the public physician, has just announced a MOOC related to Medicine in the Digital Age.

What I do know is that medical schools really MUST teach this material to students and trainees.  It is our obligation to the future of the profession to understand digital literacy and the impact of our storytelling on patients, each other and ourselves, given how easy it is to push out blogs into the public space.


Thanks for reading.

Thursday, January 29, 2015

Enhancing Social Media within Medicine

So Twitter recently announced that it now has a video feature (up to 30 seconds).  See this post.

I wonder how we can use such an opportunity in medicine and medical education,  Will short snippets or "nuggets" of information now be sent via Twitter from one doctor to another?  Interesting to see what will come of this.  The hope would be that health care professionals would use it for dissemination of information that IS allowed in the public space, and not to violate privacy laws.

For those interested in learning more about social media within medicine, here is a nice review from JMIR on the topic, published within the last year.  The enhancement of such services is a great example of how innovation in technology has the potential to improve communication and education.

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!

Alex

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.