More (or less) Hope and Change (for the worse) In Healthcare: Are Doctor Shortages Really All Due To Training Bottlenecks?

There is no doubt that Affordable Care Act has changed the landscape of medicine in the US.  Now, private practice is becoming a thing of the past. Financial pressures, increasing regulatory requirements, electronic medical records and outrageously complex coding systems are forcing long time private physicians to enter into agreements with academic centers and large hospital systems in order to survive.  As a result, medicine today is more about increasing patient volumes, completing reams of paperwork and administrative duties than it is about interacting with patients and providing superior care.  The American Academy of Family Practice (AAFP) estimates that there will be a significant shortage of primary care physicians in the next several years unless we increase the number of primary care trainees by more than 25% over the same time period.  In fact, the AAFP suggests that the primary care workforce must increase to 260K physicians by the year 2025–which translates to an additional 52K primary care doctors.

Given the need for more physicians and the pending shortage (particularly in primary care), many analysts have suggested that the reason for the shortage is a lack of training slots in primary care.  The ACA will add an additional 32 million patients to the pool of insured and primary care doctors will be at a premium.  In the New York Times this week, the editorial board collectively penned an article discussing their thoughts concerning the doctor shortage.  The NYT editorial board suggests that the shortage is all about an imbalance between Residency training slots and medical school graduates and can be easily corrected by federal funding of a larger number of training positions.  However, I think that the issue is much more complex and the solution is far from simple.

Primary care is an incredibly challenging specialty and requires a broad knowledge of much of medicine.  Reimbursements for primary care work continue to lag and physicians are now spending more time with administrative duties than they are with patients.   I do not believe that the so called post graduate training “bottleneck” will come into play.  I would suggest that many primary care training slots will go unfilled over the next 5-10 years even without increasing the numbers of available positions.  Increasing training slots for primary care specialties may do nothing to alleviate shortages if there are no students who wish to train.  While medical school enrollments have increased over the last decade, much of this increased enrollment may be due to a lack of jobs available to recent college graduates.  Moreover, as the ACA continues to evolve, physicians are now realizing lower compensation rates, increased work hours, more administrative duties and LESS time spent caring for patients.  Many physicians are forced to double the number of patients seen in a clinic day–resulting in less than 10mins per patient–in order to meet overhead and practice expenses.  In a separate article in the New York Times, author and cardiologist Sandeep Jauhar discusses the increased patient loads and subsequent higher rates of diagnostic testing that is required in order to make sure that nothing is missed–ultimately increasing the cost of care.

For most of those who have entered medicine, the attraction to the profession is all about the doctor-patient interaction and the time spent caring for others.  I would argue that the primary care shortage (and likely specialist shortage) will worsen in the future.  Many bright minds will likely forego medicine in order to pursue other less government-regulated careers.  In addition, many qualified primary care physicians will opt out of the ACA system and enter into the rapidly growing concierge care practice model.  The answer to the physician shortage may be more political than not–politicians must realize that laws and mandates only work if you have citizens willing to devote their time, energy and talents to the practice of medicine.  Going forward, more consideration must be given to physician quality of life and autonomy must be maintained.  In order to make healthcare reform sustainable, those in power must work with those of us “in the trenches” and create policies that are in the best interest of the patient, physician and the nation as a whole.  Cutting costs must be approached from multiple angles–not simply reducing the size of the physician paycheck.

Medicine remains a noble profession.  Those of us that do continue to practice medicine are privileged to serve others and provide outstanding care.  In order to continue to advance, we must continue to attract bright young minds who are willing to put patients and their needs above their own–at all costs.  I think that there is still HOPE to save medicine in the US.  It is my HOPE that our government will soon realize that in order to continue to propagate a workforce of competent, caring physicians we must provide time for physicians to do what they do best–bond with patients and treat disease.  (as opposed to typing into a computer screen and filling out endless reams of electronic paperwork).  It is my HOPE that those physicians in training  that will follow in my generation’s footsteps will realize the satisfaction that comes from impacting the health and lives of patients over time.  It is my HOPE that the ART of medicine can be saved before it is too late….

 

Medicine in the Age of Mobile Technology: How Tablets Are Transforming the Patient Encounter

Medicine is becoming mobile.  Physicians, nurses and other healthcare providers must be able to quickly assimilate and react to an overwhelming stream of data.  Tablet technologies, such as the Apple iPad, have been incorporated into the workflows of many clinics, emergency rooms and hospitals.  Medical Schools and Residency programs are quickly adapting the technology for teaching.  While tablets do present some security challenges, most clinicians who are currently using them tout them as revolutionary and efficient. Moreover, there appear to be many new medical uses for tablet technologies in the pipeline that may forever change the way medicine is practiced.

Tablet Utilization:  Pros and Cons

Many hospitals are now using tablet technology to help physicians and other treatment team members prepare and interact with patients while on the move.  With healthcare reform and cost containment strategies, many hospital systems are looking for ways to streamline care and cut costs.  Potential advantages of tablet use include the ability to improve workflow on rounds, reduce staffing requirements, and increase productivity and efficiency without compromising patient outcomes.  In many centers, physicians are able to “sync” their devices wirelessly or via sync stations located throughout the hospital.  Rather than moving to a computer terminal to sit down and review labs, consult notes, test results, etc, a team can move through the hallways and discuss these findings via an interaction on the iPad.  There is virtually no downtime and less staff is required to see patients in an efficient way.  When interacting with patients in their room, caregivers can actually show them images and results and discuss findings with them.  In fact, a recent study from the University of Sydney showed that secondary review of radiology study images on an iPad was just as good as a standard LCD computer screen.  For patients, it improves education and engagement in the care plan when they are able to see an image or test result as they discuss the finding with their providers.  When patients have a better understanding of their medical problem and are able to participate in their treatment plans, outcomes improve.  Tablet technology helps facilitate this type of engagement.

Some centers are incorporating their EMR (electronic medical record) into the tablet via a mobile application and this allows for quicker documentation and immediate record of the day’s plan for the patient–available for all team members to access “real time”.  The EMR mandates put in place by the federal government have become a burden to many facilities and providers–by interfacing with these technologies via tablet technology, adoption of EMR and efficiency of documentation may improve.

As with any computerized medical record or medical application, security and HIPPA regulatory compliance are always a concern.  In addition, the small size and mobility of the iPad device makes keeping the devices in the hospital a challenge.  Although several major academic medical centers, including Massachusetts General Hospital have begun to incorporate tablet technologies into their practice, many others have not due to the cost of stocking the institution with the relatively expensive devices.  Now, many EMR companies, including EPIC (a major EMR player in academic centers) have created secure applications for tablets and other mobile devices that protect privacy and are HIPPA compliant.

Tablet Technology:  Future Applications in Medicine?

At this point, we are only seeing the tip of the iceberg when it comes to mobile technology in medicine.  Tablets are very powerful, portable, and user friendly.  I believe that these devices will become standard issue in medical schools across the country.  Rather than spending 1000 dollars per student on printed materials for a year of medical education, schools such as the Yale University School of Medicine are now issuing iPads to all students and utilizing the iPad for nearly all curriculum related materials.  According to the AAMC, tablet technology is being adopted all over the country and is being used to replace reams of learning materials on paper.  In a recent survey of medical students published in the Journal of the American Medical Library Association, most students go utilize electronic based medical resources at least once a day and over 35% use a variety of mobile devices to access information.

Applications continue to be developed that have important educational roles in medicine–apps for learning EKGs, reviewing histology, learning pharmacology and others are becoming mainstream and will likely be an integral part of medical education going forward.  A recently published study in JAMA: Internal Medicine evaluated the changes in resident efficiency when using iPad devices for clinical work.  In the study, the authors found that the utilization of mobile devices improved workflow and both perceived and actual resident physician efficiency.  In fact, orders on post call patients were placed earlier–before 7am rounds–likely resulting in improved care and more timely delivery of medications, treatment plans and orders for diagnostic studies.

For patients, tablet technologies may improve their visit experience and may help reduce medical errors.  I can foresee a clinic where patients check in for their appointment and are given an iPad to fill out forms and answer a wellness screening questionnaire prior to their visit with their primary care doctor.  With more “meaningful use” requirements imposed by government bureaucrats, these electronic screening opportunities will allow clinicians to not only meet regulatory requirements but also continue to spend meaningful time with their patients during a visit.  In addition, patients can have the opportunity to review imaging with their clinician at their side and actually “see” what the doctor is able to see.

For physicians, the possible applications of tablet technologies are endless.  Ultimately, I believe that these mobile technologies will revolutionize medicine and allow for care to be provided to patients who have previously been underserved.  Tablet based electronic patient encounters are on the horizon.  As physicians we must ensure that we continue to embrace technology and we must not resist change–medicine remains both a science and an art.  We must continue to strive to incorporate BOTH technology and human touch into our patient encounters.  Change is coming–we must adapt and embrace these technologies in order to provide our patients with the healthcare and caring that they deserve.

“Thinking” About How We Lead: How We Make Better Decisions and Produce Better Outcomes

As physicians we are trained to assimilate data, analyze and interpret findings, and make the correct decision–every single time.  Often these tasks must be performed very quickly and in emergency settings.  For those who perform invasive procedures, decisions are often made “on the fly” and can have significant consequences.  In addition to our clinical duties, physicians are now thrust into executive roles as well.  Managing practices, budgets, government mandates and regulations have now become part of everyday clinical life for many practitioners.  The concept of the physician executive is now commonplace—and for many doctors and practices– a key to survival in an unstable and volatile healthcare market.  Improving skills in both decision making and communication can be critical to success in the new world of healthcare.  Learning to LEAD is critical to providing outstanding care for our patients every single day.

This week in the Wall Street Journal, author Andrew Blackman explores the inner workings of a business executive’s brain–exactly how the brain functions when making effective decisions in the world of business.  Researchers evaluated how executives make decisions under a variety of circumstances–they localized the biologic processes that occur in the brain via advanced neurologic imaging techniques.  From a biological standpoint, this research provides great insight into how successful decision makers formulate plans and solve problems.  In addition, the research provides insight into how leaders can make more effective decisions when under duress.  Using complex imaging to map the electrical connections in the brain when decisions are made, researchers are able to better quantify–biologically–what makes some leaders better than others.

By shedding light on how our brain functions when making good decisions, we may be able to one day “train” our brains to utilize particular regions during specific tasks.  For now, much of what Mr Blackman reports concerning optimal conditions for making decisions is applicable to physicians and other leaders in medicine in one way or another.

According to the Wall Street Journal, there are several things to consider when making important decisions:

(1)  Deadlines and Time Pressures may Limit Creativity and Innovation

In medicine, every day is a deadline.  Schedules of patients packed into the office or procedure list remain a reality.  Making decisions under pressure is a big part of what physicians do on a daily basis.  However, the recent neuroimaging research indicates that often the deadline pressure may stifle creativity and lead to poor decisions.  Stress induces more activity from the area of the brain associated with “task completion” and less activity in the areas responsible for new and creative idea generation.  According to Harvard researchers, one way to potentially combat this change in thought centers during times of stress may be to train workers and leaders to become more self aware and use “mini meditation” to help the mind wonder.  Although in medicine, we are trained to REACT to acute situations, it may be that while we REACT, we can also work to explore other creative centers of our brains in the process.  By combining both quick REACTION and creative thought, we may not only be able to stabilize a critically ill patient but also provide a unique treatment plan going forward.

(2)  Worry and Uncertainty can lead to bad Predictions and poor decisions

I have been accused of being “Chicken Little” on more than one occasion.   Uncertainty is something that is commonplace in medicine yet it makes most of us uncomfortable.  As physicians we rely on data to make good decisions.  However, uncertainty remains a significant part of what we do in medicine on a daily basis.  We often deal with limited data and must make a decision based on the best available evidence.  Clinical trials bring us some level of certainty  but our patients are biologic organisms, each with potential differing responses to treatments and disease.  According to researchers, the areas in the brain that are activated when you are working on problems that are cause you worry are often associated with anxiety and disgust.  Many poor decisions are made due to the “worst case scenario” line of thought.  While worry and uncertainty can never be completely avoided, psychologists argue that the way to avoid poor decisions during these times, is to learn to accept uncertainty and control the things that you can control.  No decision is ever final–even in medicine there are opportunities to act, refocus and change directions if necessary.

(3)  Good Decision Makers may look past the Facts and Incorporate “Gut Instinct”

Many decisions in medicine are made by considering the best available data and incorporating clinical judgement and instinct in order to make a determination as to the best course of action.  Interestingly, when MRI scans were performed on the brains of very successful business executives who were involved in making difficult decisions, the areas of the brain responsible for emotion and social thinking began to light up more than the purely analytical areas.  Researchers concluded that those leaders who relied not just on facts but on gut instinct and emotion tended to be more successful.  Social thinking–in simple terms–is the ability to look at a problem from numerous angles.  Seeing the potential impact of a potential decision from multiple points of view can provide invaluable insight and may lead to better decisions in the long run.  In medicine, involving other team members–nurses, technicians, and support personnel–in the care and formulation of the patient’s treatment plan may actually help a physician leader to make better decisions.

(4) Effective Leaders must stay positive and Inspire Teams

When leaders begin to inspire teams of people and lead with passion, certain other areas are activated in the brain–particularly those areas associated with positive emotions and social thinking.  Along with involving other team members in the care of the patient, it is essential for an effective leader and decision maker to incorporate “praise, encouragement and rewards” when motivating teams to perform at a high level.  Creating an emotional bond among members of a medical team can be as simple as asking for input from all involved parties and recognizing outstanding contributions to patient care.

The Bottom Line…

Business executives are adept at making determinations that affect millions (if not billions) of dollars and these decisions can move markets.  In medicine, we must make decisions every single day. While some decisions may be trivial, others may permanently impact the lives of our patients and their families.  Moreover, from a business standpoint, the management of a medical practice in today’s market requires impassioned leadership and great skill in order to remain viable. The work that is done with neurologic mapping in decision making may have provide us with guidance in the future as we develop new leaders.  It may be that through practice and coaching, we will one day be able to activate specific areas of the brain when we are working to make tough decisions.  The strategies and skills that we are able to glean from these types of research activity will allow us to be more effective physicians, leaders and executives in the years to come.

Communication in Medicine: Lessons Learned By Wearing A Gown

Communication is critical to success in medicine.  Our patients depend on us to help them understand their disease and the risks that it may pose.  In previous blogs I have commented on how vital effective communication can be in determining outcome–much of my writing has focused on the success associated with outpatient doctor-patient relationships.  We now know that when doctors and patients engage, patients become invested in their own healthcare and are more likely to comply with lifestyle modifications and take medications as prescribed.  However, when a patient is ill and hospitalized, a entirely new level of complexity is added to the communication mix. The role of patient places one in a difficult position–you lose control, you lose your individuality and you may often become frightened due to the uncertainty of the clinical outcome.  The dynamic of communication in the acute hospital setting may be quite different in that the patient may be interacting with a new team of healthcare providers that they have no previous relationship with.  In addition, disease related factors such as pain, fever, and sedation may play a role in a patient’s ability to comprehend what is being said to them at any given moment in the hospital setting.  I can now speak to this from personal experience–this last week I became an unexpected patient.  I spent several days navigating illness and a complex yet compassionate hospital system.  My experience as a patient has inspired this particular blog–and has inspired me to become a more effective communicator in my practice.

This month in the New York Times, two articles were published that discussed different aspects of physician communication with patients.  Both pieces are important and should be read and carefully digested by both patients and physicians (as well as any other healthcare provider). In the first article, author Theresa Brown discusses the discussions that physicians and other healthcare providers commonly have with patients during a time of illness.  Particularly in the hospital, teams of providers at all levels enter a patient’s room and discuss all aspects of the case (Both with the patient and amongst one another).  It is interesting to realize just how much of what is said during these encounters is “lost in translation.”  During periods of illness, even the most educated and medically sophisticated patient can have difficulty comprehending exactly what the medical team is trying to convey.  Pain, worry, and emotional fatigue may all play a role in a patient’s inability to comprehend the clinical situation, the possible diagnoses, the testing required and the treatment plan.  In a separate article, authors Gilligan and Sekeres explore whether or not there are effective ways in which we may be able to teach better communication skills to physicians in training.  Several studies have demonstrated that no amount of training will convert an introvert to an extrovert communicator–however, communication training may open a healthcare provider’s eyes to the profound impact that their interaction with patients may have on outcome.  Once a provider is aware of the impact communication may have, they are more likely to be able to better engage patients and engage in a more effective way.

During my unexpected role as a patient this week, I often did not understand what to expect–even with my years of medical training and experience–I could only focus on my symptoms and my fear of the worst possible outcome scenarios.  During my patient experience, I interacted with many physicians, nurses and other team members–ER doctors, specialists, imaging technicians, transporters, etc.  My particular providers were very compassionate and spent a great deal of time attending to my needs and explaining their thought processes, differential diagnosis and treatment plans.  However, I was unable to process most of what was said.  I was often distracted by pain and my ability to assimilate and comprehend information was limited by the sedation I had been appropriately given.  Ultimately, emotion and fear would come to the forefront and dominate my thoughts, further limiting my ability to actively and effectively communicate with the medical team managing my hospital care.  My caregivers were dedicated and wanted only the best outcome for me and my family.  However, I was often confronted with large amounts of clinical information and I began to hear only pieces–I would latch on to particular words such as surgery and potential complications and would lose focus–no longer able to follow the conversation.  My ability to think rationally and effectively process clinical information (as I would as a physician)  was severely impaired.  I can only imagine what the experience would have been like for a non medically sophisticated person.

Fortunately, as the week progressed, my condition improved and I was ultimately discharged from the hospital.  My physicians and nurses spent time later in the week making sure that I understood what had happened to me and what the next steps would be.  My hospital stay and treatment provided me with new insights into the patient experience.   I now am able to envision ways in which I can improve my own interpersonal skills with my hospitalized patients–by actively taking time to make sure that each patient understands and truly hears what is being said to them.  From my experience, one of the keys to promoting  understanding is to provide time for questions–from both patient and family–during the inpatient hospital visit.  My caregivers did this often and it did provide comfort and some semblance of control.  (as much as one can have in an ill fitting hospital gown).  In addition, providing small, easily digestible bits of clinical information at several points throughout the day seemed to improve a patient’s ability to process and comprehend their condition, treatment and prognosis (at least it did in my case).  Although is is not practical for the physician to make multiple stops to the patient room throughout the day, phone calls for updates by the treating physician and visits by other providers such as nurses, PAs and NPs can make a difference in patient understanding and comprehension.  As Ms. Brown rightly states in her New York Times piece, hospitals and medical care are well focused machines–most providing efficient, quality life saving care.  We must remember, however, that we are treating patients–human beings with emotion and fear that can certainly impact a disease process.  We must take time to ensure that we not only provide the high quality efficient care but we also are able to care for the human being lying in the bed in the awkwardly draped hospital gown.

I am glad to be home from the hospital.  I am grateful for the wonderful care and compassion that me (and my family) received from many over the last week.  I am happy to be sitting outside in the sun writing this blog today.  I am excited about the opportunity my experience as a patient has afforded me.  I will take what I have learned and apply it to my practice–I hope to work every day to improve my communication with all of my ill and hospitalized patients.  Most of all, my experience has reminded me that although medicine is the application of science to the treatment of ailments suffered by human organisms, it is the human that really matters.  Our patients are people–they are often alone, frightened, emotionally exhausted and suffering.  We must all engage them in a way that best facilitates their understanding of their situation and focus equally on both treating a disease AND treating a frightened person lying in the bed before us.

The Advantages to Team Approaches to Patient Care: Extending NOT Replacing Physician Care

Let me start by stating that I am a supporter of team approaches to medical care.  Data from numerous observational trials has shown that patient outcomes are improved when a diverse group of healthcare providers work together to coordinate overall patient care.  In my practice, we rely heavily on the excellent care provided by both Physician Assistants as well as Nurse Practitioners both in the hospital and in the clinics.  These physician extenders are essential to coordinating admissions, evaluations testing and treatments.

Last week in the Wall Street Journal, columnist Laura Landro discusses the new push for team based care in today’s healthcare market.  As Ms Landro states, there are numerous advantages to the team based approach.  Patients benefit from the more intensive one on one time that they are afforded with nutritionists, pharmacists, nurses and other advanced practitioners.  In previous decades, most of this work was solely the responsibility of the physician.  However, increasing demands for documentation and electronic paperwork have begun to consume physician time.  While the ACA promises to flood primary care offices with even more patients, physicians are scrambling to perform all of the duties that are currently required of them (with more government mandates on the horizon).   Most of my colleagues prefer to focus on patient care (rather than administrative paperwork and government mandates) but are often frustrated by how little time they have to interact with their patients.  Managing chronic disease is a process and requires numerous “touch points” with the patient in order to be successful.  In reality, as a cardiologist, I am able to see most of my stable patients only once a quarter–unless they have an acute event or decompensation.

It is clear that patients now are living with more complex diseases and that we have far more advanced therapies to treat them with.  Many of these therapies rely on strict patient compliance and on patients having a thorough understanding of their disease process and its management.  For instance, a patient with Congestive Heart Failure (CHF) may need to be able to interpret daily weights and adjust diuretic dosing accordingly in order to prevent hospitalization from a more serious CHF exacerbation.   Now, rather than see a physician for medication discussions every three months, a patient can make an appointment with a Pharmacist in our office and see them on a more frequent basis to discuss concerns over efficacy or side effects of their medical regimen.  In our experience, this has improved patient compliance and improved metrics such as blood pressure control and time spent in the therapeutic range for chronic anticoagulation patients.  Other primary care physicians report similar results when managing diabetes via frequent nurse educator or NP visits–patients seem to have more consistent control and better HbA1C results when they have more frequent touch points.

While a team approach is quite effective, each team must have a leader.  The team leader must be experienced and well trained.  While physician extenders do receive extensive training in a 2 to 4 year program, nothing replaces the years of experience that MDs obtain during residency.  In order to maintain a high standard of patient care, these teams must still be led by physicians.  With the cost cutting efforts and the changes that are occurring in healthcare due to the Affordable Healthcare Act, I am concerned that hospital administrators and government bureaucrats will ultimately attempt to replace physicians with other healthcare providers in the interest of curtailing costs.  Physicians are trained in real life patient care scenarios over a period of years–many residencies last from three to ten years depending on specialty.  The experiences of call nights and handling real time emergencies over a period of years (under the supervision of more experienced attending physicians) cannot be undervalued.  My experiences during my 7 years of post-graduate training at both the University of Virginia and Duke University Medical Center certainly shaped my clinical judgement and certainly sharpened my diagnostic abilities–I call on these experiences even today when faced with complex cases.  Efforts to replace physicians with other healthcare professionals with less intensive training may ultimately harm patient care.

Patient care comes first–I believe that a team based approach is essential to optimizing outcomes.  We must all work together–Nurses, NPs, PAs, Pharmacists, Nutritionists, and MDs–in order to provide the best possible patient centered care.  However, we must not attempt to replace physicians and the experience that they bring to the clinical arena in the interest of cost containment.  While balancing cost and optimal care is a slippery slope, we must always focus on the patient–nothing can or should replace the Doctor-Patient relationship–we must all work together to preserve the core principles of our noble profession and put our patients first.

Charisma In Medicine: Inspiring Others To Improve Patient Care

By its very nature, Medicine involves close personal contact with others.  Communication with patients, families, staff and colleagues is essential to success.  All physicians have different ways in which they communicate–some more effective than others.  The best communicators are able to inspire, engage, and cultivate trust.  Everyone is born with different skill sets and communication styles may vary widely.

Recently, I came across an article in Inc.com that discussed the importance of charisma and how it can improve the success of leaders in the business world.  Author Jeff Hayden goes on to describe 10 habits of very charismatic leaders.  As I read the piece, I began to reflect on ways in which these tips could make me and my physician colleagues better communicators and better leaders in the world of medicine…

As we always do when tackling an issue in medicine, lets start with the available data….

Websters defines charisma as :

1. A personal magic of leadership arousing special popular loyalty or enthusiasm for a public figure

2. A special magnetic charm or appeal 

So, how can this help us take better care of our patients?  If we are able to inspire and produce excitement amongst our team–from nurses, to physician extenders, to support staff–both our patients and our employees will have a better experience when working with us.  If we are able to appeal to our patients and their families we are able to provide much needed trust and are more likely to be able to partner with our patients in an effective way. 

As we examine Mr Hayden’s Tips for Charismatic Leaderships more carefully, we can find insight into ways in which we can improve our own communication with patients, colleagues and staff:  (In each case below, I have listed Mr Hayden’s Tips from his Inc.com article and then applied them to our space as physician leaders)

1. Listen more than you talk–This one is tough for many physicians.  In training we are taught to speak up when you know the answer.  We are often motivated to provide quick results and to communicate them readily.  We strive to quickly assimilate facts and produce a plan.  However, much can be learned by listening–to patients, to families and to other healthcare team members.  When team members see that their ideas are considered by the leader, the tend to be more engaged and more productive.  It matters not who gets credit for the individual pieces of the puzzle–it is more important that the puzzle is completed successfully and the credit becomes a group effort.

2. Do not practice selective hearing–It is essential that physician leaders treat all team members with respect.  Everyone has a role to play and it matters not what title or status a particular individual may hold in the team heirarchy.  By including everyone (and making each person feel like a contributor) we inspire hard work and more participation. Ultimately the patient receives much better care. 

3. Put your stuff away–In the age of mobile phones, ipads and computers on the hospital wards distractions abound.  However, when leading a team and listening to others express opinions and ideas, it is essential to leave the digital media in its holster–nothing makes others feel more unimportant than a disinterested leader.  Take time to engage each person on the team and avoid the distractions of a text, a phone call or a tweet.

4. Give before you receive–In medicine it goes without saying but be sure to put your patients and their families first.  Within the care team, allow others to take credit and receive praise for a job well done before any is directed your way as the leader.

5. Don’t act self important–Medicine breeds ENORMOUS egos–particularly in world-renown academic centers.  To be more effective, we must put ego aside– forget the fact that you may have published half of the manuscripts in the medline search that the medical student just performed.  Focus instead on others and what they bring to the team.  Remember, we are all human–we are all connected.

6. Realize that other people are important–As Mr Hayden states clearly–”you already know what you know..you can’t learn anything new from yourself”  Listen to what others have to say–focus on their opinions and learn from their biases.

7. Shine the spotlight on others–Everyone feels validated by praise.  There is never enough praise to go around.  As the team leader make sure that you are adept at deflecting praise from yourself to those around you.  Team members who feel that their work is recognized and appreciated as excellent tend to work harder and produce more.

8. Choose your words–How we go about asking others to perform tasks can greatly alter their perception of the task.  If a task is presented as an obligation, it is viewed very differently than if it is presented as an opportunity or a privilege.  By carefully choosing your words you inspire others and make them feel as thought their position on the team is a critical component for success.

9.  Do not discuss the failings of others–Let’s face it, the hospital is a fishbowl and people gossip.  However, nothing is more destructive to team dynamics that when a leader speaks negatively about a team member, a colleague or another physician.  This behavior undermines morale and does not inspire confidence.

 10.  Admit your own failings–It is essential for teams and leaders to feel connected.  Nothing promotes connection more than when a leader admits his or her own mistakes and failings to the group.  However, when admitting a mistake it is essential that the leader set an important example–when admitting a failing also admit what was learned through the event and what corrective actions you plan to take to avoid the mistake in the future. This sets a wonderful example for self improvement for the team and at the same time promotes connectedness within the care team.

What’s the Bottom Line?

Effective communication and inspiring leadership are essential to the success of any medical team.  When teams are engaged and focused on the ultimate goal–the care of the patient–outcomes improve.  It is the job of the physician and other team leaders to motivate people and form cohesive, effective teams.  As leaders, we can learn a great deal from the business and political world–charisma is a characteristic that can move markets and change the course of entire nations.  Charisma allows a leader with a vision to effect change.  Charisma can be the difference in connecting with patients, families and co-workers.  Charisma can ultimately improve care and improve the delivery of care–the key is to learn to focus on them….not on me…..

Evaluating Surgical Skill to Improve Outcomes: Lets Go To The Replay Booth

Just as elite athletes are born with amazing skill, elite surgeons and doctors in other procedure-based specialties are also equipped with innate abilities that others do not possess.  Surgical skill is often difficult to quantify.  Certainly, outcomes data can be obtained and reputations are formed over time.  Years of training allow the truly gifted surgeons to develop their skills and perfect their craft.  However, all surgeons are not created equal.  During training, residents and fellows learn by watching the senior staff.  As they progress in training they begin to perform procedures with guidance and as they near the end of their training they are working independently with minimal oversight.  Once training is over, most surgeons have little or no opportunity to continue to improve their skills.  So, how can we best evaluate surgeons and allow patients to make more informed decisions?

For patients, it can be difficult to choose a competent surgeon.  Last week in the New York Times, the issue of how a patient may best evaluate a particular surgeon’s skill was discussed.  Surgery can be life-saving in certain situations but every procedure has finite risks associated with it.  Complications associated with a particular procedure are issues that patients must consider when choosing a doctor.  The best physicians have learned to minimize complications and are also adept at dealing with them quickly and effectively when they do occur.   Certainly, metrics such as board certifications and memberships in professional organizations (such as the American College of Cardiology) can provide some guidance.  However, most measures of surgical ability are purely indirect–board exams containing multiple choice questions and oral exams just aren’t enough.  In residency and fellowship, a trainee can complete all of the requirements of the the ACGME and be declared graduated–even with substandard surgical skills.

Now, a new study published in New England Journal of Medicine explores a new more direct and objective way to evaluate surgical skill.  Previous studies have focused more on what surgeons may do before or after surgery in the care of their patients and very little focus was placed on what exactly was done in the Operating Room.  In the new study, researchers brought together a panel of expert surgeons to evaluate 20 other surgeons ability thru the use of videotapes of the same surgical procedure obtained from the Operating Room.  The researchers found that there was a large variance in skills–the evaluators commented that the surgeons rated the lowest had skills similar to those of trainees and that those at the highest end of the ratings were considered “masters”.  For the first time a study now shows what has been intuitive for years–the dexterity of a surgeon makes all the difference in outcome.  The surgeons rated in the lowest quartile took 40% longer to complete their procedures and had much higher complication and mortality rates.  Moreover, those in the highest rated quartile had much lower rates of readmission and re-operation rates.

In addition to evaluation of skill through video review another very reliable source of information is the opinion of the nurses and support staff that work with the surgeons on a daily basis.  Experienced OR nurses are very good at rating the talent of the operating physician.  They quickly recognize gifted hands and can easily point out those that are not.  However, there is no mechanism in place for other staff to provide feedback to a particular surgeon.

As we continue to work towards healthcare reform, assessing the skill and effectiveness of physicians will be an important part of cost containment.  Significant complications and negative outcomes are costly to both the patient as well as the healthcare system as a whole.  Objectively evaluating surgical ability may transform the way in which patients and insurers are able to choose physicians to care for themselves and their families.  As physicians we have a responsibility to provide the very best care for our patients.  We must use every tool possible to ensure that we can continue to improve our skills as we progress in our careers.  Evaluations such as video observation should be incorporated into training programs and may also play a role in continuing education for physicians throughout their careers.  Ultimately we must protect patients and improve outcomes–Primum non nocere.

Exploring The Leadership Potential of Three Little Words: Applying “I Don’t Know” To Medicine

Recently I read an interesting article on leadership published at Inc.com.  Although most of the journal is focused on those in business, many of the pieces on leadership are very applicable to those of us in Medicine.  In this article author Curt Hanke writes about the inspiration and leadership positives found in the three simple words:  “I Don’t Know.”   On first blush, we may think that a leader speaking these words may no longer inspire confidence and may lose the support of his or her troops.  However, as Mr Hanke goes on to detail, the words “I Don’t Know” may provide inspiration and motivate teams to perform even better.

As physicians, we are leaders–we lead teams, we lead students and other trainees, and most importantly we lead patients.  There are times when we lead and guide patients and families on very challenging journeys through brutal, sometimes devastating diseases.  Often, being a good leader is the most important part of our job.  With leadership comes many responsibilities– and those whom we lead look to us to show confidence as we provide guidance in uncertain times.

As physicians are leadership roles are two fold:

1. We lead teams of caregivers with a common goal–the best outcome for our patients.  Our teams look to us for confident judgements during crisis (such as during a code blue) and guidance when making day to day clinical decisions.  Our teams are bright and capable.  Our team members are diverse both in training, ability and in education–nurses, physical therapists, pharmacists and other physicians–all working in concert to achieve clinical success.

2. We lead patients and families.  We are the experts in a complex field that is foreign to many–we are relied on as guides, as advisors as well as generals on the field of battle.  We must inspire confidence and show kindness at all times.  Our patients are often frightened and uncertain.  We must help them learn, grow and adapt to changing medical and clinical scenarios.

To lead in this way can be very challenging but is not terribly dissimilar from leading in the business world.  We must be prepared–with knowledge of disease and the best available therapies.  We must be aware of the strengths and weaknesses of each individual on our medical team (including our own) and we must be able to motivate those in very different roles to band together for common good.  We must lead patients and families with compassion–we must understand things from their perspective and apply their needs into the equations we use to make clinical decisions.  We must lead both groups with honesty.  We must be willing to say “I Don’t Know” when appropriate.

Then we must harness the power of “I Don’t Know” in four distinct ways (according to Mr Henke):

1. Creates Possibilities--As a leader, saying “I Don’t Know” in medicine, may create an opportunity to bond with patients, families and team members.  Having the courage to articulate your shortcomings as the leader may actually garner more respect and tighten bonds through your honesty.

2. Inspires Engagement–As a leader, saying “I Don’t Know” in medicine may provide opportunities for others to take center stage and bring forward ideas that they may have otherwise kept to themselves.  It allows others to think more creatively and inspires team members to find “ownership” in working to solve a particular clinical mystery or treatment problem.

3. Avoids Complacency–As a leader, saying “I Don’t Know” in medicine provides me with the motivation to learn more and to be better.  Not knowing the answer right away drives me to reflect on my particular skill set and take stock in what I can do better both as a leader and as a team member.  When the leader works to improve, it often inspires growth among team members as well.

4.  Inspires “Fun” During Difficult Times–As a leader, saying “I Don’t Know” rather than a positive effect on morale–A culture of “I Don’t Know” produces engaged team members and these engaged team members are more productive.  Ultimately a more productive medical team results in more positive patient outcomes.

Effective leadership is vital to success in both business and in medicine.  The most effective leaders know their own limitations and are not afraid to share that with the team that is inspired to follow them.  Courage to say “I Don’t Know” may be the difference in discovering the most accurate diagnosis and prescribing the most effective treatment plan for a patient and their family.  Be willing to admit when you fall short–as Socrates stated “The only true wisdom is in knowing [what] you don’t know”

Changing the Mindset in Medicine To Improve Outcomes: Prevention Rather Than Reaction

Much of my medical training in residency and fellowship was all about learning to react to particular clinical situations.  Long nights of call with exposure to a high volume of patients allowed me to quickly recognize common signs and symptoms, develop a working differential diagnosis and initiate testing and therapy right away.  This rapid fire exposure to disease was incredibly important in my development as a physician.  Moreover, the ability to react to clinical findings is essential in providing quality medical care as well as producing positive outcomes.

However, very little of my training focused on prevention.  Even today, residents and other physicians in training spend far more time treating disease rather than figuring out how to derail the disease process (even before it begins).  Certainly, we all learned about proper timing of routine screening tests for colon cancer, breast cancer, prostate cancer, etc.  In contrast, we did not spend much time learning effective ways in which we could counsel patients about lifestyle modification and risk reduction.  We did not talk much about how to educate patients about potential diseases that they may be at risk for and the potential negative impacts these diseases might have on an individual patient’s overall health status and quality of life.

Today in the Wall Street Journal, an article detailing a new report of an overall reduction in preventable cardiovascular death in the US today was published.  On first blush, this sounds like a very positive report–fewer Americans are dying of heart disease.  However, on closer examination, the data becomes quite disturbing–the largest reduction in preventable death was in the older population (greater than 75).  In the younger population (age less than 65) the decline was much less impressive.  Subgroup analysis revealed significant racial and geographic disparities as well–African Americans had a two fold higher rate in preventable cardiovascular death.  Residents of the southern states were also found to have much higher rates of preventable death.

Why is this?  What can we do to impact the large number of preventable cardiovascular deaths?

Based on this data, it seems to me that we are now seeing a large number of younger patients who are at risk for cardiovascular disease that are not being aggressively screened, evaluated and treated.  Many of these younger patients are not seeking medical attention until they experience their first (and often fatal) cardiac event.  According to the CDC nearly a quarter million of the 800K annual cardiovascular related deaths are preventable.  Long standing cardiovascular disease and its myriad of complications are expensive…in terms of dollars and in terms of human life.

The solution is all about prevention.  As cardiologists we must be more vigilant and screen young at risk populations more aggressively.  We must treat hypertension, hyperlipidemia and diabetes in younger patients.  We must spend more time counseling patients about lifestyle modification–not just smoking cessation.  Other healthcare providers in both primary care and in other specialties must also redouble their efforts on prevention.  We must all work together and refer patients who are at risk to the proper provider.  In addition, we must pay extra attention to higher risk groups such as minorities and we must focus efforts in geographies such as the south with higher than average preventable death rates.

Most importantly, we must all work to change the mindset in medicine.  Clinical competence and the ability to think on our feet and react is certainly essential and should remain a cornerstone of training.  However, we must also look a little deeper.  Obviously, we all love to be cast as the hero in the medical drama and save a life with an emergency procedure–however, it is just as heroic to prevent the emergency in the first place.  We must strive to train physicians who not only are able to react to disease and its presentations but who are also adept at recognizing risk and counseling patients to prevent negative outcomes later in life.

Ben Franklin had it right way back in the 1700s.  Even though we didn’t listen to Ben then, we have a real opportunity to listen and act now!  Remember–”an ounce of prevention is worth a pound of cure!”  Now that’s a low cost way to reduce the costs of healthcare AND save lives in the US today.

Providing The Best Care For Our Patients: Sometimes An Old Dog Must Learn A Few New Tricks

When I was in training at Duke University Medical Center, we prided ourselves on practicing evidence-based medicine.  During my tenure there, Dr Robert Califf had constructed the clinical research mecca known as the DCRI (Duke Clinical Research Institute).  As cardiology fellows in training, we were all actively engaged in clinical trials and quickly understood the importance of choosing therapies that had been proven to be safe and effective through rigorous evaluations in randomized controlled clinical trials.  (RCT).  In fact, when making rounds in the coronary care unit (CCU) with my attending physician, I can remember being chastised because I had prescribed an ACE inhibitor without mortality data rather than one that had been proven to save lives.  In the eyes of my attending,  I had wrongly assumed “class effect” and had used an unproven therapy.

This week in the New York Times, author Nicholas Bakalar explores the same issue in today’s medical practice.  In a recent publication in the Mayo Clinic Proceedings, investigators evaluated 10 years of published studies in a single high impact journal.   Of the studies evaluated, 367 represented an examination of a well established medical practice or therapy.  Surprisingly, 147 of these studies of established practices found that the accepted therapy was no better or even worse than the alternative treatment practice.  Of these well established treatment practices that were examined, nearly 40% were found to be ineffective or actually harmful to the patient.  However, physicians continued to utilize these particular therapies.  Why?  What can we do to effect changes in practice?

Old habits die hard.  Often, in medicine, the momentum it requires to make a change in practice can be overwhelming.  We often do things because mechanistically, they just make good sense.  Many physicians that are procedure-oriented like myself fall into the trap of believing that if we are able to impact the cause of a problem or change the course of the disease, that the outcomes will be improved.  This is not always the case.  For example, in the case of coronary artery disease, it makes sense that if we “un-block” an occluded coronary artery, we should be able to make the patient live longer.  In fact, the data clearly shows that angioplasty and stenting are valuable in relief of symptoms but have no impact on mortality.  This does not necessarily mean that we should not revascularize patients percutaneously BUT it does mean we must understand the true impact our revascularization procedure will have on the patient and their quality of life.

In medical school, most physicians were trained to think as scientists.  The scientific method suggests that scientists should evaluate a problem in the following manner:  1. ask a question, 2. make a hypothesis, 3. develop a “test” for the hypothesis and then 4. Collect and interpret the results.  As practicing physicians, we must continue to think like  scientists and look for evidence to guide our clinical decision making.  We must ensure that even if we believe that a particular treatment makes good biologic and mechanistic sense, it must still be proven effective by rigorous clinical trial evaluation–if it is not or if it is shown ineffective, we must find alternative therapies without delay.

Medicine remains an art.  The way in which we are trained has a significant impact on how we practice later in our careers.  In residency and fellowship, we are taught the current, state of the art therapies for that particular time.  Thankfully, medicine is not static–innovations and improvements in care occur almost every day.  We must learn to adapt to changes in the “state of the art” as medicine continues to advance.  A good scientist (and a good physician) continually evaluates the “state of the art” in order to see if there are better ways to treat and serve our patients.  It is essential that we continue to practice evidence based medicine and provide the best PROVEN therapies  (and reject those that are found to no longer be effective)–even if it means and “old dog” must learn a “new trick”