MedX | Ed Reflections

I am a medical educator and have been privileged to teach at the Indiana University School of Medicine as a faculty member for over 14 years.  I have had the opportunity to train many residents and students over the years, with the addition of focusing on faculty as well through overseeing the CME unit in recent years.  This is a privilege not taken lightly.  I feel strongly about trying to further my own professional development with respect to being the best teacher and physician I can be.  One such way to do this is to attend conferences relevant to one’s specialty.  I have attended many of these over the years, allowing me access to resources for networking and meeting other people who have similar interests.

Given my interest in emerging technology to improve patient care and education, I submitted an abstract to the MedX | Ed conference this year, and was pleased to have been accepted for an oral presentation related to lifelong learning and emerging technology.  I have watched the MedX conference via the live stream over the past few years, but attending in person—WOW!  What an inspirational two days!

There were so many different things to learn, and this short blog doesn’t truly do it justice; nevertheless, I will give just a few highlights that stick out for me.  Some were about newer technologies, such as what Dr. Neil Mehta presented on how to integrate technology with information management.  Some were about interprofessional education, which makes me excited when I see that the CME/CPD community has been really emphasizing the importance of this over the past several years.  Some were about connection and human touch (I expected to enjoy Dr. Abraham Verghese’s talk, but was inspired beyond my wildest dreams) to show empathy with patients.  Some were medical students themselves creating startup companies to improve medical education (Picmonic and Osmosis).  Some were about shifting the paradigm and creating curricula on updating topics related to medicine on Wikipedia.  Some were about storytelling (both from learners themselves and from patients; INCREDIBLY powerful), which I emphasize but am convinced I must emphasize even more [and for the record, YES, CME/CPD conferences SHOULD be providing MORE patient panels to hear more about the patient perspective].

This is truly a one-of-a-kind conference!  I thought I tweeted a lot during meetings (see my recent reflections on Tweeting the Meeting here and here, but wasn’t even close to some of the influencers in complete “status tweeticus”.  I thought I blogged quickly, but others created wonderful blog posts within hours and even live.

It was also great to meet many of these folks in real life (although I admit I could have been better).  In addition, through the power of social media related to this conference, I was contacted (while in the airport heading to the conference) for my opinion on a story about skills that physicians of the future need to have, which was published on day 2 of the meeting.  

A hearty “Thank You” to Larry Chu and the entire MedX | Ed team for putting on what I think is the most innovative conference I have ever had the privilege of attending.  To solve some of the current problems in healthcare, we need more than just doctors, and this conference delivered on describing some real solutions!  I hope to attend again in the future, and look forward to seeing and meeting new folks in future years.

P.S. Yes, my own presentation did include descriptions of emerging technology, storytelling, and how innovative methods of education can influence the learning process and potentially patient care!

Physician Leadership and Lifelong Learning

I haven’t been posting much recently, with valid reasons.  I began a Business of Medicine MBA Program at the Kelley School of Business, and have homework, readings, and assignments that have immersed me in new subjects.  I absolutely love being a student again!  The lifelong learning which I enjoy writing about is alive and well, and I feel invigorated with the opportunity to learn new subject areas with other like-minded physician students who are in this with me.  The class demographics are quite diverse and reflect different specialties and reasons for choosing to enroll in an MBA program designed for physicians.

In one course, Healthcare Revenue and Delivery, we discuss issues relevant to healthcare today.  We had the opportunity to delve into the implementation of learning healthcare systems, and also physician leadership and engagement.  Some key takeaways are critical and reflect some of the educational curricula that are being updated both at the medical school level and also at the residency level.  These takeaways are challenges faced by physician leaders of the future, but should be tackled if we are going to actively address healthcare in the current environment.

First, team approaches to solving problems usually are better than just one independent voice making decisions in a unilateral manner.  We absolutely see this in the training environment, where some trainees function at a very high level when working with others health care providers, and some need more guidance with respect to understanding team dynamics.

Second, asking questions is probably just as important as (and maybe more important than) having the answers.  This gets at not necessarily being the “captain of the ship”, but rather a facilitator of others.  Much learning goes on when leaders listen and ask questions!

Third, leaders need to leverage external innovation (partnering with others who have expertise different from one’s own) as a valuable asset to move an organization forward.  We all can’t be experts in everything!

Fourth, it is important to make the mission and vision of an organization real.  Sometimes this means saying “no” to something that is in direct conflict with one’s values.  Constant reminders of the mission are always helpful when making key decisions.

There were many other points made, but these resonated with me as important aspects to take away during our first few days.  I anticipate more posts as a result of these vibrant, healthy discussions about healthcare, including not only where it is but where it is going!  

#ITeachMedicine

I have mentioned for several years now how social media has been able to impact how I teach, and how others learn in medicine.  It has been an incredible journey to see, as I have met many folks virtually whom I would otherwise never meet.

It is also amazing how quickly information can be spread via social media.  Sometimes, this can be bad, but other times, it can be very good.  A great example of advocacy within medicine began earlier this month, with a tweet from a surgeon-in-training, Dr. Heather Logghe (@LoggheMD).  A blog which began this campaign describes early successes.  This campaign continues to grow, and has amassed an incredible number of tweets and impressions.  It is so refreshing to see stereotypes broken down, and to see the human side behind these incredible physicians.  I've never met Heather, but as a residency program director, I am impressed!

I got to thinking: the #meded hashtag (for medical education) has really taken off over the past few years due to my colleague, Dr. Ryan Madanick from the University of North Carolina, and includes a weekly tweetchat and many other tweets at any time.  #meded has even been described in the peer-reviewed literature (here and here).  How about highlighting some of the amazing medical educators out there who enjoy teaching medicine (at any level)?

So here goes: #ITeachMedicine is starting today with this blog.  Please distribute to all of those dedicated teachers who make medicine and the teaching of and within it a wonderful profession! I am a #meded ‘er, and #ITeachMedicine !!

Etiquette for Live Tweeting at Conferences

Recently, I published a paper on the topic of “Tweeting the Meeting”, along with Dr. Janine Zee-Cheng.  In that paper, we briefly discussed the topic of etiquette with respect to tweeting during conferences.  I came across this piece from a few days ago in Nature about conference tweeting.  The blog piece describes two options for the “default” at meetings.  Should the default be that tweeting is allowed (unless the speaker explicitly asks attendees not to) or that tweeting is NOT allowed (unless the speaker gives explicit permission to do so)?  I am not sure of the right answer for this, but given how common this has become, I believe that conference organizers should actively discuss this option when planning meetings, and make the default answer explicit as possible.

A problem might ensue when the default is that it is allowed, but individual speakers who know very little about Twitter are upset when they find their content disseminated via this social network.  It begs the question that guidelines or policies really should be created and disseminated to potential presenters at the time that those presenters submit their abstracts.

I wonder how many scientific associations have formal policies about this topic, and if they do, how is that policy disseminated prior to meetings?  Maybe this is an area ripe for more research, and one that should be discussed among those who plan scientific conferences.

Learning Theory and Social Media

I read this really interesting piece on learning theory for medical educators interested in the use of social media.  The authors hint that it is really important for educators to consider an understanding of learning theory when integrating social media into the learning process.  I agree wholeheartedly for many reasons.  

First, after having given a recent grand rounds (to two separate audiences) on the topic of learning theory in medical education and how technology can help, I feel that it is very important to reflect on these theories for a better understanding of why learners use (or don't use) social media and other emerging technology.  Communities of practice (CoPs) are a great way to bring groups of people together around a common theme, and virtual/electronic CoPs are catching on in medicine and medical education.

Second, it is important, as the authors mention, to consider connectivism and constructivism as key theories behind why some learn with social media (and may prefer to learn via such tools).  Using constructivism, learners should be reflective, and the teacher needs to adopt a facilitative approach (instead of being an "expert").

For the educators out there who are integrating social media into your learning methods, which theory or theories reflect why you use social media or how your learners use social media?

CME, Industry and Outcomes

Recent medical literature describes the challenges of demonstrating the impact of CME on physician learning (with a focus on the lack of impact), and the need to reform the current system.  Writers suggest that it really is not having the impact that it should, given the financial resources provided.  Others have questioned how it is funded, suggesting that it may be biased given the resources provided by industry, and that it should be changed. 

While I admit my own bias as an Associate Dean for CME for a major medical school, I feel that it is important to study the peer-reviewed literature to best understand this important topic.

First, is the industry influence really that significant?  A piece by Cervero discusses this, and found limited evidence of the impact of industry influence on CME.  In the recent ACCME 2014 report (Table 8), only 11% of accredited CME received commercial support from industry.  My interpretation of this is that the commercial support is certainly not an overwhelming part of CME programs (our own institutional data would definitely mirror this finding).

Second, what is the real impact of CME?  The same above author recently published a piece in JCEHP (full disclosure: I am the social media editor for this journal, but was not involved in any way in the creation, revision, or decision to publish this manuscript) that concluded that CME can indeed impact patient outcomes and physician behavior (the former more than the latter).

Third, improvements in how CME is disseminated should occur.  Within this realm, patients should be included, and interprofessional learning should occur in team environments; this is highlighted by the new President and CEO of the ACCME, Dr. Graham McMahon, in a Viewpoint piece in JAMA that came out online earlier this week.

So where should we go from here?  I think there are several things we can consider.  Most importantly, physicians and other healthcare providers should continue to learn in order to provide optimal care of their patients in a changing environment; CME is one way to aid this learning.  Those in the field have been thinking about how to restructure it for many years and have made major strides in focusing on quality improvement.  Second, we should also consider learning healthcare systems as a way to promote learning for those who provide care for patients.  Lastly, we should be diligent about using technology to make our learning more effective.  Examples include online journal clubs and virtual communities of practice.  Given the complexities that abound in medicine in the current environment, anything that can make the process of learning how to "keep up" and best care for our patients easier should be welcomed.  

Learning Theory vs Learning Approach

I had the privilege of giving a grand rounds presentation recently on the topic of lifelong learning in healthcare.  In the presentation, I discussed how adults learn within medicine, and reviewed literature on "adult learning theory".  Malcolm Knowles wrote extensively on the topic of Adult Learning, creating "principles of adult learning" also coining the phrase "andragogy" (as opposed to "pedagogy").

Others have questioned the concept of Adult Learning Theory, and have evidence to suggest that having one learning style is a misnomer.  In fact, an article this month suggests that, at the undergraduate medical education level, we should consider a focus on learning approach rather than teaching to a specific learning style.  Learners may not learn optimally with their self-proposed best learning style, and it is hard to say that a learner can learn with only one particular style.  See here http://www.danielwillingham.com/learning-styles-faq.html  for a great review of this.

So what should educators do, given this dichotomy?   Should we focus on the content and a delivery style that "meets the needs of today's learners"?  Should it be about teaching the content to the learners, and nothing more?

In clinical medicine, where I spend most of my time, I do think it is critically important to focus on not just the content, but also the context in which that content is delivered.  Learning environment, sometimes referred to as learning climate, is critical to making the learning process successful.  It is the backbone upon which is built the process where ideal learning can take place.  Given the IOM description of the Learning Healthcare System, this is essential.  After all, where there is a healthy learning environment, there is an opportunity for all to learn with and from each other in order to provide the best care of the patients for whom we are privileged to care.

Demonstration of "Tweeting the Meeting"

I had the privilege of writing a paper recently with Dr. Janine Zee-Cheng on Live Tweeting in Medicine: 'Tweeting the Meeting', which came out a few months ago (and allows free open access to all articles through the end of June, 2015).  In it, we highlighted the importance of lifelong learning through the use of Twitter at conferences.  I also encourage a quick read of this other great piece giving suggestions on how to live tweet in conferences.

Dr. Zee-Cheng, a pediatric critical care physician from my institution, is giving a presentation on a social media-related project she did as part of her fellowship, at a conference currently going on this week in Chicago.  The hashtag is #smaccUS (to reflect social media and critical care).  I highly encourage those who are reading this blog now to check out the tweets from this conference.  The discussions, on a variety of topics, are truly epic, and range from general content in the management of critically ill patients, to the emotional side of medicine, to introspective reflection about one’s practice, to frank humor.

While I am not at the conference (we are orienting new incoming interns to begin their clinical duties), I have learned so much from reading tweets from participants.  I encourage all interested in this topic, and literally, medicine in general, to check out the #smaccUS hashtag—you will not regret it!

Social Media in Medicine: Lifelong Learning for All Through Free Open Access

I recently posted about online resources for lifelong learning.  This is a very important topic as emerging technology continues to be a part of medicine.  Just last month, I was privileged to be an author for one article on Live Tweeting in Medicine, within an entire issue of a medical journal focusing on social media.  The guest editor, Dr. Meg Chisolm, has worked with the journal, International Review of Psychiatry, to make the entire issue free open access from now until the end of June 2015.  This is extremely exciting as it makes available to all some wonderful reviews of social media within medicine in a variety of contexts.  I encourage you to take advantage of reviewing these articles, and saving them as resources.  The link to the entire issue of the journal (with free access to all articles full-text through June 2015) is here. 

In addition, a Twitter chat discussing pertinent issues of social media in medicine, under the hashtag #nephJC will take place on June 16, 2015 at 9 pm EST, and again at 8 pm GMT on June 17, 2015 (as a time more conducive for our colleagues in Europe/Africa).  Many of the authors from this issue will be tweeting in during that discussion.

This is a leading example of sharing materials for lifelong learning for all.  Please share via social media to demonstrate the impact that social media can have!

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.  

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.

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.

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.

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.