✚ Shorten med school, but not overall training

This past week, the Washington Post published an article detailing some recent efforts to shorten med school to 3 years. The illustrious Dr Cranquis weighed in with his usual acerbic, dead-on commentary.

Pauline Chen MD took on this issue back in October in the NY Times, primarily in response to point-counterpoint essays in the NEJM. As with this most recent article, it generated quite a bit of commentary. One of the most thoughtful and informative pieces I read in response to Dr Chen’s article was from Josh Freeman MD, a professor of Family Medicine at my own institution and graduate of a 3 year med school program.

One lesson I’ve taken to heart in medical school is that good education takes time. In order to truly learn something, you have to read and think about it, breathe it in and live it [1]. Doing so takes time. The implication of this is that appreciably shortening the time to train a doctor will likely be difficult.

However, just because shortening total training length seems unwise or difficult does not mean we still can’t reform the structure of medical training. Ideally, I think we should shorten medical school to 3 years but lengthen residency training to 4 years (which would maintain 7 total years of training for most specialties). A greater emphasis needs to be placed on premed education so that basic science education can be completed in the first year of medical school. Some of this can spill over into the clinical training in second and third year. For example, intense anatomy education with time in the cadaver lab seems better suited to occur during a surgery rotation rather than 1–2 years prior. Basic clinical training—which now occurs solely in the 3rd—could be spread over two years.

In terms of residency, such a schedule could help cope with the increased focus on limiting work hours and patient safety. Residencies would have an additional class to help with patient care. The interns would gain more active patient care experience while the senior residents will have additional time supervising trainees.

Our current training paradigm poorly allocates time. Nearly everyone in medical education will agree that active patient care is where the most useful and longest-lasting education occurs. Instead of blindly trimming a year off of training, let’s reallocate that time to more useful education and contribute to taking care of our ever-increasing patient population. [2]

  1. This is why the bulk of medical education (3rd &4th year of med school + a minimum of 3 years in residency; 5 of 7 years) is hands-on, seeing and learning from real patients.  ↩

  2. Will such a restructuring ever happen? Almost certainly not; it would disrupt the current economics of medical education too much. Medical schools would get one less year of tuition and residency programs would have to find ways to support an additional class. Residency programs can’t even find money to expand their classes to cope with the increased number of med students. How are they ever going to deal with a seismic shift like adding a full residency class?  ↩

How doctors choose doctors | The American Resident Project →

Zack Permutt MD:

Why is it so difficult to find a good doctor?

Why are we still using word of mouth when it comes to choosing doctors? 

Why is the health care industry so far behind in bringing the basics of social media to help improve the patient experience? 

Great post on the arcane methods we use to select some of the most important people in our lives.

Evidence based medicine—it’s time to be critical | BMJ Blogs →

Speaking of evidence-based medicine, here is a great piece by William Cayley:

It takes effort to go beyond what the guidelines, experts, and adverts give us, but that work is part of medicine—and critical thinking about how to do a better job of curing, comforting, and caring is at the heart of being a doctor.

✚ 'Real Science' is so much more than controlled trials

During this past week’s #meded chat [1], I stumbled upon the following tweets from Joel Topf MD:

The thing about resident research is that real science is multi-center with hard outcomes. #MedEd 1/3 [original]

The time and $ limitations of residency prevent implementation of these types of research studies so… #MedEd 2/3 [original]

We really are teaching residents to think small and how to do poor research. This is not a good idea. #MedEd 3/3 [original]

The same day, I heard a prominent researcher giving Grand Rounds state, ‘We have to do real science and randomized-controlled trials are real science.’

The notion that ‘real science’ is solely the purview of large, multi-center randomized-controlled trials is a dangerous one. Yet it is a refrain I hear often.

All things being equal, a large, multi-center, randomized, placebo-controlled trial is the strongest method for answering a question [2]. But things are never equal. Research is constrained by the real world. Ethics, time, and money all participate in the process of systematically answering a clinical question.

Often, it is not ethically possible to randomize one group to treatment and one to a placebo. This is generally true when a known effective treatment exists—antibiotics are a good example—and it would be harmful for the patient to withhold the existing treatment. In such cases, non-inferiority or equivalence trials are conducted.

Time also plays a major factor in answering clinical questions in which the clinical sequelae take years or decades to develop. Cancer studies are the classic example here [3]. It is nearly impossible to conduct a randomized trial of almost any exposure we believe leads to cancer (or is protective) because cancers can take decades to manifest themselves. Such a study would be plagued by loss-to-follow-up and high costs. In such situations, we use case-control studies.

Even though we don’t like to admit it, money frequently determines research priorities and design. One area where large, multi-center, randomized, placebo-controlled trials are routinely conducted is pharmacologic prevention of heart disease. Why? Because pharmaceutical companies can make billions of dollars on a single blockbuster drug to support such research. They use very large trials because these are convincing to doctors and they invariable demonstrate ‘statistical significance’ even for very small improvements. In most other areas—especially pediatrics—there is generally not such a free flow of money for expensive controlled trials.

This past week, we were reminded about the Surgeon General’s 1964 report on the ill effects of smoking. This report relied on over 7,000 documents. None of the evidence used in this report included human randomized trials. In fact, the lack of controlled trials is what the tobacco companies used for years as a rebuttal to the medical evidence against smoking. Are we any less convinced today of smoking’s ill effects because it is not supported by the ‘real science’ of controlled trials?

The BMJ illustrated the many limitations of randomized-controlled trials in their classic article, ‘Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.’ Given such constraints, controlled trials are only possible for a fraction of our clinical questions, yet we answer meaningful questions with good research all the time. Our problem is not a dearth of controlled trials, but an overabundance of bad research of all types. A bad, poorly designed randomized trial never trumps good cohort or case-control studies. Our focus should not be on study type, but the overall quality of research.

To Dr Topf’s point about ‘teaching residents to think small and how to do poor research,’ I will grant that I think this happens frequently [4]. However, it’s not because time and money constraints preclude us from engaging them in randomized trials, but because mentors seem complacent with involving residents in bad research. Too often, resident research projects seem to be poorly designed chart reviews. This is an exact recipe for how to turn residents off to research—tedious data collection with little prospect of wide interest.

I am enthusiastic about research in large part because I have avoided projects that require lots of tedious data collection and because I’ve had some early success. The first paper I led was picked up by the mainstream media and has been cited dozens of times. This should never be one’s sole measure of success, but it certainly helps to know that some people think the work you’re doing is worthwhile.

How do we ensure similar success for residents? First and foremost, make sure we are asking clinically meaningful questions. Mentors are crucial for this. While a resident (or med student) may see a pattern in their clinical experience and want to explore that further, a mentor must guide the question with their knowledge of the research world’s context. This involves shaping the original question to be meaningful in light of existing research. Mentors have the unique perspective of ‘knowing the field’. I have proposed many research questions that were subsequently modified or outright turned down because my mentors correctly recognized they would be low-value in light of existing or planned research.

Second, use the power of electronic medical records to avoid tedious data collection. EMRs and large databases allow us to extract datasets in a fraction of a second to answer clinical questions. I truly believe if residents are given the opportunity to spend the bulk of their time manipulating data, instead of collecting it, they will enjoy the research process much more. Alternatively, give residents access to an existing dataset for subanalysis; anything to avoid tedious data collection.

Finally, it is important to champion residents’ research. While it is great to support the dissemination of resident research through an institution’s own conference or research day, it much more fruitful to present elsewhere. Here, mentors can make sure they target the proper conference or journal for dissemination. Such targeting should begin as early as the conceptualization and design phase (an ‘insider’s trick’ not often talked about).

I truly believe research should be an integral part of medical education, both at the undergraduate and graduate levels. Evidence-based medicine is pervasive throughout health care today. Trainees need an understanding of the utility of evidence and, more importantly, its shortcomings. The best way to gain this understanding is to participate in generating such evidence. It gives trainees a rare, behind-the-scenes look at the outwardly glossy, but inwardly messy research world.

  1. I was not able to participate in this #meded chat. If you also missed it, you can read up using the transcript.  ↩

  2. Arguably, a meta-analysis is the definitive research study. However, in terms of single studies, controlled trials still reign.  ↩

  3. To be clear, I’m talking about carcinogenic exposures, not oncologic therapeutics.  ↩

  4. Prior to medical school, while working full-time as a researcher, I had the opportunity to work with a few residents on research projects. I’m not coming to this topic completely cold.  ↩

✚ Make waffles for your residents

Nobody likes to work on the weekends. However, people obviously get sick and need to be taken care of on most other peoples’ days off. In academic medical centers, attendings (the physicians in charge) try to make weekends a little bit more palatable for residents and medical students by not asking too many educational questions (i.e.—“pimping”) and running a relaxed schedule.

Let me suggest an even better solution: make waffles

This has many benefits:

  1. Everybody loves waffles
  2. They are easy to make (use a dry ready-to-make mix) and can be accomplished with little equipment and effort
  3. You can get really creative with some simple toppings
  4. Waffles fulfill a basic and persistent need among residents and med students (i.e.—food)
  5. It is a fun, team-building exercise

This last point is actually the real reason why I think you should make waffles in one of the resident rooms after morning rounds. Bring multiple teams together in the house staff area and delegate tasks (usually to the med students because…well…because why not). A few can mix up the batter, others can slice up toppings while someone runs the waffle iron and another makes coffee. While all of this is going on, people are talking, making jokes, enjoying each other’s company, and may be doing informal education in the form of discussing difficult cases they had over the past week or talking about something they just can’t figure out.

Bottom line—making waffles gets people out of their silos. All of medicine hinges on communication. Anything we can do to improve communication—by meeting the other residents and students on other teams/services—will improve health care. So, next weekend try making some waffles.

Health care in America: Going public, and private | The Economist →

...by the early 2020s the taxpayer will be footing the bill for half of America’s health spending, which will have risen to a staggering $5 trillion, equivalent to one-fifth of the country’s entire economic output.

I find this a bit unnerving...all parts of it.

I Had My DNA Picture Taken, With Varying Results | NY Times →

An interesting look at direct-to-consumer DNA testing. Interpretation by these companies can be quite variable:

In the case of Type 2 diabetes, inconsistencies on a semantic level masked similarities in the numbers. G.T.L. said my risk was “medium” at 10.3 percent, but 23andMe said my risk was “decreased” at 15.7 percent. In fact, both companies had calculated my odds to be roughly three-quarters of the average, but they used slightly different averages—and very different words—to interpret the numbers. In isolation, the first would have left me worried; the second, relieved.

Not to mention the limitations of the technology these companies employ (SNPs v whole genome sequencing). Craig Venter, who led one of the teams that first sequenced the human genome, is quoted in the article:

“Your results are not the least bit surprising,” he told me. “Anything short of sequencing is going to be short on accuracy — and even then, there’s almost no comprehensive data sets to compare to.”

Genomics will play a role in the future of medicine, but we’re not quite there yet.

The Post-Renaissance Man | slackadem →

In response to a recent Wired column entitled, Let’s Bring The Polymath—and the Dabblers—Back, Amol Utrankar argues in this post for ‘institutional collaboration: a culture that prizes sharing, communicating, and coordinating between different pillars of expertise.’ I don’t find this be an ‘either-or’ proposition necessarily. I think we will need people well-versed in the myriad of ‘tools’ for the modern world as well as organizational culture and structure that fosters collaboration.

Perhaps this is just a restatement of the polymath argument [1], but I find the most useful way to think about this subject is the notion of the ‘T-shaped specialist’. This is something first popularized by Tim Brown (of IDEO). In his words:

[T-shaped specialists] have a principal skill that describes the vertical leg of the T—they’re mechanical engineers or industrial designers. But they are so empathetic that they can branch out into other skills, such as anthropology, and do them as well. They are able to explore insights from many different perspectives and recognize patterns of behavior that point to a universal human need.

In my own conceptualization, the vertical leg of the T represents a domain where you are an expert. Not only are you well-versed in the tools of that domain and can use them with aplomb, but you also understand the theoretical side of the domain. The broad part of the T represents related domains where you may know some of the tools and some of the theory, but could not independently create or function proficiently in that domain.

This is the theory that shapes medical education—4 years of broad education in theory and practice with the tools of the trade followed by 3+ years in a specific domain. Unfortunately, medicine seems to fail at the ideal because we rarely revisit the broad part of the T. In such a world, Utrankar’s notion of ‘institutional collaboration’ is paramount (and this is ostensibly what we see with general practitioners consulting specialists).

However, to take on the challenges facing medicine today, we need more T-shaped doctors. We need experienced physicians to revisit the broad part of the T. This can take many forms. Dr Amesh Adalja recently wrote about his cross-training in infectious diseases and critical care. I recently worked in a clinic where an experienced general pediatrician spends a half day each week seeing patients with pediatric dermatologists so she could learn how they approach skin issues and take that knowledge back to her practice and her partners. You don’t have to look too far to see doctors with additional degrees in public health, business, public policy, education, etc. They are bridging two domains and enriching each with their knowledge. Some argue doctors should be learning how to code in order to bridge the gap between medicine and information technology [2].

The challenge of medical education—specifically graduate medical education and continuing medical education—is finding a balance between specialty knowledge and cross-domain education. And the challenge for hospitals, private practices, and other health care organizations is how to cultivate T-shaped specialists amongst their own ranks.

  1. I think there is more than a semantic difference between a ‘polymath’ and a ‘T-shaped specialist’. I conceptualize a polymath as someone with multiple deep expertises, cultivated over a long time with dedication to each of those fields. A T-shaped’ specialist, on the other hand, has one true expertise with some training/education in multiple other fields.  ↩

  2. Some argue that since you can’t become an expert in one of these other domains, why learn anything about them at all? The Digital Doctor podcast episode I’ve linked to addresses this nicely. It is not about being an expert in multiple disparate domains (which is what I would consider a ‘polymath’ to be), but being well-versed enough in those domains to engage others in meaningful collaboration (and—almost more importantly—to know when to engage others in those domains).  ↩

Setting Boundaries on Smartphone Use in Hospitals | The Doctor's Tablet →

I completely understand why an institution would create a 'smartphone use' policy. But at the same time, how little do you trust the people working for you? How broken is your culture of professionalism that people now have to announce why they are using their smartphone? Do you also make them ask permission to go to the bathroom?

First and foremost, attendings and senior residents must set the example. Then, these same supervisors need to keep a casual eye out for interns and med students misusing devices. If that were to happen (which is much less likely if the attendings and senior residents create a culture of professionalism), then pull the junior member of the team aside and address the issue.

I don't think this requires a separate policy and I don't think the creation of such a policy is something to celebrate.

Teaching Hospitals Examine New Ways to Convey Research Risks, Benefits to Patients | AAMC Reporter →

I find it encouraging to see researchers looking for innovative ways to improve the informed consent process. However, given the United States’ low health literacy—well, low literacy in general—I find true informed consent to be an elusive ideal. I think it would be prudent for Institutional Review Boards, especially non-medical community members, to make this an area of interest when reviewing proposals.

I believe the biggest challenge is not necessarily the complicated biomedical science that may be involved, but the probabilistic nature of research. When a research question has true equipoise, we really don’t know what will happen. That is a difficult concept to explain and even harder one to wrap your head around when facing an illness.

Using Good Design To Eliminate Medical Errors | FastCo Design →

This article exemplifies how I think design thinking combined with patient safety/quality improvement tools will change health care. However, the road will not be easy:

The lead designer of DOME [‘designing out medical error’] was Jonathan West…he initially thought there’d be one or two glaring areas for improvement that could be tackled in a couple big designs. He quickly realized, though, while shadowing doctors and nurses at the hospitals of the Imperial College of London, that what makes the problem so persistent is that it’s extremely complex.

“It’s not like an airplane falling out of sky or a nuclear power plant exploding–there’s no one big thing,” West says. “The process is different for each patient, so the process can go wrong in unique ways, which makes it very hard to tackle in terms of design.”

Unfortunately, not only is the task difficult, but current financial incentives are not aligned for investment in such initiatives. Improving design in health care will require upfront investment whose return is difficult to measure [1] and ultimately decreases revenues [2]. But, we know it is best for the patient, the ultimate guiding edict in medicine.

We need physicians and other health care providers trained in design thinking to move patient safety/quality improvement efforts forward.

  1. Note which outcomes they cited in measuring the success of the CareCentre: ‘Compared to wards with standard equipment, those with the CareCentre had better hand hygiene, fresh glove and apron use, and old glove and apron disposal.’ These are all process measures; there is no indication of whether or not medical errors were reduced or if more patients got better.  ↩

  2. Remember, under our current fee-for-service system, most hospitals get paid more for doing things. Preventing errors means there is less to do.  ↩

Mission Impossible V - The MOC Exam | Dr Wes →

Taking exams to become a physician—all the way from the MCAT, to the Step exams, and specialty boards—seems to require an inordinate amount of security. When taking the Step exams (which allow for 6 or 7 breaks), you have to signout, sign back in, rescan your fingerprint, and pull out your pockets each time you take a break [1]. But who is going to stand up to the boards and challenge these ridiculous procedures? They don’t care; they never go through this stuff.

  1. My best test-taking tip—don’t wear anything with pockets.  ↩

✚ Tech Rounds - Twitter tools

For me, Twitter has become in invaluable tool in keeping up-to-date with what is going on in the health care world and connecting with others. Twitter’s growth in its early days relied heavily on third party clients. Until some recent changes, Twitter cultivated a rich ecosystem of third party apps. Thus, there are lots of Twitter tools to choose from. However, I essentially rely on only a few choice apps for 99% of my Twitter use. Below, I talk about each—divided by platform—and how I use them.

Computer

Tweetbot

Most of the time I’m at my computer, I have Tweetbot open in the background. It is a simple, but powerful app. Though you can open multiple panes or even windows to view various timelines, I generally leave my main timeline open. Tweetbot will stream your main timeline, so I can keep an eye on tweets while doing other things. I have also linked my Pinboard account so that when I see a link I want to look at later, I can easily send it to Pinboard.

Tweetdeck

The other main Twitter tool I use while at my computer is Tweetdeck. I primarily use Tweetdeck for two purposes—viewing multiple timelines and participating in tweetchats. Unlike Tweetbot, I do not keep Tweetdeck open all the time.

Though you can open multiple panes in Tweetbot, Tweetdeck serves this purpose better because it was designed for such activity. With Tweetdeck, I’ve created a layout with my main timeline, several hashtag searches, my lists, and a few other miscellaneous timelines. So, when I want to see what’s going on in multiple places, I can simply open up Tweetdeck and check in.

Tweetdeck is also ideal for participating in tweetchats. Simply create a column in Tweetdeck with a saved search for the hashtag used for the tweetchat. Tweetdeck will stream the tweets for that hashtag (as long as you’re at the ‘top’ of that column). I also place a column with my @mentions next to the tweetchat hashtag column so that I can keep an eye on people who are responding to me.

Twitter

Twitter does make their own client. I have it on my computer, but I only open it to remind myself what a terrible user-experience is like.

A note on managing multiple accounts—Both Tweetbot and Tweetdeck allow you to work from multiple Twitter accounts. Tweetbot is ‘modal’ in terms of account management—you can only work from one account at a time, though it is easy to switch between accounts. Tweetdeck allows you to easily intertwine multiple accounts and send a single tweet from various accounts. Each approach has its pros and cons. If you’re prone to accidentally tweeting from the wrong account and it is important for you NOT to tweet from the wrong account, then Tweetbot’s approach is ‘safer’. Tweetdeck is much less cumbersome to switch between accounts, with the obvious tradeoff that it is much easier to tweet from the wrong account.

Mobile (iOS)

Tweetbot 3

Tweetbot exists on both the Mac and iPhone. Like the Mac version, Tweetbot 3 (their latest iteration) is my go to Twitter client on my iPhone. It is almost unquestionably the best Twitter client not only on the iPhone but on any platform—iOS, Android, Mac, PC. It works similarly to the Mac version, so it is easy to switch between the two. Just get it, you won’t be disappointed [1].

When setting up Tweetbot, don’t forget to go to the settings and then into the account specific settings. Here, you can hook up your Pinboard account as the ‘Read Later’ service. This will allow you to send tweets and links directly to Pinboard.

Twitterrific

The only other Twitter client I have installed on my iPhone is Twitterrific. I love the design of Twitterrific, especially the dark theme. Unfortunately, Twitterrific has an Achilles’ heel for me—it doesn’t stream tweets. While Tweetbot will continually add new tweets if you’re at the top of your timeline, Twitterrific requires the ‘pull to refresh’ gesture to check for new tweets. Though I don’t often sit and just watch my timeline on my iPhone, when I do I don’t want to have to constantly be tugging at the screen to get new tweets. Aside from this rather significant shortcoming, Twitterrific competes for best iPhone Twitter client. It has a few unique features—most notably a unified timeline—that are worth checking out.

HootSuite and Buffer

Both HootSuite and Buffer seem to be very popular. I don’t use either of these services. I think they add an extra, unnecessary layer and I’ve found I can accomplish anything they provide using other services [2]. Additionally, if you want or need any of the paid features with either service, they are exorbitantly expensive.

Those are the basic tools I use for interacting with Twitter. I have tried some others, but these are far and away the best. If you have any suggestions for a Twitter client I should try or a topic for Tech Rounds, please let me know.

  1. Tapbots updated Tweetbot on the iPhone to match the redesign that came with iOS 7. Thus, Tweetbot 3 is an iPhone only app; previous versions of Tweetbot were universal apps (e.g.—both iPhone and iPad). I assume Tapbots is furiously working on an iPad version and will release it as soon as it’s ready. Until that time, the old Tweetbot is probably the best iPad Twitter client. It just looks a bit out of place with iOS7.  ↩

  2. If people are interested in how I accomplish what HootSuite and Buffer do via alternative means, just leave a brief note. I will respond directly or do a post about it. I didn’t go into it here because I think it would be exceedingly boring.  ↩

Shopping for health insurance is hard - Understanding it is even harder | Washington Post →

The article quotes a study in Health Affairs:

Low health literacy could reduce the gains for consumers, particularly…if the consumers who do enroll face unexpected out-of-pocket expenses.

I do not have low health literacy and I find it difficult to understand health insurance plans. In a class recently, we were given various Medicare patient scenarios and then challenged to use online Medicare calculators to figure out which coverage would be best. Everyone—about 25 fourth year med students—found this to be challenging at best.

I think we are moving towards a tipping point where more direct financial relationships between physicians and patients will be necessary.

How Google Glass will save your life one day | iMedical Apps →

Nothing in this article led me to believe Google Glass will save my life one day [1]. Iltifat Husain MD gives a brief run-down of his experience with Google Glass over the past few weeks, but fails to provide any concrete examples of where it made a difference in his practice of medicine.

His major point is that ‘hands-free is a big deal’:

In medicine, we use our hands all the time, whether we are examining a patient, administering medications, or doing a procedure. Glass enables you to do all three of these things while keeping your hands free.

And then on the next page, he also writes:

It’s crucial to know how distracted you look when using Glass. When you’re using the audio and touch prompts, it gives a look of you being in your own world…I would argue the best patient edict is to hang Glass around your neck when talking to a patient.

Being able to do something hands-free doesn’t mean you’re then able to do multiple things at once. Practicing medicine requires attention, both when talking to patients and doing procedures. I don’t think it is prudent to divide one’s attention between placing a central line and a screen in the corner of your field of vision. I think most patients would prefer the doctor to be focused on one task when they’re shoving a giant needle into their neck. And if you’re constantly hanging Glass around your neck to avoid Google Glass attribution error, doesn’t that hinder the immediacy of information, one of the key features?

Additionally, the hands-free feature of Google Glass seems to be quite poor. A cardiothoracic surgeon at UCSF who trialed Google Glass for three months found voice commands with Glass to be so problematic that he eventually put a separate technician in the operating room to ‘keep things running smoothly.’ Though this will undoubtedly improve with time, voice commands will also have to deal with medical jargon and may prove too unintuitive for much beyond basic navigation.

Google Glass likely will find a place in many physicians’ practices, but I think those will be specific use cases. I also think it is going to be several years before anyone develops anything of particular use to warrant widespread adoption among physicians.

  1. This article title is such link bait, I initially resisted posting about it. Google Glass will never save anyone’s life; possibly, somebody using Google Glass may save your life…someday…  ↩

Rag3 Aga1nst the Fax Mach1ne | med*t3ch →

When I see a fax machine, I can’t help but wonder: Are physicians not ashamed that paper charts, nine-to-fivers, and ancient technology stand in the way of instant decision-making?…Are they not embarrassed that barriers to information sharing put patients at risk for the morbidity associated with repeat diagnostics? Do they not feel foolish when they perform the same tests that were done recently at an outside hospital?

Exactly. We should all feel ashamed, embarrassed, and foolish.