Medical School Graduation: The "Calling"

Today was graduation for the Indiana University School of Medicine (IUSM).  It was a privilege being a part of this special day for the graduates; I was honored to be a recipient of a Trustee Teaching Award, and so I was able to sit on the stage for the ceremony and watch all of the graduates receive the hood, as well as congratulations from the Deans.  What an awesome spectacle!  Over 300 IUSM medical students became physicians, and their names now all end with “MD”.  Very cool!

I wonder what others think about graduation ceremonies.  It is a long day for all; the room is packed with people (there were over 3000 at the Sagamore Ballroom at the Convention Center in downtown Indianapolis). Parents, grandparents, spouses, significant others, friends, children and others were able to witness this special day for the graduates.  I saw the pride in so many faces.  Eight of them will be joining me as part of the IUSM Med-Peds Residency Program (sorry, my pics didn’t turn out so great; you all walk too fast!).

One student who would have graduated today passed away earlier this year.  His wife spoke to those in attendance after an honorary posthumous degree was granted.  There was not a dry eye in the room, including my own.

This year our amazing Dean, Dr. D. Craig Brater, is retiring after over 25 years of service to the IUSM. He will certainly be missed, and has been the face of IUSM, leading us with honesty, integrity, and humility for 13 years.

In addition, graduation today included a keynote speaker, Dr. Tom Nasca, the CEO of the Accreditation Council for Graduate Medical Education, which is responsible for graduate medical education in the United States.  It was an honor to meet him before the ceremony.  Dr. Nasca is probably one of the busiest physicians in the United States now, overseeing the accreditation of all of the training programs of residents and fellows.  He is an internationally known medical educator.  We were blessed to have him be part of the ceremony.

In his address today, he showed no slides about duty hours.  He did not mention Milestones or competencies.  Rather, he focused on the “why” of going into medicine, as a “calling”.  He told a story about a dialysis patient who had an incredible impact on him when he was in nephrology training.  He reiterated why many of us choose medicine as a profession: to care for others, and delved into the impact that a patient can have that teaches us as physicians or physicians-in-training.  This was inspiring, and helped me to reflect and understand why I do what I do: to help patients, to train the doctors of the future, and to help educate students, residents and faculty in some small way. 

To all the medical students graduating and becoming physicians over the next few weeks: kudos to you for all of your hard work.  The journey is not yet over, and the learning is really just beginning!  Be proud of your amazing accomplishments, but more importantly, embrace what lies ahead.  The opportunities to do good in the world, and care for others, are now coming to fruition.  Congratulations to the class of 2013!

P.S. If you were wondering, yes I did tweet parts of the graduation.  Check out the hashtag #IUSMGraduation for tweets and pics.

Technology in Medical Education

I was given the privilege of presenting the keynote talk at a faculty development session for the Indiana University School of Medicine Department of Emergency Medicine earlier this week.  The theme of the entire day was using technology in education.  The opening speaker, Dr. Bart Besinger, gave a phenomenal talk on “How to give a lecture with or without technology”.  It was one of the most engaging talks I have ever heard, and included practical information and tips for making one’s didactics top notch!  Later in the day, the topic I spoke about was the use of social media to communicate and teach in medicine.  It was a wonderful opportunity to network with colleagues from outside of my own departments, and I found the faculty completely engaged and willing to try something new.

We discussed some of the literature on the use of social media in medicine and medical education, and how educators can leverage social media as a tool to disseminate medical information.  The highlight came at the end, when we taught the faculty how to use Twitter.  The goal was to have 5 new faculty join Twitter.  Many more joined, and the discussion was nothing short of fabulous.  It was clear that the faculty were wholly accepting of taking the plunge to use Twitter in medical education (the hashtag used was #IUEMFacDev).

Today, the learning that took place just two days ago was put into action.  The faculty used a hashtag (#IUEMTalks) for their own lecture series.  Kudos to Dr. Dan Rusyniak, for putting on this great workshop.  I appreciate so much the invitation to share and learn from emergency medicine faculty colleagues, as well as the  willingness of so many to put into practice this new learning tool. 

Here is a link to the workshop handouts.

In an upcoming venue, our institution is privileged to host the 1^st inaugural Mobile Computing in Medical Education conference on May 31, 2013, in Indianapolis.  In this conference, we will showcase several different ways in which medical students, residents, fellows and faculty utilize mobile tablets in medical education.  We look forward to sharing the learning opportunities in this one-of-a-kind conference.

So how are you using emerging technology to further medical education?

Residency Match Day

The residency match just concluded last week.  For those unaware of this annual event close to the end of medical school, students interview with and rank residency programs, and programs do the same with interviewing medical students.  Information about the results of the Match can be found here. 

Students found out their individual match results on Friday, March 15, 2013, opening envelopes with the name of the program where they are headed for their residency training.  It is an incredibly anxiety-provoking yet exciting event that most physicians remember for years to come.

From the program point of view, I am ecstatic to see the names of the medical students I have the privilege of training for the next four years after they graduate in a few months.  This year was no exception.  I couldn’t be prouder of the students matched to my program!  The joy that comes from observing the opening of the envelope and just knowing where one will spend the next few years is a sight to behold.

With the advent of smartphones and tablets that can capture moments like Match Day easily, it is exciting to see how different schools approach this rite of passage.  There was even a Twitter handle to capture the information across the country: #Match2013.  Below is a short list of how some medical schools “observe” Match Day.  The list is certainly not exhaustive, but is fascinating to show how different schools approach Match Day festivities.

Baylor

Cincinnati  

Einstein

Michigan  

And some, like my own institution, Indiana University School of Medicine, found students who threw a bit of humor into the day:

Indiana 

Congratulations to all of the students who matched!  May your futures be bright, and may your passion for caring for patients continue to flourish!

Promotion and Tenure: Peer Review

In the world of academic medicine, Promotion and Tenure (P&T) refers to the process where someone “applies” to rise up the ranks from Lecturer, to Assistant, to Associate, and ultimately, to “Full” Professor.  There are set criteria for this process set forth by academic institutions.  I am impressed at how the P&T process at my institution is disseminated out to faculty: complete transparency in what the expectations are.

I recently attended a session for faculty to teach us about this process.  I have been to these before, but I learn something new every time I attend these.  It allows me to understand what I need to be doing within a timeline, what data I need to collect, and how I should go about crafting my “personal statement” (akin to the same personal statement one writes for residency applications).

While hearing about the criteria at a faculty development session on P&T, I learned about different ways to apply scholarship.  I am pleased that my institution uses the word “scholarship” instead of “research”, because scholarship is more broadly defined and does not restrict it to only publishing papers in traditional medical or scientific journals (although those are still the “holy grail” of scholarship).

Given my interest in social media, and blogging, I asked a simple question: “Would describing my blog and my foray into social media through Twitter be considered scholarship?”  After all, my blog is really about Medical Education in general (it is even in the title!).  It was a simple question, as at the time, other examples of scholarship besides publications in mainstream journals were being described.  The answer came in the form of a question: “Is your blog peer reviewed?”

Apparently, having something be “peer reviewed” is a critical step to making it “count” as scholarship (in the eyes of P&T, at least).  Another step is “retrievable”.  Whew!  That one is easily attainable—but the peer reviewed part—I’m not so sure.

It got me thinking.  How can we “peer review” content disseminated via social media, with respect to medicine or medical education?  A great blog here (from earlier today!) describes a future direction of medical education, called “FOAM”.  In it, the author describes the lack of peer review, but also calls into question the “traditional peer review process”.  What I love is a reference to an article titled “Peer review: a flawed process at the heart of science and journals”, which, undoubtedly and ironically, required peer review, to get into the journal in the first place.  Another article describing a survey to chairs related to E-learning as educational scholarship concludes that chairs feel that e-learning is valuable as scholarship. 

So here is the question to ponder: how can those who blog or use other social media tools within medicine or medical education achieve the “peer review” criterion for P&T?  Or should we call into question that criterion, as demonstrated in the article?  Given the explosion of social media (including blogging) in today’s society, should we push to abandon or adapt the “it needs to be peer reviewed” component necessary for scholarship within academic P&T committees?

At this time, I am still crafting my own opinion on this, but figured “Why not crowd source the question and see what others think?”  In reality, that is a version of a “peer review process” in and of itself.  Please feel free to weigh in on this topic; I would love to know your opinion.

Reflections on ACEHP13 - Halfway Through

The Alliance for Continuing Education in the Health Professions annual conference is going on right now in San Francisco.  It is about halfway done now, and this post is a series of my thoughts so far based on discussions I have had, or comments people have made in workshops or plenary presentations, that have impacted me as a part of my personal learning network.

1.       The far-reaching, ultimate goal of continuing education is really about improving and optimizing patient care, specifically at a population/community health level.

2.       Quality improvement and patient safety are not fads; they are an integral part of the practice of health education, and linking education to these areas is crucial to achieving #1 above.

3.       Research about education practices is critical to advance the field.

4.       There is a broad scope of activities beyond “live activities” for education of health professionals [I especially like Performance Improvement CME and Point of Care Learning CME as examples, and we need to be doing more of these].

5.       Emerging technology is becoming more relevant every day in continuing education, and we need to embrace it rather than shy away from it.

6.       We need a new paradigm for health care education that needs to be learner-centric, ultimately to achieve #1 above, and communication skills will be a critical component of that education.

7.       Engaging all members of the health care team (from physicians to pharmacists, from nurses to social workers, just to name a few) is critical to the success of optimal patient care and #1 above.  This includes interprofessional education, and also interprofessional practice.

So what do you think?  What are some other take-home points from the conference so far?  Please let me know by coming to the breakout session I am privileged to host with Dr. Jennifer Gunter on February 1, 2013, at 3:15 pm, on “Perspectives in Learning Through Social Media”.

Mobile Tablets in Clinical Medicine

I read this piece on perception of professionalism around use of mobile tablets in medicine this morning, and it struck a chord with me.  I am the first to admit that I have had both formal and informal discussions with medical students and residents about looking on smart phones or tablet in the middle of rounds.  I have discussed it in a variety of terms likely related to “this is not professional, and it appears to me as if you are disinterested.”  The traditional thinking is that the learner is bored and/or distracted, and either surfing the internet, checking email, playing a video game or doing some other activity besides listening intently on rounds.

However, this survey article on the use of mobile computing by trainees is quite intriguing.  40% of academic physicians and trainees said they owned a mobile tablet, and 50% of those, or 20% total, use them for clinical medicine at the point of care.  That is a lot, and I bet the number is growing daily.  Many residency programs have begun purchasing mobile tablets for their trainees specifically for the use in the clinical arena, either for the purposes of medical education, or direct patient care activities.  The University of Chicago Department of Medicine residency program even published outcomes on the impact of providing trainees with tablets.

So what should we do about the professionalism issue?  One thing I would suggest is calling out the “elephant in the room”.  Trainees could actually state up front to their faculty instructors that they use their tablets to look up information.  Second, faculty could embrace it, and have, for example, “tablet breaks”, where in the middle of rounds, for 5-10 minutes, everyone could stop, take a break, and look at their tablets for whatever they wanted (be it looking up information, checking email, or whatever they feel is important for themselves personally). [credit for this idea goes to my Executive Associate Dean for Education, Dr. Maryellen Gusic, who suggested it to me].  Third, faculty can lead by example.  Specifically, they could show trainees how to use tablets and collect and disseminate information from the use of mobile tablets at the point of care, without appearing completely engrossed in the tablet itself (provided they know how to do so themselves).  Literally, this would be done as a teaching point just like any other golden nugget of teaching.  We highlighted this example as a workshop at the APDIM Spring conference in April of 2012.

One example from my own personal learning is what I do every week.  When in attendance, I tweet Pediatrics Grand Rounds every Wednesday at 8 am EST, at the hashtag #IUPedsGrRounds.  I wonder what I look like to others in the room as I am typing furiously on the tablet keyboard to keep up with the speaker.  I can honestly say that I am totally listening to the speaker, trying to learn as much as possible, and also trying to get the information out there onto Twitter.  I could probably argue that I am more engaged in learning from the one-hour session than others in the room—but I see how it could appear to others that I am distracted, and doing something less than "scholarly-appearing".

Have you seen instances where trainees appear to have their faces buried in their tablets or smartphones, and how have you handled it?  What can we say to trainees to help them avoid the appearance of being unprofessional, especially when they may be doing the exact opposite: helping the team find information to optimize patient care?

As a way of highlighting the importance of this and other ways to integrate mobile tablets into the medical education arena, we are excited to host the inaugural Mobile Computing in Medical Education conference on Friday May 31, 2013, on the campus of the Indiana University School of Medicine.  Topics like this would be definitely welcome.  The call for proposals is still open—please submit if you are interested in attending, and disseminating your work to others!

Maintenance of Certification and Quality: There Are Two Sides

I had written a previous post on this subject earlier, but with two articles out this week in premier journals (the New England Journal of Medicine  and JAMA), I am seeing some interesting chatter on Twitter from well-respected physicians describing the downsides of Maintenance of Certification, or MOC.  Here are two previously written blogs (#1  and #2) outlining these “downsides”.  It is clear to me how these physicians feel about the MOC process.

There could be many ways to discuss the issue of MOC in this blog.  I will try to focus on simplicity: “for” and “against”, along with literature that highlights each of these arguments.

Arguments challenging the current process of MOC

1.       It takes physician’s time away from direct patient care.

2.       It is a “bureaucratic scam”, due to the fact that it is very costly, with the beneficiaries of monies being the leadership of the Boards comprising the ABMS (American Board of Medical Specialties).  [Interesting that this article is not referenced in PubMed, but can be found through standard non-medical search engines.]

3.       It is out of touch with the current practice of medicine.

4.       It has not been shown to benefit patients or patient care.

Arguments in favor of the MOC process

1.       If not the current ABMS MOC process, then there exists the possibility that other regulatory agencies (such as OSHA) could dictate how physicians should practice (see quote in article by Dr. Robert Wachter). 

2.       There exists a correlation between higher scores on MOC examinations and quality of care. (Article 1 and Article 2).

3.       Physicians who spend the majority of their time in practice, not just “academic types”, validate the content of MOC examinations.

4.       The farther out a physician is from training, the lower is the quality of care provided.  While this seems to be a pretty harsh statement against the “there is no substitute for experience”-argument, the current literature does support this position.

I am sure that there are many other arguments for and against MOC.  This blog is not intended to be a mathematical "weight comparison" of articles on the topic.  My own opinion on this is simple: physicians need to engage in lifelong learning (Article #1 here and Article #2 here), under the “Practice-Based Learning and Improvement” competency.  Whatever the ideal process should be for this, I cannot say with certainty, but I would much rather have those within my own specialty, who also understand educational methodologies, regulate ongoing physician certification, rather than others that are removed from the day-to-day challenges of the current practice of medicine.  The current leaders in my specialties, who dictate the regulations as they currently stand, are the ABIM and the ABP.  This was summarized in my Annals of Internal Medicine letter to the editor earlier in 2012. 

So what do you think about the process of MOC as a way for the ABMS to hold physicians to a standard acceptable to the public?  Is it working well?  If not, what could be improved?

In full disclosure, I am not employed by the ABIM or any of the ABMS boards.  I personally know one member of the ABIM, from his days as a former program director.   I have not written examination questions for the ABIM or the ABP.  I get no royalties from the ABIM, the ABP or the ABMS, and have no stock in these companies or any of their subsidiaries.