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.