Wing of Zock http://wingofzock.org Academic Medicine in Transformation Tue, 05 Jan 2016 16:02:36 +0000 en-US hourly 1 https://wordpress.org/?v=4.4.10 Health Care Mergers and Acquisitions: A Promising New Environment for Medical Research? http://wingofzock.org/2015/12/18/health-care-mergers-and-acquisitions-a-promising-new-environment-for-medical-research/ Fri, 18 Dec 2015 16:39:14 +0000 http://wingofzock.org/?p=4143 Continue reading Health Care Mergers and Acquisitions: A Promising New Environment for Medical Research? ]]> The changing health care landscape, accelerated by the Affordable Care Act, has signaled a move of the federal government, as well as private insurers, from fee-for-service to value-based reimbursements. To ramp up for this change, academic health centers are creating larger, integrated care delivery systems through mergers and acquisitions of hospitals, physician practices, and potentially of digital health companies.   

The thinking is that scale will help academic health centers leverage their size and unique strengths to: 1) establish a large patient base and market share, which will allow them to endure and continue to provide the safety net care for the most complex and vulnerable patients; 2) mitigate the risks in transitioning from fee-for-service to more global reimbursement models; 3) position themselves to more effectively negotiate with payers for favorable reimbursement rates; and 4) preserve the academic missions of education and research.

Economists, regulators, policy makers, insurers, academic medicine leaders, patient groups, and consumer groups have voiced both support and cautions for the moves to integrate large health systems. However, there has been less attention on the impact on medical research; there are some extraordinary opportunities and some daunting risks.

The opportunities: First, the expansions will significantly increase the size and the diversity of the patient and population base for outcomes research. With the anticipated requirements for addressing the social determinants of health in quality improvement efforts and reimbursements, a more diverse patient base will present advantages for integrating research into care delivery and community-engaged research to target social determinants to help reduce health disparities.

Second, the integration will provide new opportunities for conducting health care delivery science across different sites with different cultures, practices, and attitudes. Implementation science, at its best, can serve to evaluate various interventions, then scale or spread those that work and stop those that do not. The recent growth of centers that focus on innovation, improvement, and implementation science, from 10 in 2006 to 48 in 20151, points to academic health centers’ efforts to build an infrastructure for care delivery and population sciences.

Third, with the President’s Precision Medicine Initiative, the expanded patient base will provide a superb venue for integrating demographic, diagnostic, EHR, and other data with genomic data. This comes at a time of concurrent efforts to accelerate EHR interoperability to enhance care, lowering the historical hurdle to clinical outcomes research across systems.

Fourth, care delivery science and patient outcomes research can have “local” benefits on the patients and communities the system directly serves. Such impacts are easily observed by local community members and policy makers, building trust and support for the institutional efforts and continued partnerships.

Finally, this area of research can establish evidence-based approaches to improve care and patient outcomes which can, in turn, help influence future federal and state policies that take into account the complexity of caring for patients served by safety net health systems.

The risks: Basic research is one area of academic medical research that may be at risk. Unlike outcomes and care delivery research, basic science may not directly benefit the patients and populations served by the health system in the short term.

Basic science builds on thousands of incremental but crucial advances in laboratories across the globe to create new knowledge. Take the well-known “statins,” a drug class for treating high LDL cholesterol, and also the recent new treatment class, the PCSK9 inhibitors: both came from a nearly a century of basic science. Biochemical, molecular, cellular, and physiological studies were conducted in laboratories throughout the world that identified intricate details of pathways for the metabolism of LDL cholesterol, uncovering potential sites in the pathway for treatments. This is one example, and there are thousands more. While basic science may not provide the relatively more direct effects on the patients and populations served by the health systems, the results will ultimately have a tremendous impact on both patients’ health and the costs to the health systems.

Under the intense pressure to reduce costs and preserve fragile margins, will the newly integrated, large health systems focus singularly on care delivery and population management and not see the importance of investing in basic research as a priority and part of the research mission? I hope not. Abandoning basic medical research is abandoning our future.

A note of optimism. Perhaps bigger and more integrated academic health systems can intentionally leverage the forces at play in their environment to continue to ensure on-going support for basic science. We know that academic health centers are committed to investing in medical research; as our recent study with Huron Consulting Group shows that, for every $1.00 of sponsored research received, the average academic health center spends an additional $0.53 out of their own pocket.

There is also an increased effort by academic research leaders to focus on research priorities that are consistent with the institutional and community missions, needs, values, and resources. Perhaps we can borrow from pharmaceutical companies’ agreement on “precompetitive spaces,” in which research across different integrated health systems is also integrated – where some centers work collaboratively to address vexing health problems like diabetes, heart disease, and cancer through integrating basic science, clinical research, outcomes research, and implementation science.

The voices of the academic research community have been relatively silent on the issue of mergers and acquisitions, and it’s time to engage. There are some extraordinary opportunities for medical research, and some daunting risks. Ignoring either is short-sighted. If the academic medicine community works together to achieve the goals of consolidation, stabilizing fragile clinical margins, and calming the sustainability concerns, it can also sustain its historical commitment to investing in medical research to improve the health, wellness, and quality of patients’ lives – sometimes even finding cures for them.

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Ann Bonham, PhD, is chief scientific officer at the Association of American Medical Colleges. She can be reached at abonham@aamc.org.

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Navigating the Reproducibility Rapids to a “Learning Research System” http://wingofzock.org/2015/11/20/navigating-the-reproducibility-rapids-to-a-learning-research-system/ Fri, 20 Nov 2015 20:24:29 +0000 http://wingofzock.org/?p=4130 Continue reading Navigating the Reproducibility Rapids to a “Learning Research System” ]]> Reproducibility has emerged as a touchstone controversy within the scientific community, the public and the Congress over the past few years. In the wake of recent reports and headlines, science has come under intense scrutiny. But revelations about failure to reproduce experiments, alone, should not shake our trust in the legitimacy of the medical research enterprise. In fact, the attention may be a good thing. As scientists, we understand the complexities of science, but understanding among ourselves will not reassure the public and Congress. If we truly want to engender the public trust and enhance our own learning, let’s welcome this opportunity to address limitations and uncertainties and improve our processes and communication in science rather than overlooking, ignoring, suppressing or railing against the topic.

The term itself, “reproducibility,” can provoke an array of reactions – from immediate confidence (the results were reproducible and so are credible!) – to consideration of the context of the results (differences due to biological variables and applicability of the model, e.g. Were the results obtained in male humans, animals, and cells not generalizable to female species? Was the animal model simply not applicable to humans? Are there discrete differences in the population studied that masked important differences?) – to unfortunate misperceptions (science is fickle. The results must be fraudulent).

Perceptions in the public and in Congress shape policies. To that end, the NIH has just taken a big step toward ensuring reproducibility by increasing the requirements for rigor and transparency in the research that it funds.

At the 2015 GREAT Group and GRAND Professional Development Meeting, prior to the release of the new policy, NIH principal deputy director, Larry Tabak described the NIH’s proposed solutions within the policies to enhance reproducibility: 1) being accountable for adequately describing the methods or materials; 2) noting limitations in the study design; 3) considering all relevant biological variables in the scope of the research (the NIH specifically called out that sex is a biological variable and focusing studies on male animals and cells may obscure the importance of sex on biological processes and responses to interventions); 4) authenticating key biological and chemical resources; and 5) bearing in mind implicit biases in how the results are interpreted or disseminated. Thankfully, from the evidence available, fraud or misrepresentation of findings accounts for only a small percentage of the problems identified, and the scientific community and federal sponsors have effective means to address misconduct.

Navigating the reproducibility rapids goes beyond this policy. There are additional steps the entire research community can take to advance rigor and transparency; and that is by promoting and sharing negative findings as a rule. Beyond enhancing a sense of openness, there may be vital scientific knowledge residing in those negative findings – a legitimate source of “irreproducibility” that could help dissect when and for whom certain interventions may be promising and when and for whom they may not. And, isn’t that a clear signpost for building public trust?

This will take all of us. Sharing data (both negative and positive) would need to be a consideration in merits and promotions, welcomed for publication in respected journals, and established in trusted infrastructures and venues where data sharing is not a prohibitive time and resource burden for the scientists who do the work, or a concern for not protecting privacy in human studies.

In the end, navigating the reproducibility rapids may lead us not only to public confidence and supportive policies, but also to a “learning research system.”

This post originally appeared on aamc.org

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Ann Bonham, PhD, is chief scientific officer at the Association of American Medical Colleges. She can be reached at abonham@aamc.org.

 

 

 

 

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Left Behind: Why Excluding Residents from Delivery System Reform Hurts Us All http://wingofzock.org/2015/10/30/left-behind-why-excluding-residents-from-delivery-system-reform-hurts-us-all/ Fri, 30 Oct 2015 14:51:49 +0000 http://wingofzock.org/?p=4116 Continue reading Left Behind: Why Excluding Residents from Delivery System Reform Hurts Us All ]]> Several weeks ago, I was fortunate enough to attend a meeting at the Association of American Medical Colleges (AAMC) on a new mandatory payment model for joint replacement. I was the only resident physician among the more than 70 health professionals at the meeting. What I learned is that for most trainees in medical school and residency, little time is spent understanding the nuances of health care finance or practice management.

At some point, we will all start our own practices, and the clinical decisions we make will have direct financial impact on our patients, our practice, and ourselves. Many of us are prepared to survive in a system utilizing fee-for-service reimbursement models that we have experienced in training. However, the world of health care finance is changing. With increasing pressures to control cost, payers are responding by developing new models of reimbursement. With an aging population, Medicare is seeing an ever-increasing cost burden and the Centers for Medicare & Medicaid Services (CMS) is seeking ways to control costs while continuing to provide essential patient services. This necessitates creative new reimbursement models that promote cost control and consistent, quality patient care. The Comprehensive Care for Joint Replacement Model (CCJR) is one such example that has been proposed by CMS. CCJR is centered on a bundled payment to a hospital for a total joint replacement and the subsequent 90 days of care with the goal of incentivizing hospitals and physicians to control cost and improve perioperative care. Such a model shifts risk from the payer (CMS) to the providers of care.

As medical students and residents, the majority of our training is spent obtaining the knowledge and skills necessary to effectively treat patients in our chosen specialty. Little, if any, time is spent on learning about practice management, or reimbursement models, and how they impact the care we spend so much time learning how to deliver. This is an unfortunate shortcoming of our current medical education. We should be demanding that our faculty and trainees gain knowledge of these emerging models that are directly influencing our practices.

The CCJR model provides an excellent opportunity to reflect on the downstream consequences of payment models for our health systems. In a fee-based reimbursement model, volume is incentivized and implant cost, physician fees, hospital stay, rehabilitation, and other medical services are all billed on an individual basis. In a bundled repayment model where 90-day episode costs must be accounted for, attention must be paid to a wider variety of cost control and quality of care measures as the surgeon and hospital assume much higher risk. The bundled payment reconciles historical baseline costs with actual costs, and health systems must either pay CMS excess episode costs or may generate savings if they more efficiently delivered care. In the bundled payment world, more extensive collaborative care with anesthesiologists and primary care providers can better optimize preoperative medical care. Postoperative rehabilitation and medical care may need to be focused on better preparing patients for a discharge home. More intensive postoperative care plans may need to be implemented for patients to minimize their postoperative medical or surgical complications. Access to more extensive home health care resources may need to be developed. Graduating resident orthopaedic surgeons planning to perform total hip and total knee replacements could be ill-prepared to develop a sustainable practice without a sound understanding of this emerging model. This is but a single example in a single specialty. Every medical specialty will see changes in their practices as payers develop new reimbursement models.

Educating residents and students on upcoming changes to payment models is in the direct interest of practicing physicians in academic practices as well. Resident physicians and medical students help deliver medical care in the operating room and on call every day throughout the country. It is vital for resident physicians to have the skills and knowledge necessary to provide excellent and cost-effective patient care. Our knowledge of historical and emerging reimbursement models will allow us to be more proactive and influential in the evolution of these systems. In addition, being aware of the influence of reimbursement models on our ability to provide effective, appropriate patient care allows us to be better prepared to advocate for our patients and our practices.

There is little doubt that physicians must play an active role in reducing health care costs and improving patient care, and we must become engaged early in our medical education. We must be able to influence, instead of react to, the ever-changing environment of our health care system.

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Michael Decker, MD, is a PGY-4 orthopaedic surgery resident at the University of New Mexico in Albuquerque, NM. He can be reached at mdecker@salud.unm.edu

Dr. Michael Decker

 

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Activating Patients to Achieve Better Health Outcomes: Spotlight on NYU School of Medicine http://wingofzock.org/2015/10/20/activating-patients-to-achieve-better-health-outcomes-spotlight-on-nyu-school-of-medicine/ Tue, 20 Oct 2015 10:15:52 +0000 http://wingofzock.org/?p=4109 Continue reading Activating Patients to Achieve Better Health Outcomes: Spotlight on NYU School of Medicine ]]> Highly activated patients take proactive, collaborative roles in maintaining their health. They are more likely to engage in healthy and preventive behaviors than their less activated counterparts, and incur lower health care costs. Higher activation often corresponds with improved health outcomes and greater patient satisfaction. However, increasing patient activation can be difficult, especially when patients face such additional challenges as low literacy, language and cultural barriers, and physical disabilities.

Patient activation is a fundamental component of the Patient-Centered Medical Home (PCMH), a care model that increases patient engagement with a team of health care providers through coordinated care and the use of technology. A clinical education and research project team led by Adina Kalet, MD, MPH at the NYU School of Medicine, Division of General Internal Medicine, part of the NYU Langone Medical Center (NYU Langone) is developing and testing an innovative Patient Empowerment Program (PEP) within NYU’s PCMH and linking it to the training of primary care residents. This work was supported by a Clinical Care Innovation Challenge Award from the Association of American Medical Colleges.

Increasing Patient Engagement

Especially for patients with chronic conditions, increasing engagement with the health care team so that their needs, values, and preferences are respected and they have input in their care is vital. But how do patients learn to be equal partners in their care? The NYU Langone team is tackling this challenge head-on with PEP to benefit not only the patients they serve, but to spread and support health systems redesign and provider training in the long term.

Rather than utilizing standardized patients as in other simulation approaches, the NYU Langone program works with actual patients from its PCMH, which allows for direct feedback and impact for both patient and learner. Patients with type 2 diabetes were recruited from the NYU Langone PCMH to participate in a series of PEP sessions to demystify the medical encounter and learn the skills to be active participants in their care. Medical students and residents participate in the sessions and focus groups to assess the barriers to patient activation and from there develop a set of training materials to be disseminated broadly. Although they’re working with real patients, the PEP sessions and focus groups utilize elements of standardized patient training, a well-established, performance-based intervention that uses actors in the education of physician trainees.

The NYU Langone research team is making progress with their PEP work. Thus far, they have engaged 80 adult diabetic patients in a series of focus groups with the trainees and providers. A significant ‘aha moment’ comes when trainees see patients benefiting from being more activate in their own care. ”While many schools use trained standardized patients who play the role of a person with a given condition or symptoms, we are with actual diabetic patients who have very real concerns about their health. Many start out feeling vulnerable and disempowered. As the students and residents hear how the patients are feeling and what is most important to them, we are honing our communication skills and learning to engage in shared-decision making. The patients are more activated. It’s a win–win,” says Joseph Plaksin, a dual-degree, fifth-year student who has been facilitating PEP focus groups.

Evidence of Change

When actual patients participate with the trainees and the health care team, there is evidence of behavior change for each of them. Patients have lost weight, some stop smoking, while others take the critical step of completing their health proxy and living will forms. Trainees have more empathy for patients and think about how to be more sensitive in other clinical scenarios they face.

The lessons learned from this project will contribute to the development of educational and training materials for patients, students, and residents, as well as a protocol for a PCMH program based at Bellevue Hospital Center, which serves a diverse and medically underserved population and is a primary teaching site for the NYU School of Medicine residency training program.

The NYU Langone team is also looking at the long-term impact of this program, including systems-based reductions in health care costs and more efficient care. A recent study demonstrated that when patients’ activation in their own health care increases, health outcomes improve and costs are reduced, even several years later. Project lead Adina Kalet, MD, MPH says, “For our population of diabetic patients, we anticipate an increase in adherence to medical advice, fewer hospital admissions, fewer missed appointments, and an overall reduction in high-cost outcomes. In the short term, we will be looking at measurable changes in the patients’ hemoglobin A1c levels and anticipate there will be decreases.”

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Adina Kalet, MD, MPH was a recipient of the 2014 Association of American Medical Colleges Clinical Care Innovation Challenge Award. If you are interested in obtaining more information about this project or another CCIC project, please email innovationchallenge@aamc.org. The 2016 Clinical Care Innovation Challenge Awards application period is currently open and accepting applications.

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Creating a Culture of High Value Care at Massachusetts General Hospital http://wingofzock.org/2015/10/16/creating-a-culture-of-high-value-care-at-massachusetts-general-hospital/ Fri, 16 Oct 2015 14:26:23 +0000 http://wingofzock.org/?p=4096 Continue reading Creating a Culture of High Value Care at Massachusetts General Hospital ]]> Three in four physicians stated that unnecessary tests and procedures contribute to the high cost of health care in the United States, according to a survey conducted by PerryUndem Research/Communication. In recent years, medical societies and health care professionals alike have begun to speak out on the overutilization of tests and its harmful effects on health. Nilay Patel, MD, an internal medicine resident at Massachusetts General Hospital (MGH), understands that we must shift away from our “more is better” culture. That shift can start by equipping residents with the proper knowledge, skills, and tools to promote a culture of high-value care among their patients.

Cost-Value of Patient Care

Patel partnered with his faculty advisor, Ryan Thompson, MD, to investigate MGH residents’ knowledge of the relationship between cost and value due to residency program curriculum, and their consideration of cost–value during daily patient activities. The results were startling: Only 35 percent of residents felt that the current curriculum prepared them to consider the cost–value of patient care during delivery; fewer than 50 percent of residents considered cost–value of procedures and tests on a daily basis.
“These results verified that there was a need for a new, innovative curriculum to train internal medicine residents at MGH in the delivery of high-value care,” said Patel.

“Approximately one-third of MGH internal medicine residents are involved directly in quality improvement initiatives. However, their involvement typically is sitting on a committee with faculty. Through this project, our goal was to change the culture of high-value care by implementing a quality improvement initiative that was primarily peer-driven, and allowed residents to obtain constant feedback while applying their knowledge and skills.”

As a 2014 Clinical Care Innovation Challenge Pilot Award recipient, a program sponsored by the Association of American Medical Colleges, Patel led the development and implementation of a multifaceted, high-value care curriculum for internal medicine residents. The curriculum was disseminated in three phases: awareness, education, and application. The awareness campaign engaged residents by highlighting internally generated goals relevant to the residents’ daily patient care, which were displayed in resident work areas. It drew inspiration from the American Board of Internal Medicine Foundation’s “Choosing Wisely” campaign.

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Massachusetts General Hospital Poster Campaign


Value Dashboard

Seeking an innovative approach to measurement during the application phase, Patel constructed the Value Dashboard, a feedback mechanism that provides residents with monthly qualitative and quantitative assessments on high-value care metrics.

Quantitative feedback is reported as compliance rates with the internally generated goals, while the qualitative reports show the results from resident surveys administered throughout the year that assess perceived competency in recognizing and providing high-value care.

“The Value Dashboard is a novel approach that did more than just provide feedback to residents and data to the team,” said Thompson. “It helped in the facilitation of peer-to-peer learning and mentorship. Additionally, the experience of this quality improvement project gave residents a sense of responsibility in the project’s success, which added more value to their daily work.”

Patel designed the curriculum to serve as a model for other residency programs with an interest in expanding their quality improvement programming. MGH continues to change the culture of high-value care among internal medicine residents at MGH and other institutions through this curriculum.

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Nilay Patel, MD, was a recipient of the 2014 Association of American Medical Colleges Clinical Care Innovation Challenge Award. If you are interested in obtaining more information about this project, another CCIC project, or the awards program, please email innovationchallenge@aamc.org. The application period for the 2016 Clinical Care Innovation Challenge Awards will open on Tuesday, October 13, 2015.

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Training Residents to Be Error Free http://wingofzock.org/2015/10/13/training-residents-to-be-error-free/ Tue, 13 Oct 2015 14:01:18 +0000 http://wingofzock.org/?p=4091 Continue reading Training Residents to Be Error Free ]]> Patient safety is essential to addressing and improving the quality of our health care.  The release of “To Err is Human,” the landmark report by the Institute of Medicine (IOM), highlighted the need for health care professionals to discuss patient safety in relation to medical errors. With a primary focus on systems-based errors, most hospitals and residency programs have designed and implemented structures to address this type of error. However, large gaps in resident education around error remain prevalent. Emily Ruedinger, MD, assistant professor at Seattle’s Children’s Hospital, formerly of the University of Minnesota; and Andrew Olson, MD, an assistant professor at the University of Minnesota, are steadfast in their mission to expand resident training and reduce cognitive error.

“Many medical training programs devote considerable time to systems improvement and knowledge expansion rather than critical examination of cognitive error,” said Ruedinger. “Cognitive error should be considered crucial to reducing overall error, particularly in the cognitive specialties. There are a limited number of resident training programs that include curriculum for and/or discussion of cognitive error. Without such curriculum, a knowledge deficit is created.”

Assessing Medical Errors

As recipients of the 2014 Clinical Care Innovation Challenge (CCIC) Pilot Award, a program sponsored by the Association of American Medical Colleges, Ruedinger and Olson spearheaded the creation and implementation of a novel, longitudinal cognitive error curriculum for pediatric residents at the University of Minnesota. Additionally, an evaluation pre- and post-test tool was piloted with family medicine residents, who served as the control group. The assessment centered on the residents’ knowledge level, attitudes, and opinion of culture in relations to medical errors.

Ruedinger and Olson incorporated active learning techniques that promoted practical application of concepts and skills into the curriculum. Residents developed and expanded their awareness, knowledge, and competencies of cognitive error through interactive approaches such as faculty panel role-modeling, small group discussions, skill-building workshops on peer feedback, written self-reflection, and other structured activities. One facet of the curriculum sought to build residents’ content knowledge surrounding metacognition of medical decision-making, the risks and benefits of different decision-making strategies, types of cognitive error, and development of systems to reduce cognitive error. The incorporation of interactive learning techniques shifted residents’ attitudes toward a culture that supports transparency of thought process and creates an open environment for error disclosure and discussion.

“With academic health centers and teaching hospitals looking to improve care delivery, our curriculum presents an innovative approach to addressing a primary component for improving patient safety,” says Olson. “Through this curriculum, residents could delve deeper into topics and develop applicable skills, which is a vastly different approach from traditional training programs. Moreover, residents were exposed to the perspectives of multiple individuals, like the patient’s family and lawyers.”

Now in their third year of implementation at the University of Minnesota, Ruedinger and Olsen are looking at avenues to bring the curriculum to different audiences and institutions, both locally and nationally. They have received a great deal of interest from colleagues in the medical community, and have been invited to present at a number of meetings and conferences. In her position at Seattle’s Children’s Hospital, Ruedinger is working with colleagues in safety leadership to identify opportunities to integrate the curriculum.
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Emily Ruedinger, MD, and Andrew Olson, MD, were recipients of the 2014 Association of American Medical Colleges Clinical Care Innovation Pilot Award. If you are interested in obtaining more information about this project, another CCIC project, or the awards program, please email innovationchallenge@aamc.org. The  2016 Clinical Care Innovation Challenge Awards application period is currently open and accepting applications.

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Helping Babies Breathe: Resident Spotlight at Cincinnati Children’s Hospital Medical Center http://wingofzock.org/2015/10/08/helping-babies-breathe-resident-spotlight-at-cincinnati-childrens-hospital-medical-center/ Thu, 08 Oct 2015 14:35:32 +0000 http://wingofzock.org/?p=4077 Continue reading Helping Babies Breathe: Resident Spotlight at Cincinnati Children’s Hospital Medical Center ]]> Part two of a five part series on the 2014 AAMC Clinical Care Innovation Challenge Pilot Award Winners
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Several years ago in Brazil, medical student Anatalia Labilloy witnessed a newborn die in the delivery room when the care team could not properly perform neonatal resuscitation. The experience left an indelible memory with her. She was early in her medical training and she was anxious about encountering other occasions to resuscitate babies knowing what could happen. Now as a resident at Cincinnati Children’s Hospital Medical Center, Labilloy is practicing vital resuscitation skills to help babies breathe.

Labilloy knows firsthand the value of the simulation-based training she receives to prepare for those rare instances when she will need to provide life-saving resuscitation care. What’s novel about the simulation training at Cincinnati Children’s? The teaching methodology is a competency-based curriculum with simulation to actively engage the learner.

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                            NeoNatalie by Laerdal

 

Using NeoNatalie, a low-technology, low-cost plastic mannequin that can mimic crying, spontaneous breathing, and exhibit chest wall movement, residents engage in a more active form of learning by doing with the intent of better attainment, retention of resuscitation skills, and improved patient outcomes.

This pilot research project is supported in part by an AAMC Clinical Care Innovation Challenge Award and a Cincinnati Children’s Perinatal Institute Pilot and Feasibility Grant. Project leaders Beena Kamath-Rayne, MD, MPH and Gary Geis, MD are determining if an evidence-based educational program to teach neonatal resuscitation techniques in resource-limited areas – such as in developing countries – could also improve U.S. pediatric residents’ retention of basic resuscitation skills.

Care Delivery Innovation
The need to practice and retain such skills is critical with changes to duty hours in residency requirements and more limited delivery room experience. Kamath-Rayne says, “Because traditional methods of teaching neonatal resuscitation have not been successful in regards to learner retention, we are using a curriculum based in adult learning theory, which includes more hands-on practice for more active learning, and providing additional opportunities for residents to practice basic resuscitation skills. Our goals are aligned with the AAMC award, to create innovations in clinical care delivery that will improve outcomes, plus improvements in graduate medical education that will advance quality and patient safety. We think this can serve as a model for other pediatric residency training programs and translate into improved delivery room practices.”

The simulation-based training with NeoNatalie is replacing the lost clinical opportunities. “It’s been important for residents like me to have the training where and when I need it. Otherwise, in the hospital there are few opportunities to apply the skills we are learning with patients. The repetition with NeoNatalie has been key,” says Labilloy.

Importance of Simulation
While many babies only need basic resuscitation, including stimulation, warmth, and suction, a small proportion – about 5 to 10 percent – need bag-mask ventilation (BMV) to establish their own respirations. The interim project results from 28 residents are promising. In a sub-group that rotated at a Cincinnati delivery hospital neonatal intensive care unit (NICU) where the low-dose/high-frequency practice with NeoNatalie provided weekly “just in place” simulation practice, the residents were faster at BMV than a sub-group of residents that rotated without the weekly simulation experience when assessed with a practical Objective Structured Clinical Evaluation (OSCE).

“At Cincinnati Children’s, we use innovative approaches to carry out intensive teaching of 180 residents over three years during their neonatology rotations so they can retain these basic resuscitation skills and have very good clinical outcomes,” says Javier Gonzalez del Rey, MD, MEd., director of the Pediatric Residency Program at Cincinnati Children’s.

The project team is also interested in the optimal intervals of simulation practice that are needed by the residents to maintain those skills once they leave their NICU rotation and complete pediatric residency training. This small-scale study supports the need for a larger research study. With additional funding, there is an opportunity to enhance the skills of more residents, which in turn can lead to more effective resident education and better outcomes for newborn patients.

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Beena Kamath-Rayne, MD, MPH was a recipient of the 2014 Association of American Medical Colleges Clinical Care Innovation Challenge Award. If you are interested in obtaining more information about this project or another CCIC project, please email innovationchallenge@aamc.org.

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Medicine and Video Games: A New Approach to Engaging Diabetic Patients http://wingofzock.org/2015/10/06/medicine-and-video-games-a-new-approach-to-engaging-diabetic-patients/ Tue, 06 Oct 2015 14:11:26 +0000 http://wingofzock.org/?p=4060 Continue reading Medicine and Video Games: A New Approach to Engaging Diabetic Patients ]]> Part one of a five part series on the 2014 AAMC Clinical Care Innovation Challenge Pilot Award Winners
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Imagine this video game scenario:  a player explores a small town participating in everyday activities aimed to help them better understand and manage type 2 diabetes.  The player wanders into the local town café, and is asked to pick out a snack that is suitable to their dietary needs.

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Dapper, the online video game that seeks to improve the health of type 2 diabetic patients

If the player picks a snack that does not match their dietary needs, a pop-up window provides information about the snack and the reasons that it is not appropriate to consume. This video game is real, and its name is Dapper.

Amanda Wright, MD , a family medicine physician at University of Illinois College of Medicine at Peoria and UnityPoint Health Methodist, knew that Dapper would be a challenge, but her passion for improving the health of patients with type 2 diabetes was all she needed to lead the project.

“Dapper has changed the way many residents look at quality improvement. Residents who worked on this project now see that an unlimited amount of possibilities and changes can come from thinking outside of the box,” said Wright. “Most important, it gave residents the opportunity to obtain real-life experience with working on teams outside of the hospital staff, and to have hands-on involvement in every phase of the project.”

A project supported by the Association of American Medical Colleges through the 2014 Clinical Care Innovation Challenge (CCIC) Pilot Award, Dapper was created and designed through a interdisciplinary partnership with UnityPoint Health Methodist/University of Illinois College of Medicine at Peoria and Bradley University. The project team was  comprised of professionals from multiple disciplines and fields, including physicians (both residents and attending), medical students, undergraduate students, faculty, dieticians, nurses, graphic designers, game designers, and business professionals.

To assist in developing the game, the team conducted focus groups to obtain patient feedback about how they receive information about managing their condition and its usefulness, the challenges they face in managing their condition, and their level of interest in using a video game as a vehicle to help them in managing their condition on a daily basis.

Drawing upon the attractive features used in social media games, Dapper incorporates type 2 diabetes health information to increase players’ awareness and educational levels and leverages motivational theories to improve players’ lifestyle choices related to their health. The game is structured so each player works with a team of medical staff (physician, nurse, and dietician); medical staff players can be members of multiple teams. The team serves as resource and support for players in making right decisions about their health throughout their game activity.

Currently, residents at UnityPoint Health Methodist/University of Illinois College of Medicine at Peoria are looking to further develop the game and possibly transform it into an app for mobile devices and tablets.

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Amanda Wright, MD, was a recipient of the 2014 Association of American Medical Colleges Clinical Care Innovation Challenge Pilot Award. If you are interested in obtaining more information about this project, another CCIC project, or the awards program, please email innovationchallenge@aamc.org. The application period for the 2016 Clinical Care Innovation Challenge Awards will open on Tuesday, October 13, 2015 and close Friday, November 13, 2015.

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Remove the Filters To Expand Your Vision of Medical Education http://wingofzock.org/2015/09/29/remove-the-filters-to-expand-your-vision-of-medical-education/ Tue, 29 Sep 2015 04:00:09 +0000 http://wingofzock.org/?p=4053 Continue reading Remove the Filters To Expand Your Vision of Medical Education ]]> Originally posted September 26, 2015

By Steven M. Christiansen, MD

Let me share with you a few insights so far on Stanford Medicine X 2015 (MedX), but first, let’s talk about colored filters, how our individual filters blind our perspective, and why we must remove our individual filters in order to make the most of Medicine X.

FiltersAs you know, when the white light from a flashlight is shined onto a canvas, the canvas is illuminated. If, however, a blue-colored filter is placed in the light’s beam, the only color seen on the canvas will be blue, and the same goes for red, yellow, or other colors within the visual spectrum. Said differently, the colored filter removes from view all colors except that of the filter itself.

This week at MedX I have been inspired, engaged, and enthused for the future of healthcare. I have listened to amazing presentations by physicians, medical students, nurses, pharmacists, social workers, patients, caregivers, innovators, and thought leaders. MedX, organized by the talented Dr. Larry Chu, delivers as promised, strategically placing MedX at the “intersection between medicine and emerging technologies.” I have enjoyed the presentations, the panels, the small-group discussions, and have attempted to contribute relevant content and insights to the live #MedX Twitter feed. In a few days, MedX will be but a fond memory for the masses, but its legacy will be in its ability to catalyze change.

My fear, however, is that our personal filters, speckled with bias, background, and experiential anecdotes, if not carefully scrutinized, may limit our vision. These filters, if not removed, may cause us to screen out the insights of all the other colors, leaving us only to view MedX through our own polarized filter, and blind to views different from our own.

MedX has benefitted from representation by many groups, including:

  • The providers – physicians, pharmacists, nurses
  • The educators – academicians, interdisciplinary learning experts
  • The patients – cancer survivors, chronic disease sufferers, patient advocates
  • The caregivers – parents, children, friends
  • The innovators – tech entrepreneurs, 3D printers, virtual realists
  • The thought leaders – book authors, renowned experts

Each group, often seated together, watches as the MedX spotlight shines on the stage’s canvas, with group members internalizing, annotating, and tweeting their insights. These insights, however, seem to occasionally be limited by participants watching MedX through only the filtered biases of their background. The patient advocates argue for increased democratization of health records, the providers shudder at impending realities of external hard drives of scanned PDFs brought by e-patients to clinic visits; the educators hear these discussions and wonder only how they can possibly teach tomorrow’s doctors to give more face-time to the patients and away from the computer, the entrepreneurs consider only how to create apps to aggregate big data to make big dolla, and the thinkers pontificate in an attempt to put it all together with insight and profundity.

This phenomenon is natural, you argue. ‘We are a product of our experiences and these experiences mold our perceptions.’ Yes–indeed very true. I have not yet experienced the difficulties of chronic illness, nor sat among academicians responsible to develop a curriculum for tomorrow’s learners, nor entrepreneured a multi-million dollar startup supported by parental angelic investors. We enter the halls of Medicine X with our own unique backgrounds, though these same backgrounds may skew our views and alter our analysis. The MedX diversity is what makes it MedX, bringing together all who believe we can collectively use technology and innovation to improve healthcare for all.

Our individual and group backgrounds, however, have the potential to be just like the colored filter, causing us to view MedX only through our colored filter, remaining blind to the other viewpoints of those around us. If not careful to remove the filter from my view, I may disregard the patient advocates’ plea for increased engagement and autonomy, fail to empathize with the academician struggles to design tomorrow’s curriculum, not fully appreciate the contributions of nurses, pharmacists, and social workers, or remain critical of my smartphone-staring-students without realizing these medical students are simply using digital apps like Picmonic or Figure 1 in a learning strategy different from my own. To view MedX through only my filter is a disservice not only to the other colors in the rainbow, but also to myself, for it is by viewing the entire visible color spectrum that I can better contribute insightful solutions to the challenges facing healthcare today.

The solution is simple, the challenge is difficult, but the result will be priceless. When watching a presentation or following the #MedX Twitter feed, we must do all we can to remove our filtered lenses, as it is only by understanding and appreciating all the colors of MedX may we create lasting change for the better.

Steven M. Christiansen, MD, is a PGY-1 Transitional Resident at Methodist Hospital in Indianapolis. Follow him on Twitter @eyesteve.

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At Stanford #MedX | ED, Breakthroughs and a Prescription for Change http://wingofzock.org/2015/09/24/at-stanford-medx-ed-breakthroughs-and-a-prescription-for-change/ http://wingofzock.org/2015/09/24/at-stanford-medx-ed-breakthroughs-and-a-prescription-for-change/#comments Thu, 24 Sep 2015 20:02:03 +0000 http://wingofzock.org/?p=4050 Continue reading At Stanford #MedX | ED, Breakthroughs and a Prescription for Change ]]> By Jennifer J. Salopek

As editor of Wing of Zock for the past four years, I have had the honor of learning about hundreds, perhaps thousands, of innovative ideas to reimaging medical education. On the first day of the inaugural Stanford Medicine X | ED conference Wednesday, I got enough new ideas to fuel a year’s worth of posts. A diverse lineup of presenters—educators, students, and patients—collectively created, through words, images, videos, and music, a vision of a possible future for medical education. They reported on promising innovations in medical education that aim to better prepare the doctors of tomorrow. Accompanied by colored lights, diffuse video backgrounds, and a varied soundtrack, the high-energy atmosphere that is the hallmark of Stanford Medicine X pervaded a conference on medical education.

Designed to be different in every way from traditional academic meetings, Med X | ED features numerous icebreaking and networking opportunities; a low-key product exhibit area; announcements by Gary Williams, the voice of the San Francisco 49ers (“the voice of God”); and constant visual reminders of its living mascot, Zoe, a French bulldog owned by MedX executive director Larry Chu, MD. Attendees received glowsticks in their registration packets that they used to reward effective presenters.

“Jazz and glowsticks. Things not found at traditional #meded meetings,” tweeted Bryan Vartabedian, MD, a gastroenterologist from Baylor University in Houston.

The trappings, rather than making the content seem less serious, instead make it more accessible, more memorable. The entire conference is an incarnation of the Von Restorff effect, a concept I learned just this morning, that posits that we are more likely to remember things that are unusual, or fun, or inappropriate. While you might not remember the last session you attended on interprofessional education, you would remember the one Paul Haidet, MD, delivered. Haidet, a general internist and health sciences researcher at Penn State University Hershey, used three recordings of the same jazz standard, “Waltz with Debbie,” to illustrate the ways in which small teams can collaborate. It’s likely that many attendees were searching iTunes for the tracks afterward.

Taking its theme from Chu’s opening remarks, in which he said, “The care we receive tomorrow depends on the doctors we prepare today,” the schedule featured 10-minute Ignite! talks, panel discussions, and keynote presentations by Howard Rheingold and Abraham Verghese, MD. Topics ranged from the collaborative redesign of a mental health unit in Nashville to the use of whiteboard videos to encourage healthy behaviors to the rise of medical student communities of practice. Leveraging technology and social media, it is clear that medical schools are trying to address the needs and learning styles of this generation of learners.

But presentations also included pleas to close the gaps, including Ignite! talks by Nisha Pradhan, who lamented the lack of instruction in creativity and critical thinking skills. In true Medicine X style, her presentation was nicely balanced by that of Dutch medical student Tim Van de Grift, who talked about the importance of art in medicine. Continuing the thoughts addressed in his spring New York Times editorial, Dhruv Khullar discussed the need for more time to spend with patients. Gallaudet professor Joseph Santini delivered his talk in American Sign Language as he observed conditions that reduce access for patients and students with disabilities.

Medicine X is a conference that teaches about social media and relies on it. As presenters discussed the ways social media can be used for patient-driven medical education, pharmacy education, research, patient advocacy, and other efforts, the Twitterverse was alight with tweets from the meeting. [Full disclosure: I had the privilege of guest tweeting from the @StanfordMedicineX account.]

Symplur analytics show that the conference generated more than 6,000 tweets and 32 million impressions. [This information was delivered personally by Audun Utengen, co-founder of Symplur and the Healthcare Hashtag Project. You get to meet the most amazing people here.] Backchannel conversations included the sharing of resources, idea generation, and promises to get together IRL or virtually to move new initiatives forward. One proposal that got a lot of traction was the idea of pairing medical students with patient mentors.

A panel of current medical students, moderated by Roheet Kakaday, provided real insights into what it’s like to be a medical student today: dealing with many distractions, connected but trying to be efficient, seeking disruptive models like those that exist outside of education, and striving to connect learning with lived experience. The improvements they suggested included more interdisciplinary classes, an increase in the number and type of med schools unencumbered by traditional structures, education as a continuum, and competency-based models.

In his Ignite! talk, Stanford medical school dean Charles Prober discussed his institution’s attempts to meet millennial learners where they are, through the development of a multi-institutional “blended curriculum of the future.”

Patient speakers provided moving accounts of their own (mostly negative) experiences with the health care system as they shared ways in which providers and patients can work together more closely. Dave de Bronkart, who recently served as a visiting professor at the Mayo Clinic, exhorted against academic arrogance.

“We must not train another generation of clinicians who do not know that it’s okay to admit that you don’t know something, and that it’s a tragedy with consequences if you pretend that you do,” he said.

The most profound learning experiences for me came with the presentations by Emily Kramer-Golinkoff and Leslie Rott. Kramer-Golinkoff poignantly described her experience with a rare form of cystic fibrosis as she noted that the factions of medical and pharmaceutical research are perversely incented. “I’m an orphan with a ticking clock [who] doesn’t have time to wait for a normal drug approval timeline,” she said. Rott discussed her experience as a graduate student struggling to earn her Ph.D. while dealing with a chronic illness.

“The best lessons come from interactions with patients, not what is in the textbooks,” she said.

Jennifer-1990-webJennifer J. Salopek is founding editor of Wing of Zock. She can be reached at jjsalopek@cox.net, or follow her on Twitter @jsalopek.  

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