WIHI: Exciting New Audio Program

How long is your morning commute to class or work? In high school, my commute was 45 minutes by car. My dad has always believed in never letting any time go to waste. So, rather than listen to my favorite music CD all the way through twice a day, my dad would urge me to listen to audio books.

The association of traveling and audio books has stuck. My commute now is a much more tolerable 20-25 minutes and I'm still listening to audio books and podcasts. Any of you listen to podcasts or audiobooks on your way to class or work? Plenty of novels and language books have audio formats. I've always wanted to listen to something health care related and now I finally have an answer...WIHI.

WIHI is an exciting new audio program from IHI. It’s free, it’s timely, and it’s designed to help dedicated legions of health care improvers worldwide keep up with some of the freshest and most robust thinking and strategies for improving patient care.

Each episode is 60 minutes and there's a new broadcast every other week. You can listen to WIHI live— via computer or telephone or both — or you can download an archived audio file for listening later (see the Technology tab for more information). All you need to do is register in advance.

The WIHI broadcasts will be hosted by IHI’s Madge Kaplan, who brings a wealth of experience to WIHI from her years reporting on health care for public radio. IHI’s Director of Communications since 2004, and the regular “voice” of the 100,000 Lives and 5 Million Lives Campaign conference calls, Madge is known for her ability to create a shared space for lively and enriching discussions.

The first broadcast is TODAY at 2PM and is titled, "Breaking the Cycle of Readmissions." Today's broadcast will feature Dr. Amy Boutwell of IHI and Dr. Thomas Lee from Partners Healthcare System and Partners Community HealthCare, Inc. in Boston. Dr. Lee is actively working on reinventing primary care in the U.S., a critical backbone to any efforts to reduce hospital admissions. He is also co-chair of the Committee for Performance Measures of the National Committee for Quality Assurance.

Click here for more details about registering and listening in on WIHI.

I know I'll be adding this to my list of things to listen to on my way to work!

National Nurses Day!

Today is National Nurses Day! National Nurses Day, also known as National RN Day, kicks off National Nurses Week and honors Florence Nightingale's birthday (May 12th). National Student Nurse Day is May 8th and the International Nurses day is May 12th.

As I'm sure you can all guess, National Nurses Day and Week celebrate the tremendous contribution and commitments they make to health care. During the week, several health systems will host celebrations and banquets, and patients send their nurses flowers and chocolates. These, however, are just small tokens of appreciation owed to nurses everywhere.

If you think about a typical hospitalization, it's nurses who are almost constantly by your side. They are usually the first in the care team to see you and work hard to deliver care and treatment. Nurses are also patient advocates and stewards of patient safety. If you are thirsty or in pain, they are often the first people to help you. Nurses are simply invaluable to patient-centered and continuous care.

Because of the daily work that nurses do, they are often natural leaders when it comes to quality improvement. Yet, nurses and doctors commonly butt heads even though they are playing for the same team! When we take a look at health professions education, is this that big of a surprise? To the nursing students out there, how many of you have friends who are doctors, pharmacists, physical therapists, health care administrators, etc.? On the flip side, how many doctors, pharmacists, physical therapists, health administrators can count nurses among their list of friends? When was the first time you've worked or learned alongside people outside of your field?

Here's an episode of the TV show, Scrubs, which explores this relationship between doctors and nurses. Carla, is fantastic head nurse with years of experience under her belt, and J.D. is a fresh new medical intern. In the first few episodes of the season, J.D. depends on nurses like Carla to get through the day. But soon, the traditional medical hierarchy imposed on the health care system creates tension in their relationship. How would you resolve the tension? What kind of things would you do to promote teamwork?

In celebration of National Nurses Day and National Nurses Week, find a nurse and say "Thank You!".

IHI Open School in the Media!

If the IHI Open School was a celebrity, we haven't quite reached Paris Hilton, Jennifer Aniston, Brangelina, Lindsay Lohan, or even First Dog Bo type coverage in the media, but we are well on our way!

In the AMA (American Medical Association) Monday, May 4th issue of American Medical News at amednews.com, Kevin O'Reilly writes about the IHI Open School. Click here to read! Featured in the article is the University of Chicago's IHI Open School Chapter led by Caitlin Schaninger. Also mentioned in the article are Jill Duncan, IHI Open School Director, Dr. Vineet Arora, faculty advisor to the University of Chicago IHI Open School Chapter, and Dr. David Mayer, Associate Dean at the University of Illinois College of Medicine at Chicago. Congratulations!

The IHI Open School is also mentioned in the May/June issue of Healthcare Executive magazine. Click here to read. In this piece, I discuss how health professions students are unwilling to accept adverse events and inefficiencies as inevitable characteristics of the health care system.

Please let us know if you see the IHI Open School in the media. Who knows, perhaps by the end of the year we could overtake Bo for a top spot!

Boston Regional Event Recap

On April 23rd, eight IHI Open School Chapters in the greater Boston area hosted the Boston Regional Event, bringing together students from a wide range of health professions to discuss health care quality.

Over delicious Bertucci's pasta and salad, the Open School students and faculty were led in a case study discussion by Dr. Dan Hunt, Assistant Professor of Medicine at HMS and Director of Inpatient Clinical Educator Service at MGH, and Dr. Meridale Vaught, Instructor of Medicine at HMS. Click here to see the case study we reviewed (Other case studies listed on IHI Open School page can be found here). While the case taught us all a little bit about the clinical symptoms and treatment of Adult-onset Still's Disease, the take home message was patient safety and the importance of the continuity of care. Dr. Hunt and Dr. Vaught discussed the case with the 50+ students as a large group and provided us with time to break into smaller groups to think about several important considerations. Questions such as:

• What were her presenting symptoms?


• What kinds of tests and questions need to be answered before a diagnosis can be confirmed?


• Because the recommended drug is relatively new, what kinds of considerations must the care team address?


• What's the patient's medical history? Does she have any other conditions that we need to be aware of?


• Will any of her previous medications interact with the new drug?


• How will the patient manage all of the different medications?


• Can the patient afford the medication?


• Will her insurance cover the medications?


• How will the primary care physician be looped in?


• What are some important details that the patient's family should know about?


• What kind of training will the patient need in order to take her medications?


• Will the primary care physician be familiar with treating and monitoring her condition?


• Does the patient understand that this is a chronic condition and that she will have to consistently take her medications?


• Because the drug she will need to take is relatively new, will her local pharmacy have the drug in stock?


• What kind of follow-up will be needed as she is discharged from the hospital?
  
  ...and much more.

Each small group was made up of a mix of disciplines. We had public health students, medical school students, engineers, and nursing students--all in varying degrees of training. It was immediately evident that this case was too big to handle alone and it was necessary to work as a team in order to provide the comprehensive care the patient deserved. A question that my group continually came back to was, "how will the patient feel?"

We also touched upon the roles of several different care team members that I hadn't originally thought of. The care team involved more than just the patient's doctors, nurses, and pharmacists. She also needed support and guidance from case managers, social workers, her family, and her insurance company. It only took walking through one case study to realize how complex our health care system really is.

After the case study, we broke for some delicious tiramisu and got the chance to mingle and meet students from Harvard, Boston University, MGH Institute, Boston College, Suffolk, Endicott, Tufts, and MIT (Click here to browse through the Chapter Directory and find out if your institution has a Chapter. If not, create one!). It was fantastic to meet people who were also interested in quality improvement and patient safety. Now that we've all found each other, I can't wait for what's to come in the future!



Thank you to Dr. Hunt and Dr. Vaught for leading such an engaging and informative case study session. I'd also like to thank the Boston IHI Open School Chapter leaders who worked together to organize the event: Dylan Carney, Yian Xiao, Jennifer Chi, Kevin Knoblock, Courtney Nielsen, Brady Evans, Andy Wurtzel, and Shabnam Hafiz. Thank you for a fun night!

Humanism for Patients

On April 23^rd, Dr. Don Berwick gave a lecture at Yale School of Medicine for the Humanities in Medicine series. Each lecture in the series is named after someone special. This particular lecture was named after Dr. Morris Dillard, who was actually my interviewer when I was applying to Yale medical school. Dr. Dillard, who I guess is about 80 years old, is still very sharp and active in the Yale clinical community. In fact, he was the one who stood at the door to the lecture room, and personally greeted everyone. When he saw me, I worried that he would not remember or recognize me. Immediately, however, he smiled at me, and made bowing motions with his arms as if he was playing a violin. He had remembered me after all, recalling our interview when we had talked about me playing the violin during medical school and afterwards. He still remembered this aspect of me, over a year later.

Don Berwick’s lecture was about many things. As a first-year medical student, what I took away from the talk was the importance of humanism, a concept that is repeatedly thrown at us in our pre-clinical clerkship course, but which rarely sinks in unless delivered with inspiration and precision. At this early stage, when we are beginning to develop our habits, routines, and attitudes regarding helping the patient, learning about humanism is critically important.

We were told about being a humanistic doctor. Dr. Berwick’s personal experience of learning about humanism came, in part, from one of his patients at Children’s Hospital in Boston, where he was an attending. He described a young 14-year old boy, with a chronic illness, who had been admitted to the hospital over 80 times. This boy told him three ways to be a better doctor. First, he said, please, please, tell me what you are going to do to me, before you do it. Second, talk to each other more (and this point was directly related to a larger topic of the talk, the fragmentation of the health care system). Third, ask me (the patient) for help. Patients often know more about their condition than their doctors can ever hope to know. So, it is our responsibility to ask. In a very moving manner, Dr. Berwick shared with us something very personal about his own health and what his health means to him, something that none of his own doctors know about, which allowed us—future, current, and retired physicians—to experience first-hand how incomplete our ability to care for our patients is if we never ask, what do you want? What does your health mean to you?

Finally, always thank your patient. Thank them for coming in, thank them for sharing their secrets with you, thank them for placing their trust in you. Dr. Berwick made these points in reference to Dr. Dillard, who continues to exemplify the best humanism a doctor can have. If Dr. Dillard is able to remember that I play the violin, over a year later, I have no doubt how grateful his patients must be for his strong sense of genuine care and appreciation for others.


-Adam Sang
1^st year med student

Tell me...

As a first year medical student, I spend most of my time in lecture halls dimly lit by computer projectors learning the basic sciences of medicine. Once every week I get the chance to escape from the lecture halls and spend time in the clinic with patients through a yearlong course where we learn and practice different elements of the patient interview. This course is a welcome reminder of a core reason we are drawn to this profession. However, these experiences are not without challenges.

One of the first concepts we are introduced to is building rapport with a patient and getting to know them as people. Upon this foundation, we add layers of information regarding the patient’s current illness and medical history, social support and family history. Our preceptors also incorporate in these lessons introductions to how to discuss tough issues such as alcohol and drug use, sexual history, and domestic violence. For myself and many of my classmates, it has been difficult to become comfortable with assessing when these questions are appropriate and how to discuss them in a nonjudgmental manner. Even when the patient is actually one of our preceptors role-playing, these patients are strangers and establishing mutual trust is difficult.

Whether asking about possible domestic violence or gathering all the details of the present illness, an overarching challenge that I have encountered as an interviewer is to avoid jumping to conclusions based on a patient’s initial responses. Sometimes, the excitement of remembering a detail in class that might apply to the patient (“It’s the positive pleural pressure!”) inadvertently directs me to jump to specific, closed questions that may miss an important component of the patient’s health. I have to constantly remind myself to go back to the broad, open questions, and I imagine that this balance will be easier with more clinical knowledge and experience.

A challenge from a different perspective is a patient’s reluctance to reveal all the facts or not knowing what information is pertinent to his or her health. The issue is not as simple as the stereotype of patients who lie because they think it will please their physicians, and I did not begin to appreciate this complexity until the first time I was a patient since starting medical school.

My recent visit to the university clinic was for a routine annual physical. As my physician began to ask the same questions that I had been learning throughout the year, I had a feeling of being a detached observer of the interview. I thought to myself, “Well, this is how I would expect a patient to answer,” and then I realized that it was I who was the patient.

For a few questions, I experienced a split second of hesitation to wonder if what I was about to say would be an important detail or if it was just medical school-induced hypochondria. Small things like past tobacco use or an unusual mole. Feeling compelled to be a “model” patient, I did report this information to my physician. She smiled and told me that the occasional cigars in college did not constitute being a past smoker. However, my physician also examined my skin and referred me to a dermatologist. Reflecting on these minimal internal debates, I can only begin to understand what it would be like to be wary of discussing much more serious and personal issues with a physician.

I do not think addressing these issues of communication between patient and physician are as easy as reaffirming confidentiality of the interview. In my observations, the physician does set the stage by expressing empathy and trying to build a connection. I have been surprised that silence can be as effective in interviews as follow up questions. A purposeful pause following a patient response can lead to the patient reframing a more complete response and revealing a significant detail. Yet, I worry if there will be the ability to conduct full interviews as time becomes compressed through medical school and during residency. I hope that my classmates (and future colleagues) and I do not forget the skill of maintaining a full dialogue with our patients.

-Michael Jaung
1st year med student
Harvard Medical School

What do you wish you were learning?

If you're like most students, you probably don't have much of a say over what you're learning in school. You may just be focused on making it through in one piece.

But are you learning the things you'll need to know after graduation?

During today's On Call teleconference, Dr. David B. Nash* listed five crucial skills that most health professions students aren't learning in school. These abilities included the following:

• Working effectively in teams
• Understanding work as a process
• Collecting, analyzing, and displaying data on the outcomes of care
• Working collaboratively with managers and patients
• Being able and willing to learn from mistakes

All these skills, Nash argued, are necessary if students are to improve care and patient safety.

Continue or join the conversation. What do you wish you were learning in school? Do you think the skills listed above are really crucial? What will it take to change what's routinely taught to students of medicine, nursing, pharmacy, and other health professions?

If you're a faculty member, what are the obstacles you face in changing the curriculum? What successes have you had?

You can post your thoughts by clicking the "Comment" button below this post. David Nash will be checking this site and will respond occasionally. Also, check back here in a week or so for a link to the audio recording of the call.

*Nash, MD, MBA, is a professor of health policy and dean of the Jefferson School of Population Health in Philadelphia, Pennsylvania.