Tag Archives: medical education

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.

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The Future of Medicine: Coding For An Orca Bite

When I was in medical school in the mid-1990s at Wake Forest University, the only thing I knew about “codes” was how to use an ATM machine (which was often linked to a very empty bank account).  As my training progressed through internship, residency and fellowship, the idea of coding provider services never even crossed my mind.  No one taught me anything about the “levels of service” or what an ICD-9 (The International Classification of Diseases) code actually was even though the coding system has existed for more than 30 years.  I remember my teachers and mentors scribbling on a card in the front of the chart whenever they interacted with a patient, but I had no idea what the exercise was about.  Years later, I am all too familiar with coding of patient services.

Billing codes serve as a way for the Center for Medicare and Medicaid Services (CMS) to create a payment schedule for services rendered based on diagnoses.  Each diagnosis is given a particular code and then there are “modifiers” that attempt to make the billing code more specific.  Government bureaucrats created a massive list of poorly contrived codes that have been utilized for the last decade known as ICD-9.  Over the years, those responsible for these codes have realized that in order to accurately document medical conditions and improve billing accuracy (and reduce fraud) that these codes are in need of updates.  Thankfully, our government has been working on this new system tirelessly over the last several years.  In fact, the Wall Street Journal reported on the development of this new brilliant system as early as 2008.  Next year, the new set of billing codes will go into effect–they have been created with the goal of improving the specificity of the diagnosis and improving care (through quality measures).  This brilliant work and expansive list of new codes (approximately 150,000 codes as compared to the current 18,00) includes such ingenious diagnoses as code W5621XA “bitten by an orca, initial encounter”.  Another important code that has been created is the commonly used W6112XA-”struck by a macaw”.  As a practicing physician, I am relieved that when the next patient who visits my office after suffering “a burn due to water skis on fire”–I can quickly and easily document the encounter using the ICD-10 code V9109XA.

As government seeks to continue to regulate healthcare and contain costs, it seems to me that our efforts in reducing costs and improving quality of care are a bit off track.  Instead of working to improve efficiency and reduce redundancy in healthcare, we are now focusing on creating codes for injuries that may only occur to Wile E. Coyote during an epic battle with the RoadRunner.  As a physician, I have been required to complete nearly 20 hours of online training to help me understand the new ICD-10 coding system.  After an endless marathon of computer modules, I still have no idea how or why the ICD-10 system will improve my ability to care for patients or improve either the efficiency or quality of care in my practice.   In fact, I am certain that the new coding system will actually add more hours of documentation to my already burgeoning pile of electronic paperwork.  Eventually something has to give….there are only so many hours in the day.  Personally, I would rather see patients and care for those that need my help rather than coding for an attack by a talking bird or a personal watercraft injury due to burning water skis.

Our healthcare system has lost its way.  The new coding system is just one example of misplaced priorities within regulatory agencies.  Instead of creating codes for ridiculous scenarios, we should be training docs to provide thoughtful efficient care. We should be teaching doctors to communicate with each other about patient care and to avoid unnecessary testing.  Time, money and energy could be much more effective if spent on engaging patients in preventative care strategies and modification of risk factors.  Until then, I can at least sleep well tonight knowing that there is in fact an ICD-10 code for the next patient who walks in my office after being “hurt at the opera” …I will be able to quickly use code Y92253.

Please note:  All of the codes mentioned in this blog are REAL.  They are all part of the 150,000 codes that doctors and billing specialists are supposed to know and implement in the next year.  You can verify all codes by using this ICD-10 code look-up website

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The Doctor Patient Relationship On The Brink of Extinction: The Impact of Physician Post Graduate Training

It is unfortunate, but now medicine is “on the clock”.  We now must not only battle disease, but we must also battle time.  Physicians are asked to do more in less time.  Innovations such as EMR (which in theory are supposed to increase efficiency) sometimes actually slow clinical practice to a halt.  Additionally, ongoing debate exists as to how best train medical residents and prepare them for the practice of medicine.  Technology and mhealth applications are changing the way in which doctors and patients interact.  Training programs have been evaluated multiple times over the last 20 years and sweeping changes have occurred in the way in which the ACGME regulates the working hours of physicians in training.  These changes have a significant impact on the way in which physicians practice once they have completed their residency and fellowship commitments.

Medicine, more than any other profession, is best learned through experiential training.  “Hands On” contact with patients and families allows residents to immerse themselves in disease and the continuum of care.  Studies from the late 1980s (published in the New England Journal of Medicine) suggested that although resident hours were long and arduous, much of their time was spent doing paperwork and tasks such as drawing blood and transporting patients–even in the era of the 100+ hour week for interns only 20% of the work time was spent in direct patient care.  In the early 2000s with increasing pressure from politicians and other organizations, the ACGME issued a statement limiting the work hours of housestaff to 80 hours per week.  The arguments that led to the limitations in work hours revolved around mistakes and errors during times of sleep deprivation.  Citing patient safety and resident “burn-out” advocates for change stressed that care and learning would both improve if rules were put into place to limit consecutive as well as cumulative work hours.  However, a recent study in the Journal of General Internal Medicine explored the difference in mortality pre and post reform.  Interestingly, there was no overall change in mortality pre and post reform.  In fact, when interviewed, residents and attending physicians complained about the dangers of the “patient handoffs”.  In the old days, the “sign outs” would occur only once a day–in the evening to the on call team. Lists were prepared from every team and a verbal sign out would occur doctor to doctor and team to team.  In the morning, the on call doctors would discuss the overnight patient events with each team and ensure a proper continuum of care.   In the new system with trainees coming and going at different times, there are many opportunities for miscommunication and sometimes important patient care issues get lost in translation.  Many times the night call team is not even associated with the particular service they may be covering and may only cover a night or two here and there–resulting in zero continuity of care and no investment in the overall outcome of the patient.  More importantly, trainees never truly understand the entire course of a disease process as they frequently only see a portion of the span of therapy due to work hour limitations.

Clearly, the current system for training physicians is lacking.  Neither pre reform guidelines nor post reform guidelines are adequate.  This week in the New York Times, author Pauline Chen provides a nice review of the course of reform in medical education.  However, near the end of her essay, Dr Chen makes her most important points–ultimately, by limiting time spent with patients, we are working to eliminate the formation of the doctor patient relationship.  In fact, some data suggests that in addition to a training curriculum for residents most institutions also have a “hidden curriculum” that affects the attitudes of physicians toward their patients once in practice.  If the institution is heavy on paperwork and intern “scut work” there is little time for direct patient interaction.  These training experiences can shape the way in the doctor relates to patients throughout his or her career.  It is essential that we continue to teach doctors how to be healers.  No matter what the working hour limitations may be in the future, we must continue to foster skills for building healthy doctor patient relationships in our physicians in training.   In addition, we must help residents with time management and discover ways to improve the time that they spend in direct patient care while in training.  If we do not, we will find that the art of medicine may in fact be lost forever.

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MBAs for Practicing Physicians: Learning to Lead in the New Millenium

Healthcare is changing and physicians and hospital systems must quickly adapt in order to remain solvent in these challenging economic times.  No longer is it adequate to be the best clinician, best surgeon or the most brilliant diagnostician.  Now, more than ever, physicians must have a thorough understanding of business and economics.  Many practicing physicians are finding out that entrepreneurial thinking and a shrewd business approach to everyday medicine is the answer to improving patient care all while preserving  the bottom line of the hospital or practice.

Recently, the University of Indiana began offering an Business of Medicine MBA program to practicing physicians.  This program is quite unique in that it is specifically designed for clinicians who are in practice and want to return to school without interfering with their “day job”.  Many medical schools and business schools are now offering combined degrees to medical students already and these are becoming more popular.  At Wake Forest University where I went to medical school, a combined MD-MBA was offered back in the 1990s.  However, the Indiana program for practicing physicians is the first of its kind.  Accounting for the busy schedule of a practicing physician, the program combines both online course work with “resident weekends” where classroom interaction and group work are facilitated.  The program’s first class will begin in September 2013 and will be a two year journey.  The program will focus on some of the traditional MBA topics but will have an emphasis on several healthcare themes including collaboration, innovation, analytics, transformation, optimization and sustainability.   The goal of the degree program is to produce a new type of physician executive who is able to provide leadership and guidance in this volatile time of healthcare reform.

At the University of North Carolina at Chapel Hill, my division chief and “business of medicine” mentor Dr Cam Patterson has been instrumental in the growth of the Cardiovascular Center through his physician executive leadership.  As a new incoming division chief several years ago, Dr Patterson realized the importance of business training in managing a large system such as that at UNC.  He enrolled in the MBA program at our institution and through his studies there was able to discover his remarkable talent for physician-executive leadership and entrepreurial thinking.  Although he inherited a division in need of significant overhaul, Dr Patterson was able to quickly build what has become a financially sound heart center that continues to serve the people of the state of North Carolina.  As we continue to move into uncharted waters in healthcare reform, it is essential that we continue to prepare ourselves to respond to the economic and administrative challenges that are looming on the horizon.  Examples such as Dr Patterson provide insight into the importance of having a more in depth understanding of the business of medicine.

Business of Medicine MBA programs such as the one being pioneered at the University of Indiana are essential to the success of physicians going forward into the coming years.  Certainly it is important to train young medical students in business and provide opportunity for combined degree programs.  However, the current physician workforce must also evolve in order to remain in a position to provide excellent patient care and remain financially sound.  Programs that focus on the working physician will allow for continued production in practice while learning skills that will be essential to success in the future.  Combining online coursework with weekend “MBA residencies” allows for both professional interaction and more productive learning among Physician-students.  Now, more than ever, the business of medicine has become as important as a thorough understanding of human anatomy.  We must all prepare ourselves to become the physician executives.  Physicians, rather than politicians, must lead the way in healthcare reform and Business of Medicine MBA training may help more physicians obtain a seat at the negotiating table in Washington as reform continues to evolve.

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Improving Care For Our Patients: Promoting Creativity In Medicine

The practice of medicine is based on a solid fund of knowledge and a physician’s ability to quickly assimilate and organize information during a patient encounter.  However, the process of making a diagnosis and formulating a treatment plan is not always straightforward.  Often, what separates the truly exceptional physicians from the rest is the ability to attack problems from alternative angles–more simply put, creativity.  Traditionally, medical education is centered around science.  Creativity has little role in modern western medical schools–it is not taught or encouraged.  Overwhelming amounts of fact must be committed to memory during medical school–leaving little time for creative experiences such as art, music, and drama.

Recently in the journal Academic Medicine, Dr Niamh Kelly published an editorial addressing the concept of creativity in medicine.  Inspired by Ted Robinson, a speaker at the TED conference, Dr Kelly champions the idea of promoting more creativity in medicine–not only in the clinical practice of medicine but in the delivery of care to the patients who need it.  Promoting creativity in medical education and in the everyday practice of medicine may open up a whole host of new possibilities and, as Dr Kelly argues, allow healthcare providers to reach new levels of collaboration and productivity in the treatment patients and disease.  Science is central to medicine, but promoting a culture of creativity may allow physicians to reach their full potential.  Medical schools and medical professionals must actively promote creativity by utilizing conference times, rounds and other gatherings to discuss creative thinking and pursuits.  In addition, medical education must foster experiences in the arts and music–group events for exploration.  By exploring new things and having new experiences while learning medicine, the creative side of student’s brain remains stimulated and creative thinking is cultivated even in the midst of gross anatomy, physiology and pharmacology lectures.  These creative experiences may very well produce physicians that are able to think and approach patient problems in new and unique ways.  New approaches often result in new therapies and new solutions to tough problems.

This week, in an essay in the New York Times, Dr Danielle Ofri further examines the issue of creativity in medicine.  Her comments are quite sobering as she makes the point that medicine has now become more algorithmic and more standardized. Healthcare reform and prevention of medicare fraud has made this standardization even more regimented.  Creativity has been given little room to flourish.  As providers of healthcare, we must work to reclaim some of this “creative space” in order to provide the best possible care to our patients.  Science and the thorough approach to patient care remains central to success–however, the complex social situations, personalities and individual characteristics of our patients make creative approaches to care essential.  As healthcare delivery in the US continues to be redefined creative thinking and fresh ideas may make the difference in access to care and patient outcomes.

As a profession, physicians must possess a sound fund of knowledge and be able to readily assimilate large amounts of data rather quickly.  Our ability to perform under pressure is due to repetition during years of training.  However, as medicine and healthcare systems become more complex we must be able to apply our knowledge in creative ways in order to provide the most effective care.  Although traditional medical education has not relied heavily on creativity or creative thinking we must begin to consider changes in the way in which we train medical students and residents to think.  We must foster creativity–through music, art, writing and drama.  All of these experiences will serve to make us better equipped to serve the patients of the future.

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Promoting the Team Approach in Medical Education: Dealing with the “The Gunners”

In the satirical novel The House of God, author Samuel Shem writes about experiences as a medical student at Harvard.  In the novel, many famous quotations are used that have been passed on from generation after generation of medical students and residents.  Some slang terminology is also referenced and characters are created to illustrate the qualities of certain types of students.  One particular student that is found in every medical school class is the “Gunner”.  The Gunner is a term used to describe a hyper competitive medical student who is motivated by performance and grades and will stop at nothing to succeed. Almost every medical school class in the US has a couple of students with this character trait.  All of us who have trained in the past can still remember who these students were in our own classes.  Sadly,  a Gunner feels no remorse about climbing over others to achieve success on the medical wards when being evaluated by attending physicians.  A Gunner never learns how to work well with others and, although performs remarkably well on exams and evaluations, is often left without essential skills for success in medical practice.

Last week in the New York Times, Author Pauline Chen writes about the inability of the current medical education system to “fail” students with poor interpersonal skills and the inability to work with a team.  Now, more than ever, teamwork in medicine is essential to success.  In the article the story of a bright, young medical student is detailed.  This young student is able to ace all of the written exams but isolates herself from classmates, treats nurses and colleagues with disrespect and is unable to accept constructive criticism.  The attending physician supervising the student laments that he is unable to “fail” her due to the fact that there are no objective evaluations in the medical school grading system to deal with important attributes such as bedside manner, communication skills and interaction with nurses and colleagues.

In my opinion, this story illustrates a major flaw in our medical education system.  We have a responsibility to students as well as future patients to help create doctors who are not only brilliant diagnosticians and clinicians but are also compassionate, caring and able to easily work with others.  No longer is medicine practiced by the Physician in isolation.  Today, medicine is centered around a team approach.  Nurses, physician extenders, social workers and physicians all work in concert to produce excellent patient outcomes.  Healthcare reform has now mandated certain (sometimes arbitrary) quality measures and it is only through a comprehensive team approach that these can be achieved and (more importantly for the government) documented.  Nothing productive has ever emerged from a negative confrontation with nurses or colleagues in a hospital.  We must reward students who display the ability to work well with others and effectively communicate with staff.  More importantly, we must teach students how to readily accept and respond to constructive criticism and continually self evaluate.

Certainly, proficiency with test taking and knowledge acquisition is essential to creating a successful, effective physician.  However, a physician who is able to work well with teams and communicate effectively with non physician support personnel is just as essential. We must develop a system put that actively strives to teach and evaluate these important interpersonal skills in medical school.  Once students are advanced to internship and residency, these bad habits are much more difficult (if not impossible) to break.  Competitiveness and striving for excellence are still important qualities in medical students.  However, compassion and concern for others may be even more rewarding in the long run.

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Courage to Care for the Dying: The Importance of The Art of Palliative “Caring”

As healthcare providers we are focused on Life.  We are committed to healing.  We measure success by lives saved.  Unfortunately, many diseases remain incurable.  Some diagnoses do carry with them a death sentence in spite of the best that modern medicine has to offer.  Even in theses extremely devastating cases, WE can still make a huge difference in the lives of our patients in the way in which we help them handle their own death.  Too often, treatments are prescribed which may have the effect of only prolonging suffering.  In some experimental chemotherapies, treatment may raise survival only a few percentage points.  As caregivers, we become so focused on changing the inevitable outcome that we often forget about one of the more important reasons we are treating our patients–to ease pain and suffering.  In the case of terminally ill patients, we can help shepherd them through the process of death.  Too often, however, we as healthcare providers are ill-equipped to tackle this task.

Last week in  New York Times, author Abby Goodnough chronicles the hospice care death of Martha Keochareon who happened to also be a nurse.  As described in the Times piece, Ms Keochareon, during her final days,  heroically wanted to help other nurses understand how to care for the dying.  She reached out to her former nursing school and asked if there were students who needed to do a case study for class.  She volunteered to have them come to the house and learn about hospice care–what she taught them was so much more powerful.  The students began to learn what is most important to the terminally ill patient.  Ms Keochareon taught them the importance of a gentle touch, of listening, and most significantly, taught them how to truly care for a patient facing inevitable death.   Too little time is spent understanding death and dying.  The selfless act of Ms Keochareon opened the eyes of young nursing students–in effect, the time they spent with her made them better caregivers.

As a whole, medical education for both physicians and nurses lacks formal training in dealing with death and dying.  There is little standardized palliative care training in the Residency curriculums of most programs in the US today.  Although some programs do provide a palliative care experience, many do not.  Learning from a palliative care expert and from experiences with terminally ill patients can be a career changing experience.  No matter what specialty a healthcare provider ultimately decides to focus on, all of us must deal with death and dying in one way or another.  HOW we deal with death, may impact our patients in ways that are just as significant as performing a life saving operation or providing other life saving therapies.  When patients enter into the phase of their disease where death is inevitable, quality of life, quality of interpersonal interactions and quality of companionship often become incredibly important.  As a resident at the University of Virginia, I had some exposure to an inpatient hospice unit.  Although it was often sad to see patients slip away, my experience there made a huge impact on my development as a physician.  In my residency experience, I had the benefit of watching the interactions and care provided by experienced hospice nurses and physicians.  The thing that affected me the most was the concern in the eyes of the caregivers–the connection that each of them made with their patients.  Gentle touch–carefully timed smiles–and non verbal communication through caring glances seemed to make enormous impacts.

Ms Keochareon inspirational story can teach all of us something about the process of dying.  To learn, we just have to open ourselves up to our patients and carefully listen and observe.  Even in her death, she intended to give to others.  She opened the eyes of young, impressionable nursing students.  I suspect that those students are better for having known her–even if just for a little while.  Rightly so, we are all trained to focus on the cure and to strive to make our patients well.  However, we must not forget about patients when they approach the other end of the spectrum.  It is our duty to guide our patients as comfortably and gracefully through the process of death and dying as well.  As healthcare providers, we must all work to perfect the “art” of caring–even at the very end of life’s journey.

Holding Hands with Elderly Patient