tag:blogger.com,1999:blog-591631871812355932024-03-11T21:51:08.821-07:00Mired in MedEdThis blog is about my experiences as a medical educator.Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.comBlogger91125tag:blogger.com,1999:blog-59163187181235593.post-87597474401295630652016-01-03T05:19:00.000-08:002016-01-03T05:19:10.021-08:00Medical Education Transitions<br /><div class="MsoNormal">
I have been noticeably absent from the online space over the
past few months. However, I think I have
a valid reason for this. I am excited to
announce a major professional transition.
I have been given an incredible opportunity, and am excited to begin a
new chapter in my career.<o:p></o:p></div>
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Beginning January 4, 2016, I will begin as the Education
Editor for the NEJM Group within the Massachusetts Medical Society, which
oversees the <i>New England Journal of
Medicine </i>and other educational offerings such as<i> Knowledge+</i>. This position
will allow me to learn from and work with an amazing group of folks in medical
publishing, and provide exposure to new opportunities for learning in
healthcare. I will work with the
adaptive personalized learning product, <i>Knowledge+,</i>
and will learn from the other journal deputy editors associated with the Review
Articles within the <i>Journal</i>. NEJM Group already is well established with
the <i>Journal</i> itself, <i>Journal Watch, <a href="http://knowledgeplus.nejm.org/">Knowledge+</a>, CareerCenter</i>,
and a new product launched in December 2015 called <i><a href="http://catalyst.nejm.org/">NEJM Catalyst</a></i> that focuses on healthcare delivery. Clinically, I will care for patients and continue
to teach residents through the <a href="http://www.brighamandwomens.org/Departments_and_Services/medicine/medical_professionals/residency/MedPeds/default.aspx?sub=1">Med-Peds Residency at Brigham & Women’s/Children’s Hospital of Boston</a> affiliated with Harvard Medical School, after getting
settled.<o:p></o:p></div>
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This means leaving my academic home, the Indiana University
School of Medicine, to begin this full-time position with NEJM Group. I have learned so much from the incredible
people there; I will miss my mentors, colleagues and friends who have taught me
so much. I will miss the CME team, who
has helped me better understand how physicians and other health care providers
learn. Of course, the residency program
with which I have been associated since 2002, and prior to that as a resident
trainee, will always be a part of what I do. As much as I will miss it, I leave knowing that the program is in good hands and thriving, with amazing residents and faculty!<o:p></o:p></div>
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I am excited to begin this new journey; the folks at NEJM
Group have been so welcoming to me. I
will pick up my Twitter and blogging presence, and look forward to sharing my
experiences with my medical education friends, colleagues, learners and mentors!<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com5tag:blogger.com,1999:blog-59163187181235593.post-23445371778251675882015-09-26T03:35:00.002-07:002015-09-26T03:37:32.730-07:00MedX | Ed Reflections<br />
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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.<o:p></o:p></div>
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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!<o:p></o:p></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiu6O-XrhEUI7oSpCmb8TgtvPwlriVYnvqVdzbChEcE8gC4gp4jHfckuURD0pQNKeHsqX1eLv6SmN1O0LrIW1AtT_dGsrm5K8rJ10Mo_4Tvp5AqgnFzrPWjCGEqmxYM3tTzfMocieYN34U/s1600/MedX+Ed+pic.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiu6O-XrhEUI7oSpCmb8TgtvPwlriVYnvqVdzbChEcE8gC4gp4jHfckuURD0pQNKeHsqX1eLv6SmN1O0LrIW1AtT_dGsrm5K8rJ10Mo_4Tvp5AqgnFzrPWjCGEqmxYM3tTzfMocieYN34U/s320/MedX+Ed+pic.jpg" width="320" /></a></div>
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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 (<a href="http://www.picmonic.com/">Picmonic</a> and <a href="https://www.osmosis.org/">Osmosis</a>). 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 <span style="font-size: xx-small;">[and for the record, YES, CME/CPD conferences SHOULD be
providing MORE patient panels to hear more about the patient perspective]</span>.<o:p></o:p></div>
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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 <a href="http://www.ncbi.nlm.nih.gov/pubmed/25739015">here</a> and <a href="http://alexdjuricich.blogspot.com/2015/08/etiquette-for-live-tweeting-at.html">here</a>, but wasn’t even close to some of the influencers in complete “status
tweeticus”. I thought I blogged quickly,
but others created wonderful <a href="http://amolutrankar.com/2015/09/24/medxed-fast-four/">blog posts within hours</a> and <a href="http://www.thedigitalapothecary.com/musings/2015/9/24/medxed-workshops-day-2-live-blog">even live</a>.</div>
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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 <a href="http://ww2.kqed.org/futureofyou/2015/09/24/seven-21st-century-skills-doctors-wished-theyd-learned-in-medical-school/">skills that physicians of the future need to have</a>, which was published on day 2 of the meeting. </div>
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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.<o:p></o:p></div>
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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!<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com2tag:blogger.com,1999:blog-59163187181235593.post-37442174218624152182015-09-20T05:28:00.000-07:002015-09-20T05:28:38.766-07:00Physician Leadership and Lifelong Learning<div class="MsoNormal">
I haven’t been posting much recently, with valid reasons. I began a <a href="http://kelley.iupui.edu/physician-mba/">Business of Medicine MBA Program at the Kelley School of Business</a>, and have homework, readings, and assignments
that have immersed me in new subjects. I
absolutely love being a student again!
The <a href="http://alexdjuricich.blogspot.com/2015/05/lifelong-learning-in-medicine.html">lifelong learning</a> 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. <o:p></o:p></div>
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In one course, Healthcare Revenue and Delivery, we discuss issues
relevant to healthcare today. We had the
opportunity to delve into the <a href="http://iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx">implementation of learning healthcare systems</a>,
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.<o:p></o:p></div>
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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.<o:p></o:p></div>
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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!<o:p></o:p></div>
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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!</div>
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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.<o:p></o:p></div>
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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! <o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com2tag:blogger.com,1999:blog-59163187181235593.post-14390967306776508652015-08-23T17:11:00.000-07:002015-08-23T17:11:24.424-07:00#ITeachMedicine<div class="MsoNormal">
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.<o:p></o:p></div>
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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 <a href="http://alliesforhealth.blogspot.com/2015/08/ilooklikeasurgeon-tweet-it-own-it.html">blog which began this campaign describes early successes</a>. 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!</div>
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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 (<a href="http://link.springer.com/article/10.1007/s11606-014-2975-x">here</a> and <a href="http://onlinelibrary.wiley.com/doi/10.1002/chp.21250/abstract">here</a>). How about highlighting some of the
amazing medical educators out there who enjoy teaching medicine (at any level)?<o:p></o:p></div>
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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 !!<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com0tag:blogger.com,1999:blog-59163187181235593.post-59924849185209609182015-08-22T16:11:00.000-07:002015-08-22T16:11:30.211-07:00Etiquette for Live Tweeting at Conferences<div class="MsoNormal">
Recently, I published a <a href="http://informahealthcare.com/doi/abs/10.3109/09540261.2014.1000270">paper on the topic of “Tweeting the Meeting”</a>, 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 <a href="http://www.nature.com/news/conference-tweeting-rule-frustrates-ecologists-1.18207?WT.mc_id=TWT_NatureNews">piece from a few days ago in Nature about conference tweeting</a>. The blog piece describes two options
for the “default” at meetings. Should
the default be that <u><b>tweeting is allowed</b></u> (unless the speaker explicitly asks
attendees not to) or that <u><b>tweeting is NOT allowed</b></u> (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.<o:p></o:p></div>
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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.<o:p></o:p></div>
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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.<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com1tag:blogger.com,1999:blog-59163187181235593.post-35675879236755206132015-08-15T18:12:00.000-07:002015-08-15T18:12:11.864-07:00Learning Theory and Social Media<div class="MsoPlainText">
I read this really interesting <a href="http://pmj.bmj.com/content/early/2015/08/14/postgradmedj-2015-133358.abstract">piece on learning theory for medical educators interested in the use of social media</a>. 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. </div>
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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. <a href="http://wenger-trayner.com/introduction-to-communities-of-practice/">Communities of practice (CoPs)</a> 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.</div>
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Second, it is important, as the authors mention, to
consider <a href="http://www.itdl.org/journal/jan_05/article01.htm">connectivism</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/11865749">constructivism</a> 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").<o:p></o:p></div>
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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?<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com5tag:blogger.com,1999:blog-59163187181235593.post-67462523551090636462015-07-22T17:47:00.000-07:002015-07-22T17:47:19.441-07:00CME, Industry and Outcomes<div class="MsoNormal">
<a href="http://jama.jamanetwork.com/article.aspx?articleid=2290654">Recent medical literature</a> 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. <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1754.2011.02191.x/abstract">Others have questioned</a> how it is funded, suggesting that it may be biased given the resources provided by industry, and that it should be changed. </div>
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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.<o:p></o:p></div>
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First,
is the industry influence really that significant? A <a href="http://www.accme.org/news-publications/publications/review-literature-relationship-between-commercial-support-and-bias">piece by Cervero</a> discusses this, and found limited evidence of the impact of industry
influence on CME. In the <a href="http://www.accme.org/news-publications/publications/annual-report-data/accme-annual-report-2014">recent ACCME 2014 report (Table 8)</a>, 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).<o:p></o:p></div>
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Second,
what is the real impact of CME? The <a href="http://onlinelibrary.wiley.com/doi/10.1002/chp.21290/abstract">same above author recently published a piece in JCEHP</a> (<span style="font-size: x-small;">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</span>) that concluded that CME can indeed impact patient outcomes and physician behavior (the
former more than the latter).<o:p></o:p></div>
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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 <a href="http://jama.jamanetwork.com/article.aspx?articleid=2398245">Viewpoint piece in JAMA</a> that came out online earlier this week.<o:p></o:p></div>
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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 <a href="http://www.ncbi.nlm.nih.gov/pubmed/21346497">how to restructure it</a> for
many years and have made major strides in focusing on quality improvement. Second, we should also consider <a href="http://iom.nationalacademies.org/Activities/Quality/LearningHealthCare.aspx">learning healthcare systems</a> 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 <a href="http://onlinelibrary.wiley.com/doi/10.1002/chp.21275/abstract">online journal clubs</a> and <a href="http://www.jmir.org/2014/3/e83/">virtual communities of practice</a>. 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. <o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com3tag:blogger.com,1999:blog-59163187181235593.post-4050745267844436462015-07-14T05:05:00.000-07:002015-07-14T05:05:18.162-07:00Learning Theory vs Learning Approach<div>
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 "<a href="http://elearningindustry.com/the-adult-learning-theory-andragogy-of-malcolm-knowles">principles of adult learning</a>" also coining the phrase "andragogy" (as opposed to "pedagogy").</div>
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Others have questioned the concept of Adult Learning Theory, and have evidence to suggest that <a href="http://www.tandfonline.com/doi/abs/10.1080/00461520.2013.804395">having one learning style is a misnomer</a>. In fact, an <a href="http://www.ncbi.nlm.nih.gov/pubmed/26158325">article this month</a> suggests that, at the undergraduate medical education level, we should consider a focus on learning <u>approach</u> rather than teaching to a specific learning <u>style</u>. 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.</div>
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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?</div>
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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 <a href="http://iom.nationalacademies.org/Activities/Quality/LearningHealthCare.aspx">IOM description of the Learning Healthcare System</a>, 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.</div>
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Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com2tag:blogger.com,1999:blog-59163187181235593.post-52064069904527750092015-06-25T05:16:00.000-07:002015-06-25T05:16:22.725-07:00Demonstration of "Tweeting the Meeting"<div class="MsoNormal">
I had the privilege of writing a paper recently with Dr.
Janine Zee-Cheng on <a href="http://informahealthcare.com/toc/irp/27/2">Live Tweeting in Medicine: 'Tweeting the Meeting'</a>, 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 <a href="http://journals.plos.org/ploscompbiol/article?id=10.1371/journal.pcbi.1003789">how to live tweet in conferences</a>.</div>
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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.<o:p></o:p></div>
<br />
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<br /></div>
<div class="MsoNormal">
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!<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com0tag:blogger.com,1999:blog-59163187181235593.post-80066963068261909622015-05-28T16:58:00.001-07:002015-05-28T16:58:42.263-07:00Social Media in Medicine: Lifelong Learning for All Through Free Open Access<div class="MsoNormal">
I recently posted about <a href="http://alexdjuricich.blogspot.com/2015/05/using-technology-for-lifelong-learning.html">online resources for lifelong learning</a>. 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 <a href="http://informahealthcare.com/doi/abs/10.3109/09540261.2014.1000270">Live Tweeting in Medicine</a>, within an entire
issue of a medical journal focusing on social media. The guest editor, Dr. Meg Chisolm, has worked
with the journal, <i>International Review of
Psychiatry</i>, 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 <a href="http://informahealthcare.com/toc/irp/27/2">link to the entire issue of the journal (with free access to all articles full-text through June 2015) is here</a>. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
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.<o:p></o:p></div>
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<br /></div>
<br />
<div class="MsoNormal">
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!<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com2tag:blogger.com,1999:blog-59163187181235593.post-19979262162051724582015-05-23T16:21:00.000-07:002015-05-23T16:21:41.880-07:00Using Technology for Lifelong Learning in Medicine<div class="MsoNormal">
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? <a href="http://33charts.com/literacy">Dr. Vartabedian has written extensively on the subject of the digital literacy</a> 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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-size: x-small;"><i>[Full disclosure, I have no financial conflicts with any of
these tools mentioned. My spouse is an
emergency physician in community practice.]</i></span><o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Browzine</b>. I use <a href="https://itunes.apple.com/us/app/browzine/id463787411?mt=8">this resource on a mobile tablet</a>
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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>NEJM Knowledge+.</b>
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. <a href="http://knowledgeplus.nejm.org/our-products/adaptive-learning/">Here is a link to an explanation</a> 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.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
<b>ALiEM</b>: this is a
<a href="http://www.aliem.com/">compendium by emergency medicine specialists </a>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.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
<b>Twitter</b>: 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 <a href="http://informahealthcare.com/doi/abs/10.3109/09540261.2015.1015502">using Twitter as a learning tool</a>, and one on <a href="http://informahealthcare.com/doi/abs/10.3109/09540261.2014.990421">social media for lifelong learning</a>. <o:p></o:p></div>
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<br /></div>
<br />
<div class="MsoNormal">
I am curious what other online resources and technology that
others are using for their own lifelong learning. <o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com1tag:blogger.com,1999:blog-59163187181235593.post-4975452300802003742015-05-13T03:58:00.000-07:002015-05-13T03:58:24.578-07:00Lifelong Learning in Medicine<div class="MsoNormal">
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 <a href="http://www.ncbi.nlm.nih.gov/pubmed/25906988">piece on the interplay of social media and lifelong learning</a>. 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.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
<a href="http://knowledgeplus.nejm.org/a-mid-career-perspective-on-lifelong-learning-in-medicine/">This post by Dr. John Mandrola on the NEJM Knowledge+ blog</a> 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”). <o:p></o:p></div>
<br />
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<br /></div>
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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.<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com0tag:blogger.com,1999:blog-59163187181235593.post-61475237112433561352015-03-01T07:58:00.000-08:002015-03-01T07:58:08.154-08:00Residency (GME) Positions: Addressing the Nation's Healthcare Needs<div class="MsoNormal">
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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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. <o:p></o:p></div>
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<br /></div>
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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 <a href="http://www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf">Figure 1</a>). 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.<o:p></o:p></div>
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<br /></div>
<div class="MsoPlainText">
This was a busy week for such projections. The <a href="http://www.aamc.org/download/425468/data/optimizinggmereport.pdf">AAMC came out with a roadmap earlier this week</a> describing plans for how to address this situation. The Commonwealth Fund, however, delivered
<a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/feb/how-will-aca-affect-use-health-services?utm_content=buffer5b3ea&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer">another interpretation of the situation</a>, 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 <a href="http://www.iom.edu/Reports/2014/Graduate-Medical-Education-That-Meets-the-Nations-Health-Needs.aspx">IOM report last year addressing the GME issue</a> and recommending no additional funding for new
residency positions, among other things. </div>
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<br /></div>
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<o:p></o:p></div>
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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.</div>
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<br /></div>
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<o:p></o:p></div>
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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?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<br />
<div class="MsoNormal">
Thanks for reading; I’m curious to hear differing opinions.<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com2tag:blogger.com,1999:blog-59163187181235593.post-4731322664550565242015-02-21T13:37:00.001-08:002015-02-21T13:37:22.702-08:00Storytelling, Narrative Medicine and the Digital Age<div class="MsoPlainText">
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 <a href="http://journals.lww.com/academicmedicine/Abstract/publishahead/The_Passion_and_the_Peril___Storytelling_in.98846.aspx">recent editorial</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/25692559">article</a> 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.<o:p></o:p></div>
<div class="MsoPlainText">
<br /></div>
<div class="MsoPlainText">
And then here is another <a href="http://www.theatlantic.com/health/archive/2015/02/should-doctors-write-about-their-patients/385296/">recent piece in the Atlantic</a>
about the topic, in which the author reflects on her writing about a patient experience and
whether it should or should not be published.<o:p></o:p></div>
<div class="MsoPlainText">
<br /></div>
<div class="MsoPlainText">
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 <a href="http://33charts.com/2015/02/medicine-digital-age.html">MOOC related to Medicine in the Digital Age</a>.<o:p></o:p></div>
<div class="MsoPlainText">
<br /></div>
<div class="MsoPlainText">
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.<o:p></o:p></div>
<div class="MsoPlainText">
<br /></div>
<br />
<div class="MsoPlainText">
Thanks for reading.<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com4tag:blogger.com,1999:blog-59163187181235593.post-25666647091735211672015-01-29T01:56:00.001-08:002015-01-29T01:56:35.859-08:00Enhancing Social Media within MedicineSo Twitter recently announced that it now has a video feature (up to 30 seconds). See <a href="http://www.washingtonpost.com/blogs/the-switch/wp/2015/01/27/twitter-adds-video-group-messaging-features/">this post</a>.<br />
<br />
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.<br />
<br />
For those interested in learning more about social media within medicine, <a href="http://www.jmir.org/2014/2/e13/">here is a nice review</a> 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.Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com0tag:blogger.com,1999:blog-59163187181235593.post-58671823594096181562014-12-24T06:03:00.001-08:002014-12-24T06:03:55.656-08:00Reflections in Medicine and Medical Education 2014<div><br></div>
<div>
</div>
<div>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!</div>
<div>
</div>
<div><br></div>
<div>
</div>
<div>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?"</div>
<div>
</div>
<div><br></div>
<div>
</div>
<div>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.</div>
<div>
</div>
<div><br></div>
<div>
</div>
<div>So how do people cope with this? </div>
<div>
</div>
<div><br></div>
<div>
</div>
<div>Some choose to go "nose to the grindstone" and work harder.</div>
<div>
</div>
<div>Some decide to "call it quits" and leave medicine.</div>
<div>
</div>
<div>Some opt to "fight back", through advocacy in the form of blogs saying "enough is enough".</div>
<div>
</div>
<div>Some take a step back and say "at least I have a job and job security".</div>
<div>
</div>
<div>Some are put off by the "it's a job" phrasing, opting for "it's a profession, and unfortunately it is slowly eroding".</div>
<div>
</div>
<div><br></div>
<div>
</div>
<div>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.</div>
<div>
</div>
<div><br></div>
<div>
</div>
<div>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.</div>
<div>
</div>
<div><br></div>
<div>
</div>
<div>Happy Holidays to All!</div>
<div>
</div>
<div><br></div>
<div>
</div>
<div>Alex</div>Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com0tag:blogger.com,1999:blog-59163187181235593.post-39630892594981926332014-11-28T15:56:00.001-08:002014-11-28T15:56:49.661-08:00Conflict of Interest: Managing Scandal<div style="margin-bottom: 0.0001pt; text-align: left;">
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 <a href="http://medicine.iu.edu/resources/conflict-of-interest-policy-at-iusm/">policies were recently approved</a>
(unanimously, I might add!) by all of the pertinent committees, and already,
many faculty have had comments and questions about specifics of the policy.</div>
<div style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
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.</div>
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<br /></div>
<div class="MsoNormal">
Here is a prime example.
The <a href="http://journals.lww.com/journalpatientsafety/pages/default.aspx">Journal of Patient Safety</a> 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.</div>
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<br /></div>
<div class="MsoNormal">
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 <a href="http://journals.lww.com/journalpatientsafety/Fulltext/2014/12000/Conflict_of_Interest,_Dr_Charles_Denham_and_the.1.aspx#">even published an article</a>
describing what they plan to do. </div>
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<o:p></o:p></div>
<br />
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<br /></div>
<div class="MsoNormal">
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 <a href="http://www.npr.org/blogs/health/2014/11/26/366618323/patient-safety-journal-finds-violations-tightens-standards-after-scandal">this NPR piece, “airing the dirty laundry”</a>, while painful, is a necessary step. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com0tag:blogger.com,1999:blog-59163187181235593.post-12233556387608277462014-11-19T19:59:00.003-08:002014-11-19T19:59:56.923-08:00Randomized Controlled Trials, Social Media and "Intention to Tweet"<div class="MsoNormal">
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 <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1409077?query=featured_home">PARADIGM-HF</a>
shift, some might say!<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Today, I was sent a tweet about a fascinating trial, the “<a href="http://circ.ahajournals.org/content/early/2014/11/17/CIRCULATIONAHA.114.013509.full.pdf+html">Intention to Tweet</a>” 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 <a href="http://network.socialmedia.mayoclinic.org/discussion/can-social-media-increase-medical-journal-article-readership/">Lee Aase for a wonderful review</a> of
what was done in the study, and what it might mean for the future. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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 92<sup>nd</sup>
percentile of all articles <u>within this Circulation journal</u>.
It is in the 94<sup>th</sup> percentile for all articles <u>of a similar
age</u>. 94<sup>th</sup> percentile! That is pretty awesome! Compared with <u>other articles of a similar age
in this journal</u> Circulation, it ranks 2<sup>nd</sup>, in the 85<sup>th</sup>
percentile. Again, this article came out
TODAY.<o:p></o:p></div>
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So here is the kicker.
This article on social media, <b><u>based
on these Altmetrics data</u></b>, 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 <a href="http://www.altmetric.com/details.php?domain=circ.ahajournals.org&citation_id=2900180">Altmetrics</a> from 10:30 pm EST on 11/19/14.<o:p></o:p></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgX-fNi9YwActDCTosn7dt0ar2ZEll0m_xhEwRhYu30DXAZxEtXpg6rweyACR6Z8RAHTI7kkHITgjeLbcsSfhqv6vI1Clc2i3F2MEVQXRszExrplDcY2fhBVJIARTc-TZnFhClKV6YUSD4/s1600/Capture.PNG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgX-fNi9YwActDCTosn7dt0ar2ZEll0m_xhEwRhYu30DXAZxEtXpg6rweyACR6Z8RAHTI7kkHITgjeLbcsSfhqv6vI1Clc2i3F2MEVQXRszExrplDcY2fhBVJIARTc-TZnFhClKV6YUSD4/s1600/Capture.PNG" height="206" width="320" /></a></div>
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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”. </div>
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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 (<a href="http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1554-558X;jsessionid=8A0A33F9C02238FB1F833F3D938574D9.f04t01">JCEHP</a>),
I plan to reference this article and use it in descriptions of how social media
can impact journals, and ultimately, patient health and outcomes.<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com3tag:blogger.com,1999:blog-59163187181235593.post-70245181655138858072014-11-07T04:49:00.002-08:002014-11-07T04:49:44.971-08:00Medical Education: What Matters<div>
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.</div>
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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!</div>
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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!</div>
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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!</div>
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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!</div>
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I still have another day of learning here, and lots more people to meet! Thank you to the organizers for a wonderful meeting!</div>
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<span style="font-size: x-small;"><i>[for the record, I wrote and posted this piece while on the "L" headed to the meeting]</i></span></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com1tag:blogger.com,1999:blog-59163187181235593.post-36293828808588011622014-09-07T06:17:00.000-07:002014-09-07T06:28:10.793-07:00Connecting from Afar: 2014 Stanford MedX<br />
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The <a href="http://23.239.5.112/">2014 Stanford MedX conference</a> 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 <i><a href="http://www.im.org/p/cm/ld/fid=453">Academic Internal Medicine Week</a></i> to
internal medicine educators about how to effectively use social media. <o:p></o:p></div>
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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
<a href="http://wingofzock.org/2014/09/06/stanford-medx-to-take-on-meded-with-new-academy-initiative/">medical education as a theme</a>.<o:p></o:p></div>
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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.<o:p></o:p></div>
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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. <o:p></o:p></div>
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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!<o:p></o:p></div>
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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!<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com1tag:blogger.com,1999:blog-59163187181235593.post-2392312064040724872014-09-05T12:52:00.002-07:002014-09-05T12:52:54.657-07:00Curbside Consultation and Hallway Conversations<div class="MsoNormal">
“Curbside consultation” is an interesting term in medicine. There has been an increasing interest in this
<a href="http://www.ncbi.nlm.nih.gov/pubmed/24797642">term in the recent medical literature</a>, 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.<o:p></o:p></div>
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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!<o:p></o:p></div>
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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. <o:p></o:p></div>
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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!<o:p></o:p></div>
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<i><span style="font-size: x-small;">Special Thanks go to Dr. Peter Schwartz, my colleague
referenced above.</span></i><o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com0tag:blogger.com,1999:blog-59163187181235593.post-55150963383892171712014-08-31T19:21:00.000-07:002014-08-31T19:21:11.137-07:00Clinical Practice Guidelines, Autism, and Ordering of Tests<div class="MsoNormal">
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 <a href="http://www.iom.edu/Activities/Research/GenomicBasedResearch/2014-AUG-18.aspx">IOM Roundtable</a> 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. <o:p></o:p></div>
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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!<o:p></o:p></div>
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So I recently received this advertisement card in the mail,
by Quest Diagnostics. On one side “<i>Their
future is in your hands.</i>” On the other,
a pitch to use the <i>ClariSure</i> brand of
chromosomal microarray analysis. <o:p></o:p></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8z853RK6nI_qNexLcLPWWVYFj0BfmE_NvsqKosNV8InJ7e2cXEm7j9einGR0jZBEsXdAYp84MiAycgeUT_Ar0H4-TsbrGd8NxN_spMnq1zSkwsbYoDn48ryCC6XCVKWyUZu3h-_EWvys/s1600/Chromosome+final+2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8z853RK6nI_qNexLcLPWWVYFj0BfmE_NvsqKosNV8InJ7e2cXEm7j9einGR0jZBEsXdAYp84MiAycgeUT_Ar0H4-TsbrGd8NxN_spMnq1zSkwsbYoDn48ryCC6XCVKWyUZu3h-_EWvys/s1600/Chromosome+final+2.jpg" /></a></div>
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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.<o:p></o:p></div>
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But this phrase right on the pretty glossy paper caught my
attention: “<i>Chromosomal Microarray Analysis is recommended as a first tier test
for autism spectrum disorders and developmental delay by ACMG</i>” (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 “<i>recommended as a first tier test for
autism …</i>”. How should a pediatrician
reading this pamphlet sent directly to them interpret that?<o:p></o:p></div>
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I pulled the ACMG guidelines, entitled “<a href="https://www.acmg.net/docs/pp-g-asd-schaffer-aop-gim201332a.pdf">Clinical genetics evaluation in identifying the etiology of autism spectrum disorders: 2013 guideline revisions</a>”. In that guideline, Table 4 is titled the
following: “<i>Template for the clinical genetic diagnostic evaluation of autism
spectrum disorder</i>”. 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: “<i>… for the clinical
genetic diagnostic evaluation of autism spectrum disorder</i>”. It does NOT say “<i>for pediatricians and
primary care providers</i>” 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? <o:p></o:p></div>
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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 <a href="http://www.medicalhomeinfo.org/downloads/pdfs/AutismAlarm.pdf">algorithm found here, on page 2</a>). 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. <o:p></o:p></div>
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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.<o:p></o:p></div>
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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 “<i>chromosomal microarray analysis is recommended as
a first-tier test …</i>”. I struggle with
the wording, which omits “<i>by clinical genetics</i>”. 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.<o:p></o:p></div>
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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 <a href="http://www.autismspeaks.org/what-autism/diagnosis/screen-your-child">M-CHAT-Revised</a>. 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.<o:p></o:p></div>
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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.<o:p></o:p></div>
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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.<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com0tag:blogger.com,1999:blog-59163187181235593.post-8683780285676247572014-08-23T06:08:00.000-07:002014-08-23T06:08:07.683-07:00Residency, Success, Team Sports and Being a Member of a Team<div class="MsoNormal">
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
<a href="http://archotol.jamanetwork.com/article.aspx?articleid=1351924">this article</a>, 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.<o:p></o:p></div>
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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.
<o:p></o:p></div>
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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.<o:p></o:p></div>
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There may be success regarding professionalism. Some might
take the reverse approach. When one is
unprofessional, what factors predict that unprofessional behavior? <a href="http://www.ncbi.nlm.nih.gov/pubmed/16371633">This has been studied by Dr. M Papadakis</a>, and basically, past “unprofessional” behavior
in medical school predicts future disciplinary action by state medical boards. <o:p></o:p></div>
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There may be success in securing a match position. Many educators have published on this, such
as <a href="http://www.ncbi.nlm.nih.gov/pubmed/23673567">this from plastic surgery</a>. <o:p></o:p></div>
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There may be success in other domains as well. Here is a <a href="http://www.ncbi.nlm.nih.gov/pubmed/24945869">description that uses a surgical aptitude test</a>. Here is <a href="http://www.ncbi.nlm.nih.gov/pubmed/22942969">another study looking at the utility of letters of recommendation to predict success</a>. <o:p></o:p></div>
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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 <a href="http://www.ncbi.nlm.nih.gov/pubmed/24738753">training on working in multidisciplinary teams</a>. The importance of <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=23524923">teams in medicine has also been outlined for patient-centered medical homes</a>, such that teamwork
competencies need to be defined.<o:p></o:p></div>
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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. <o:p></o:p></div>
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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.<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com1tag:blogger.com,1999:blog-59163187181235593.post-36594344262564460902014-08-17T19:26:00.000-07:002014-08-17T19:26:21.243-07:00Tweeting the (Medical) Meeting<div class="MsoNormal">
I am currently in the airport on the last leg of a brief
trip to present to the <a href="http://www.iom.edu/Activities/Research/GenomicBasedResearch/2014-AUG-18.aspx">Institute of Medicine</a> 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.<o:p></o:p></div>
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I have <a href="http://alexdjuricich.blogspot.com/2011/12/twitter-and-tweeting-during-medical.html">written about this in the past</a>. However, this <a href="http://www.mededworld.org/reflections/reflection-items/August-2014/AMEE2014-Conference-Tweeting-Judiciously.aspx#.U-_651uBmYg.twitter">piece from a few days ago</a> cautioned folks who do tweet the
meetings. Dr. Bryan Vartabedian wrote
<a href="http://33charts.com/2014/08/twitter-regulated-medical-meeting.html">this phenomenal piece</a> 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.<o:p></o:p></div>
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I hope the demonstration tomorrow goes well. If interested, please follow the hashtag
highlighting this meeting: <i>#IOMgenomics</i>.
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.<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com0tag:blogger.com,1999:blog-59163187181235593.post-46168075445780236002014-08-15T18:33:00.000-07:002014-08-16T04:12:09.967-07:00Open Payments: Impact on the Noble Profession of Medicine<div class="MsoNormal">
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. <o:p></o:p></div>
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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. </div>
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The <a href="http://blogs.wsj.com/pharmalot/2014/08/14/cms-fixes-tech-glitch-that-hobbled-pharma-data-disclosures/">Wall Street Journal detailed a piece yesterday</a> 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. <a href="http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-08-15.html">CMS itself came out with a statement today</a> describing identification of “the problem”, and instituted a system fix to
prevent similar errors. The <a href="http://blogs.wsj.com/pharmalot/2014/08/15/cms-is-sticking-to-its-deadline-for-posting-pharma-payments-to-docs/">WSJ followed up today with an updated post</a> highlighting CMS’ position to stick to the September 30, 2014 deadline.<o:p></o:p></div>
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Here is the kicker: CMS will actually withhold approximately
1/3 of the data from the site, due to “intermingled data”, according to a <a href="http://www.propublica.org/article/government-will-withhold-one-third-of-the-records-from-database-of-physicia">piece earlier today from Charles Ornstein of ProPublica</a>. “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 <a href="http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/index.html">an explanation of the NPI number here</a>: and anyone can look up an individual physician’s NPI number <a href="http://npidb.org/npi/">here</a> or <a href="https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRegistrySearch.do?subAction=reset&searchType=ind">here</a>.<o:p></o:p></div>
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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):<o:p></o:p></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_BtsZiXa2sRAmxWpNl5R334hNfT-lYYrd1XPJXV9ev_6cgqV6K4ujr7PyLFd-Ryyg_6YXiNX7D6htD0T2Ne1_agtiYWMK4tPnkKBWcxfJ5dPKoqC6JBil__OQpqpqE0NWblyhRfslDlY/s1600/Open+Payments+8-15-14+pic.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_BtsZiXa2sRAmxWpNl5R334hNfT-lYYrd1XPJXV9ev_6cgqV6K4ujr7PyLFd-Ryyg_6YXiNX7D6htD0T2Ne1_agtiYWMK4tPnkKBWcxfJ5dPKoqC6JBil__OQpqpqE0NWblyhRfslDlY/s1600/Open+Payments+8-15-14+pic.png" height="161" width="320" /></a></div>
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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 <a href="http://www.policymed.com/2014/08/physician-payments-sunshine-act-cms-extends-dispute-window-to-september-8-data-will-go-live-september-30.html">this post</a>. <o:p></o:p></div>
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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.<o:p></o:p></div>
Alex Djuricichhttp://www.blogger.com/profile/07552747135487262343noreply@blogger.com0