A personal story about quality

Happy Birthday Open School! My mom and I have both had the privilege of being involved with IHI Open School. She is a physician and professor, and serves as the proud faculty advisor to a chapter in Ohio. I served as a chapter leader while I was a nurse practitioner student at Yale Nursing School.

This past summer we became more intimately familiar with the importance of quality in our medical system than either of us would have liked.

My mom suffers from Parkinson’s disease and had progressed to the point where the disease was getting difficult to manage medically. After a great deal of consideration, our family decided that our best course of action would be for her to undergo the deep brain stimulation surgery. To shorten a very long and painful story, I will say that she got the surgery but endured multiple complications (including a faulty generator, a life threatening infection, and extra fairly high risk surgeries). At the worst times, she was unable to speak or move due to infection in her brain. We did not know what kind of recovery she would make. In addition to being terrified that we may never know our mom as we once knew her, her team had to take everything they had put in her brain, out. Four months later she is still on antibiotics and is still not sure if or when she will be able to do the surgery again. She has not been able to work, something that is very important to her. We are very hopeful but we still have a long way to go and the process thus far has left us shaken.

I share this very personal story so that we may be reminded once again of the importance of the work that we are doing. People trust us to take care of them. I cannot think of something that deserves more humility, respect, and appreciation. Procedures and physicals become routine to each of us. We have days that we are tired or distracted. But for each patient we see, let’s promise that we will treat them like they are the only person we see that day.

So from my mom and me, THANK YOU for caring about quality in care. Please keep up the good work. Happy Birthday IHI Open School.

WIHI: the Buzz about Medical Training: It’s (Slowly) Changing

Thank you for joining today’s WIHI – the Buzz about Medical Training: It’s (Slowly) Changing. Today we heard from:

• Lawrence Smith, MD, Dean, Hofstra/North Shore-LIJ School of Medicine; Chief Medical Officer, North Shore-LIJ Health System
  
• John Rock, MD, Founding Dean, Herbert Wertheim College of Medicine at Florida International University
  
• M. Brownell Anderson, Senior Director, Educational Affairs, Association of American Medical Colleges (AAMC)

Learn about how IHI is addressing student training about quality improvement and patient safety through one of its newer initiatives – the IHI Open School for Health Professions. If you missed today’s WIHI, please listen to the recording that will be posted later this week.

1. Students, are you studying at a new medical school? What is it like? Do you feel like you’re missing out or learning more than students in traditional medical schools?


2. Faculty, what do you think? Do you think your school is developing different types of future doctors?


3. Physicians, what do you wish you could change about your medical training? What would you like to have learned? What are your recommendations for today’s students and faculty?

Please share your thoughts or questions with us below in the comment section below!

The Gift of Stories

Last year, I shared a story about what I’d like to call a healthy degree of precocious curiosity about the human body and what my parents refer to as an inexplicable amount of craziness that led me to voluntarily staple my tongue. That courageous and completely unnecessary self-inflicted surgical procedure has left me with a permanent scar on my tongue. This unusual accumulation of granulation tissue on my tongue is now not only an interesting anatomical and histological finding, but represents the story of a “unique” phase in my life.

As I studied anatomy last year, your loved one, my very first patient, shared innumerable stories with me. Each lab session was filled with incredible medical discoveries. Muscles, nerves, and blood vessels are all logically arranged to accommodate our daily actions and behaviors. The mighty organs throughout our body are carefully protected by bone and layers of tissue. And individual body systems, like the eye, operate with an awe-inspiring amount of coordinated refinement. The smartest engineers and most brilliant architects may be able to create an equally powerful human body with various updates and improvements, but they will never be able to surpass the exquisite original because the artificially constructed designs cannot capture the exceptional narratives of your loved ones.

Your gift to me was much more than a gift of medical discovery because you have given me the privilege of being a part of your favorite stories about your loved ones. The slightly enlarged triceps and biceps of the right arm that we studied during our musculoskeletal sequence illuminate a possible vigorous tennis career. I bet his tennis serves were dramatic and the lightness of his feet meant he also had an unbeatable net game. The beautifully tapered fingernails that we delicately worked around as we studied the intricacies of the hand echo elegant dinner parties. Did she have a string of pearls that always added an extra touch of grace to her favorite blue dress? The clarity of the lungs that gleamed at us the first time we were able to take a look at the thoracic cavity give hints about a love for the great outdoors. Hiking, fishing, hunting, it’s likely that he did it all, but his favorite thing to do was probably taking the family out camping, right?

The most remarkable aspect about your gift is that it is a boundless gift that continues giving. This summer, I had the fortune of traveling to Ghana to conduct research. Since I’m still in the preclinical phase of my medical education, I jumped at every opportunity to shadow doctors, sit in on procedures, and interact with patients. I brought your loved one with me wherever I went. If I needed to take a pulse, I’d quickly locate the radial artery. While watching a hernia repair, I’d almost instantly recall the contents of the inguinal canal. Where is the anesthetic injected for spinal anesthesia? That’s right. The subarachnoid space. Every single time, I instinctively made correlations to what was in front of me to my first patient. Did you ever think that your loved one would have the opportunity to travel across the Atlantic Ocean to Ghana? And I’m just a second year medical student whose career in medicine is only just beginning. The stories of your loved ones will travel even farther and will touch more patients than you could ever imagine.

My first year of medical school was defined by the time I spent in anatomy. I spent hours probing through various anatomical structures and yet I feel like I only scratched the surface in my pursuit of medical scholarship. But what I did learn during those hours in anatomy lab, as I slowly built an intimate rapport with my first patient, was the invaluable lesson of the joy and fulfillment gained through listening to the stories of every bump, kink, and scar. It is the magnetic draw for these patient narratives that led me to inevitably mature from the dangerous narratives of attempting surgical procedures on myself to attending medical school and working towards becoming a doctor. Your special gift, my first patient narrative, is one that will always stay with me as I continue to learn and never stop listening. Thank you.


Delivered at the University of Michigan Medical School Anatomical Donations Memorial Service (Sept. 15, 2010)

The first IHI Open School advanced case study

A few months ago, a 29-year-old woman was living independently in a small suburb in the southwestern United States. She enjoyed cooking for friends and playing her guitar. Today, she's been admitted to a nursing home because she can no longer care for herself. What happened?

Two weeks from now, students and residents all over the world will gather in interprofessional teams and analyze the complex series of events that ended up harming this patient. They'll also design an improvement project that could help prevent similar problems from happening to other patients in the future.

Want to participate? Here's how the IHI Open School's very first advanced case study event will work.

• Visit the advanced case study page and download the instructions.
• Form a team. Teams can consist of 2-12 people and must represent at least two professions. Residents and students from a broad range of fields, including nursing, business, pharmacy, medicine, law, policy, engineering, public health, and related fields, are encouraged to participate. If you need teammates, find them on our Facebook page.
• Register your team by Friday, October 1st. Registration is capped at 25 teams, so register early! (Registration is open now.)
• Download the case from the IHI Open School home page on Thursday, September 30th. You'll have two weeks to work on it with your team.
• Email your team's presentation to openschool@ihi.org by Thursday, October 14th.
• Selected teams will present their work to IHI faculty in a series of live webinars the week of October 25th-29th. Teams will be notified by October 20th about whether they will be invited to present.

We are really excited about this case study event. It's a chance to flex your knowledge of safety and patient-centered care, lead system improvement, practice your teamwork skills across professions -- AND get feedback from the experts at IHI.

We hope you'll form a team and sign up! If you have questions, leave a comment or email openschool@ihi.org.

Costs of Care Essay Contest!

Medical bills are a leading cause of personal bankruptcy and health care providers decide what goes on the bill.

According to the Congressional Budget Office, the United States spends $700 billion dollars each year on tests and treatments that do not measurably improve health outcomes--a figure comparable to our total spending on the Iraq War. And here is where things become truly awkward: few providers understand how the decisions they make impact what patients pay for care.

Let's recap. Medical bills are bankrupting Americans, providers decide what goes on the bill ($700 billion dollars of which might not need to be there), and providers rarely have information about what things cost. That seems like something we ought to fix, doesn't it?

If you agree and have a story to tell about it, there could be $1000 in it for you. Remember a time you got a medical bill that was higher than you expected it to be? Or a time when you wanted to know how much a test or treatment might cost and couldn't find out? Costs of Care, a Boston-based nonprofit, is offering $1000 for short anecdotes illustrating the importance of cost awareness in medicine. We want to hear your story.

The submissions will be judged by a high profile crew of policymakers, doctors, and journalists that include Atul Gawande, Michael Dukakis, Jeffrey Flier, Michael Leavitt, and Tim Johnson. Submissions will be due by November 1st to contest@costsofcare.org. Additional details are available at www.costsofcare.org/essay

Dr. Neel Shah is the executive director of www.CostsOfCare.org, and a resident in Obstetrics and Gynecology at Brigham & Women's Hospital in Boston.

The IHI Open School is Two!

Two years ago, the IHI Open School team was building a startup. We were pretty sure students would be interested in learning about quality, but there were lots of things we weren't sure about. Would busy students be ready to take on another commitment? Would faculty embrace the IHI Open School concept? Would students of nursing, pharmacy, medicine, business, and other professions find ways to collaborate to improve patient care?

After many late nights and weekends in the office, our team crossed our fingers and launched this initiative on September 15, 2008. Two years later,we are constantly humbled by the energy, accomplishments, and sheer numbers of students, residents, faculty, and health professionals who have plunged into the IHI Open School's offerings -- and taught us a lot about the work that preceded this initiative and made it possible for so much to happen in such a short time.

Exactly how far have we come together in just two years? Check out the numbers:

• 38,000+ students and residents are registered on IHI.org
• 9,000 students and residents have completed a course
• 8,000 faculty and deans are registered on IHI.org
• 700 students have earned an IHI Open School Certificate of Completion (all of the courses)
• 250+ Chapters have been started in 35 countries

We offer a big, loud THANK YOU to the Chapter Leaders and Faculty Advisors who’ve taken on the challenge of leading a Chapter and getting others -- whether students, residents, or health professionals -- involved in quality improvement. Our thanks also to the health professionals who have made time to invite these students into their organizations.

Help us celebrate the last two years by telling us what the IHI Open School means to you. How have you used what you learned in the courses? Did leading or participating in a Chapter change your career? How is the IHI Open School shaping your personal and professional goals? And -- finally -- what do you want the IHI Open School community to do next?

Preparing for the Future

This summer, while I was traveling around Ghana conducting clinical quality and management research focusing specifically on the changes posting an OB/GYN specialist in district hospitals has on the hospital and the immediate community, my classmate Charlotte was busy administering a laparoscopic surgery training module to bring the technology of laparoscopy to Komfo Anokye Teaching Hospital in Kumasi, Ghana. Laparoscopic surgery, especially for gynecological surgeries, has been available to developed countries for at least 20 years, but this minimally invasive form of surgery has yet to become standard practice in Ghana. The benefits of laparoscopic surgery are many. It is cosmetically favored by patients and medically, reduces complications like hemorrhaging and has shorter recovery times. It is no exaggeration to say that Charlotte's work is ushering Ghana into a new surgical future that will bring a tremendous amount of public health benefit.

In 1910, Abraham Flexner's report titled, "Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching" ushered and shaped medical education into it's current form. The Flexner Report called for standardization of medical education that was rooted in sound and rigorous biomedical and clinical science challenging the American and Canadian medical education systems to train the highest quality of physicians. Flexner, not a physician himself, wrote a book-length report that was framed with the greater society in mind. He wrote, "The public interest is then paramount, and when public interest, professional ideals, and sound educational procedure concur in the recommendation of the same policy, the time is surely ripe for decisive action."

It has been 100 years since the publication of the Flexner Report and with 100 years of experience of modern medical education, we are due for some reflection on the alignment of the medical education system and the public interest. In an article published in Academic Medicine, Drs. Don Berwick and Jon Finkelstein write and discuss a, let's call it "Flexner Report 2.0", shaping a medical education system that will better prepare physicians to meet the needs of a today's world of health care. Read the article here.

In the article Berwick and Finkelstein outline new values that should complement the current emphasis on biomedical science we receive in medical school. These values include "patient-centeredness, transparency, and stewardship of limited societal resources for health care." There is no time in the current curriculum to add on training in these new skills, many educators would argue. Berwick and Finkelstein also review the innovative programs, including the IHI Open School, that attempt to provide medical students and residents with a foundation in these new skills, as well as outlining a new frame of reference for medical curriculum change that will incorporate these invaluable skills. I certainly can't reproduce Berwick and Finkelstein's eloquence, so I will leave the explanation of the fine details to the article. Definitely a must-read!

In the 100 years since the publication of the Flexner Report, the medical education system has trained millions of physicians who have dramatically transformed health care. It was this cohort of physicians that popularized laparoscopic surgery! Looking just at performance outcomes, we have made incredible gains in both the length and quality of life for our patients. However, there is much more we can do. If we adopt Berwick and Finkelstein's recommendations, we will be poised to create a new physician workforce adept at navigating and continually improving the complexities of health care to consistently meet patient needs. We all need to collectively reflect on and brainstorm innovative interventions to fold the skills of systems thinking into our current medical education system. If we can develop the technology of laparoscopic surgery, I'm confident that we too can succeed in reinventing ourselves to better treat our patients with the tools of quality improvement. In 100 years, the world will surely look very different. I'm imagining a modern metropolis not unlike the life of the Jetsons. But, what will medicine look like? What kinds of public health accomplishments can we celebrate in the next 100 years? Let's work together to reshape medical education so that we will have plenty to celebrate in the future!

What do you think of the Berwick and Finkelstein paper? Leave a comment!