Advice From a Third-Year Medical Student, Part II

Editor’s note: Two weeks ago, Lakshman Swamy, an MD/MBA candidate at Boonshoft School of Medicine at Wright State University, shared some advice for other students that he picked up after his third year of medical school. Not just for medical students, the advice touched on humility and the urge to complain. More than 1,000 readers have viewed the post, which you can see here.

Now Lakshman presents Part II of his advice and, again, wants it to be clear that he has made ALL of these mistakes. No one is perfect, he says, but being conscious of these mistakes – and this advice – helped him grow throughout the year. Take it away, Lakshman:

Here are four more great pieces of advice I picked up during my third year in medical school:

1. Don’t Slander. Don't talk badly about other students or, well, anyone. There will be plenty of opportunities to do so because you will see people violating all sorts of rules and you will be infuriated by it. You’ll see other students slinking away and getting days off to study on flimsy excuses – or coincidentally getting all the best cases and the least of the scut work. Ignore it all. Focus on doing the right thing and creating the best image of you. Be an upstanding citizen, ignore what others do, and have a clear idea of your own expectations and stick to them. In doing so, you will stick out and look fantastic – and deservedly so!

2. Put Yourself Together. Don't look like you slept in the hospital even if you actually did. Take care of yourself because you WILL look unprofessional when you don't – and it is very obvious. You will forget things, drop things, make mistakes that affect your team and your patients, and it all ultimately reflects on you.

3. Be a Great Learner. As difficult as it is, don’t be solely focused on tests and grades. You will have a much better time if you try to learn what you need to know because you see it as your own responsibility, rather than trying to pick out the test questions. If you allow yourself to be geared toward that objective goal (the next test, the boards, etc.), you will cement that way of thinking for your entire career. There are two problems I see with this:

1. You miss out on the depth of the information, and when atypical problems arise, you will be less equipped to deal with them.
2. You’ll be miserable.

You’ll always be looking for some future challenge that needs to be surpassed, and you won’t be able to relax and experience what is happening right now, and to excel in the moment. I’ve personally missed out on things that I would have been so excited to be a part of because I was more concerned about the upcoming quiz or test.

4. Be an Asset. Be dependable to your team. Run to get data for them and really try to know everything about your patients – just trying will pay off. As Eric Greitens said in his keynote address at the IHI National Forum last December, your strength can come from knowing others rely on you. You'll be amazed at your energy and capacity when you feel like you are an important part of the team. Relish the basic chores you have to do – don't consider them beneath you.

As a student, you’re often the first one to meet a patient and gather their story. Long after you present it, knowing those details can really come in handy and make you look fantastically on top of things. One example: Recently on call, the residents were handed a new patient with a surgery. We were walking to the patient and the residents blanked on some of the details of the case. I had done the H&P, knew everything about that patient, and saved them the hassle of logging into the EMR to get the details. Little things go a long way.


- Lakshman Swamy, MD/MBA Candidate, 2013, Boonshoft School of Medicine at Wright State University

The Immunity to Change Health Care in America

Don Berwick, during his time at CMS, had the opportunity to hear about health care from the point of view of consumers. Many times, he noticed the irony that Americans who would benefit most from health care reform were most vehemently against it. The message that health care reform is not only bad, but evil, has aroused the most basic fears – including fear of death – in a distrusting public.

Meanwhile, the message that health care reform is good for our country is falling on deaf and unbelieving ears. Why is that?

IHI staffers recently had the opportunity to hear Robert Kegan speak. In his book Immunity to Change, he points out that there are hidden and powerful assumptions that stymie people from changing habits and attaining stated goals. The inability to reach these goals is due to the reality that our current behaviors are a perfect response to these hidden and powerful assumptions. For example, a child can understand that it's good to share, but if there is an underlying fear that there's not enough, the logical commitment is not to share. It is an emotional response to the assumption of "not enough."

Most people, when asked, would conceptually favor attainment of the Triple Aim – better care for individuals, better health for populations, and lower per capita costs. However, health care in the United States is strongly counterproductive to achieving this: technology and hospitals are overused with resultant waste, access to high quality care is inconsistent at best, and unsafe care remains a problem. What are the hidden assumptions that drive Americans to hang on so dearly to a dysfunctional and unsustainable health care system?

Americans have been led to believe that good health care is a life-giving, but expensive and limited consumer product. The assumption is that health care has to be purchased. It is not a societal right. "Don't take away my Medicare" is a response to the awareness that health care must be purchased. In contrast, we generally expect education to be provided, not purchased. In the United States, people have vastly different expectations of health and education. The assumption is that this is the way it has to be.

How do you think we can alter this assumption? In other words, how can we remove this immunity to change? And how can we create a message for better health care that Americans hear clearly?

- Warren Wong, IHI Fellow

Don't Be THAT Guy: Tips From a Third-year Medical Student

I've heard quite a few of my classmates comment that they discovered the “real personalities” of many of their colleagues in the third year of medical school, when students begin to practice clinical medicine. There are a number of pressures that push people to be petty, selfish, and annoying – academic pressure, the pressure to impress your residents and attendings, the attempt to get more experience than the next guy.

And it’s not just medical school. As pressure mounts in nursing school, pharmacy school, or whichever health care path you choose, unfortunate new attitudes and behaviors can rise to the surface. Everyone goes through this, and I think everyone makes at least a few mistakes through the process.

At the end of my third year, I put together this list of things I learned to be a better student (and a better person!). The people that stick to these principles are respected, well-liked, and I think, generally happier. I also think they are far more professional than their counterparts.
My hope in sharing these tips is to create some dialogue about the importance of professionalism.

Each week for the next month, I’ll share 3-4 lessons I’ve learned and invite you to share similar stories and experiences of your own.

(As a disclaimer, I’m sure I’ve made ALL of these mistakes and probably still slip up. No one is perfect, but being conscious of these mistakes has really helped me grow throughout the year.)

Without further ado, here are my first three tips:

1. Roundsmanship. Don't make your classmates/residents/anyone look bad. If you know an answer to a question that the attending is asking and your intern doesn't, don't jump in with it. If your classmate is slipping up, don't blurt it out. It will itch, and you will want to say it (because it feels great to actually know the answer), but it is an important and difficult skill to develop knowing how and when to say it to show your knowledge while not throwing others under the bus. Sometimes you won’t even realize that this is what you’re doing until later, but believe me, there is one right way to do it and many wrong ways.

2. Humility. Don't look down on anyone and find the fine line of respecting yourself and making yourself to be a respectable professional without overstepping your boundaries. (In other words, don't be constantly hiding in the shadows, but know how and when to speak; it is rarely about you). You’ll encounter people of all levels of training that treat you like dirt, and it should just go to show you that it has nothing to do with your experience or rank –everyone should be treated with respect. The classic example of this going wrong is the OR – scrub techs berating medical students, for example. Just roll with it and learn from it, and remember that people react the exact same when you do it to them. I found that just by being nice and acknowledging the roles that other people play, everyone was suddenly bending over backwards to help me out.

3. Don’t Complain. Ever. You will have to do a lot that you think is a waste or possibly beneath you. Don't complain about it. Everyone hates people that complain. You will become well known for it. In fact, you won't even realize that you're complaining until you are critical of yourself about it. Don't talk about things being unfair to you, or about how someone else got to do something, got time off, etc. Remember, the people you’re complaining to have probably dealt with much worse!

- Lakshman Swamy, MD/MBA Candidate, 2013, Boonshoft School of Medicine at Wright State University

ProjectConnect: A Quality Improvement Project for … Quality Improvement Projects

The Tulane University IHI Open School Chapter, the first one in Louisiana, was founded in December 2010. In just one year, we've seen our membership grow to more than 70 members that have initiated multiple quality improvement projects at Tulane Medical Center.

Organizing all of those projects, ironically, turned into a quality improvement project itself.

Let’s first step back a bit. We started holding monthly meetings in early 2011, open to medical students and faculty, to discuss quality improvement related topics in health care, many of which were based on modules available on the IHI Open School website. After speaking with many students and faculty who attended those initial gatherings, we began to understand that our medical community was full of enthusiastic faculty and students who wanted to get involved with quality improvement at Tulane. However, we didn't really know how to get started connecting everyone with this shared interest and enthusiasm. We made solving this problem our main goal.

We decided that the most effective quality improvement project would be to connect the like-minded individuals in our medical community and enable them to actually do quality improvement. This is how we came up with ProjectConnect, an online quality improvement project repository and social network. We designed ProjectConnect with three goals in mind:

1. Provide a secure online platform to create, share, and manage quality improvement (QI) projects. 2. Facilitate collaboration and mentorship between Tulane faculty and medical students on QI projects. 3. Promote QI and patient safety awareness within the Tulane community.

After two months of internal meetings and guidance from our faculty advisor, Dr. Frank Rosinia, we submitted a formal business proposal to our dean's office, made a formal presentation, and secured funding for the development of ProjectConnect. We spent the next five months developing and testing the application. For example, we made sure students and faculty could log-in with their existing emails and that project data was visible to everyone after it was entered. Meanwhile, we continued holding Chapter meetings every six to eight weeks to build our chapter membership.

In August 2011, we held a faculty breakfast to unveil ProjectConnect. We asked the faculty – from Tulane Hospital, the medical school and the school of public health – to bring their laptops to breakfast so we could teach them how to log-in and enter projects into the system. (Gaining faculty support was crucial to our effort.)

Once we had some QI projects loaded, we scheduled a meeting to introduce ProjectConnect to our medical student community. The student response has been tremendous, and today there are more than 20 QI projects in the system in various stages of completion. A few examples of the work that’s going on:

• Improving patient handoff efficiency
• Reintroducing a surgical safety checklist in the ORs at Tulane
• Decreasing CLABSI rates
• Developing an effective method to train first- and second-year medical students in clinical documentation

Our Chapter continues to grow and the incoming student leadership has big ideas for developing a QI elective based on IHI Open School modules, with the goal of incorporating it into our medical school curriculum in 2012.

- Clinton Piper, medical student, Tulane University

Big Lessons: Chapters Share Learning from Event at the World's Largest Medical Center

Hi, y’all. I’m Rachel, a project coordinator at the IHI Open School. Some of you have probably seen my name at the bottom of emails or my smiling face at the IHI National Forum, but I’m still getting to know many of our students and Chapters. I got a great opportunity to do just that in my hometown of Houston late last year.

It was an experience that filled me with pride – and with help of Chapter Leader Joshua Liao, provided me with several lessons to share with new and experienced IHI Open School Chapter Leaders.

Early in the fall, I had the pleasure of working closely with Joshua, a third-year medical student and current IHI Open School Chapter Leader at the Baylor College of Medicine (BCM), to plan the first annual Houston IHI Open School Convention. The goal of the one-day convention at Texas Medical Center (the world’s largest medical center) was to use education and networking to expose attendees to important issues in patient safety and quality improvement.

The convention – a product of collaboration between IHI Open School Chapter leaders from BCM and the University of Texas Medical School at Houston – brought together student s and professionals from a wide array of educational institutions and hospitals from Houston and surrounding cities. It was inspiring and energizing, and surpassed all of the expectations we had set.

Following the convention, I asked Joshua to share details of the experience so that other Chapters could learn from them:

Who was involved in planning the event?
Early in the planning process, I took the lead in the overall vision for the event in terms of format, timing, content, and discussed these things with several other student leaders/officers before touching base with Rachel from the IHI Open School. Once that was broadly set, I moved forward with publicity with the help of a few other officers from the Baylor College of Medicine (BCM) Chapter –Jehan Alladina, Harman Kular – and Tyler Willliams , a medical student and IHI Open School Chapter Leader from UT-Houston Medical School. A number of other BCM and UT-Houston students – notably Varun Kumar, Jonathan Huang, and Mitchell George –helped with a number of pre-event and event-day responsibilities.

What topics did you include in your event agenda?
I chose two main topics - diagnostic error and safety culture - as the focuses for the event for three reasons: they are emerging, 'hot topic' issues in safety/quality, they are pertinent to the daily experience of health professions students, and we have a few of the nation’s leaders in these topics here in the medical center.

How did you select the speakers?
Given my desire to focus on safety culture and diagnostic error, Dr. Eric Thomas and Dr. Hardeep Singh were perfect choices. They are each leading researchers in these areas, respectively, and they are both very active in academic and educational roles within the UT-Houston and BCM communities.

How did you advertise the event?
I was admittedly ambitious with the scope of the event. I wanted to involve as many local Houston institutions as possible (whether they had IHI Open School Chapters or not), as well as a number of out-of-town chapters, knowing that regardless of eventual attendance, the effort and publicity from this kind of event would create important awareness and precedent for the future. As such, my team and I set out to advertise to all the hospitals and health professions schools (medical, physician assistant, pharmacy, nursing, etc.) in the medical center and also sent out invitations to other Chapters in surrounding cities. For local schools, we used paper flyers along with class-wide emails, and for hospitals we sent out invitation emails. For the Chapters and institutions further away, I drafted template letters that were sent to the appropriate deans, chiefs, and/or Chapter Leaders. We also set up a Facebook event to use social media to publicize the event and used eventbrite.com to set up an online invitation.

What was the biggest challenge you encountered during the planning process?
With the scope of this event, the biggest issue was date selection. Because everyone (speakers, student leaders, potential attendees) had increasingly busy schedules, choosing a date that worked for everyone proved to be a more difficult task that I originally imagined.

Is there anything that you learned about planning the event that other students would benefit from knowing?
Honestly, probably too many to count. But by way of overall lessons, I took away two big lessons from this event:

1. Don't be afraid to think big - While there's a time and place for smaller events, I think that if awareness and publicity of the Open School and safety/quality in general is a main goal, students shouldn't be afraid to think big (by inviting speakers, publicizing the a larger demographic, or selecting creative programming). As I learned, there are a lot of great secondary benefits to planning an event this way, even if the attendance doesn't reflect the number of invited students and professionals. From this event, I've already received several emails from people who've never heard of IHI wanting to join Chapters, and several leaders who weren't able to attend but mentioned they would love to be involved in something like this in the future. So in my case, thinking big created new connections and started new relationships that I couldn't have imagined beforehand.

2. Mind the details - For students who want to undertake planning a similar event, I would recommend that they do a large portion of groundwork before presenting or soliciting ideas from others. As mentioned before, in my experience, the planning process can stall in the early stages if student leaders wait on each other to get the ball rolling, which can be time consuming and very low yield. Whether the final agenda remains unchanged or not (in my experience it's actually a good sign if the agenda goes through multiple revisions!), having something concrete to present to other leaders and planners to discuss was immensely helpful. Because for better or worse, as one of the lead planners, the other leaders/organizers will be looking to you to fulfill that role to get the process started.

-Rachel Bissonnet, IHI Open School Project Coordinator

Wearing My IHI Blue Shirt Every Day

I couldn’t look away. I didn’t know what it was or where it came from, but I couldn’t look away. Was it someone’s sandwich wrapper? Perhaps it was a sheet of paper that someone was too lazy to toss? Either way, I had no choice.

I was compelled to pick a piece of dirty, white paper off the Orlando International Airport floor and throw it away.

You might be wondering why. (Or, you might not be very impressed: “Way to go, man. You picked up a piece of paper and threw it away. Do you want a medal?”) But it’s not so much that I picked it up. It’s why I picked it up.

And the reason can be summed up in five words: I’m an IHI Blue Shirt.

If you’ve ever been to an IHI National Forum, you’ve seen us. Flocks of us. We leave Boston’s Logan Airport by the dozens in early December – all of us bright-eyed, curious, and excited. We come home six days later – all of us bleary-eyed, content, and exhausted. The long hours in between are draining and intense. Sore feet, blisters, and sleep deprivation are more the rule than the exception.

Yet after my first experience in the blue polo shirts last week, it’s something I can’t wait to do again.

Let’s back up and define an IHI Blue Shirt. Technically speaking, we’re IHI staff members (mostly from our headquarters in Cambridge, MA), that come down to the National Forum and help make the 5,000-attendee event a success. More specifically, we run registration, check rooms, greet attendees, manage shuttle buses, create signs, maintain the staff office, provide first aid, dispense conference materials, communicate important updates to hotel staff, comprise the human wall during keynote sessions, and perform any other necessary job.

In short, IHI Blue Shirts exist to do one thing: Delight our National Forum attendees. Lost on your way to your session? Right this way, ma’am. Wondering what time the exhibit hall is open? It’s 11 - 2, sir. I hope you enjoy it. Think we can do something better next year? That’s a great idea. Let me share that feedback at tonight’s staff debrief. (And rest assured that we do discuss it!)

But I learned it’s more than just the simple tasks and extra assistance. It’s more than helping attendees wheel their luggage from one end of the hotel to the other. It’s more than walking more than 10 miles every day. It’s more than the 5 a.m. wakeups, countless paper cuts, and long stares at the gorgeous Florida sun (and glistening pools) through large hotel windows.

What is being an IHI Blue Shirt really all about? Simply put, it’s about going out of your way to help others. And the biggest life lesson I took away from my first week wearing an IHI Blue Shirt was that there’s no reason to ever take it off.

Even when the event ended at 5 p.m. on Wednesday, I wanted to help. I wanted to help clean up. I wanted to help people find the hotel lobby. I wanted to pick dirty pieces of paper off airport floors.

And in a moment of clarity (in between the hours of exhaustion), I realized that even though the experience lasts only one week each year, I should always “wear” my IHI Blue Shirt under my clothes. Why wouldn’t I hold doors, greet people with a smile, or point people in the right direction? Why wouldn’t I go out of my way to help others?

Come to think of it, what if we all wore our “Blue Shirts” every day? People would smile more. People would say “thank you” more. People would connect more. And maybe, just maybe, the world would be a better place.

I do, however, know one thing for sure: The floor of the Orlando International Airport would be cleaner.

- Mike Briddon, Managing Editor, IHI Open School

Tackling Quality Improvement Projects At Georgetown University

As the Community Manager of the IHI Open School, I have the joy of periodically visiting our Chapters to get to know them, hear about the exciting work they’re doing and, help with the challenges they face. This November, it was a pleasure to travel to Georgetown University for my first site visit.

What stood out most about the visit was the passion and energy this Chapter is putting toward its quality improvement projects.

Chapter founder, Dr. Daniel Alyeshmerni, a hospital resident, and Chapter leaders, James Cervantes and Mark Fischer, (both health systems administration students) are guiding many of the Chapter’s 70 students on eight different interprofessional projects at Georgetown University Hospital (GUH). IHI Open School Chapter at GU working group members: Cervantes, Horak, Alyeshmerni, Fisher and O’Mally

The group, which comprises students from medicine, nursing, health administration, and pharmacy, is working on these projects that began approximately 8 months ago:

- Central Line Associated Blood Stream Infections (CLABSI)
- Inpatient Handoff Communication
- Venous Thromboembolism (VTE) Prophylaxis
- Discharge
- Inpatient-Outpatient Handoffs
- Interdisciplinary Rounds
- End-of-residency Handoff Communication
- Hand washing

Just getting started can be a challenge, but the students at Georgetown have been both resourceful and creative. One of the project teams utilized the IHI Open School’s Mentor Matching Tool to identify mentor hospitals with similar demographics and low rates of CLABSI. After identifying New York Beth Israel and Swedish Medical Center as mentor institutions, the Georgetown team hosted regular conference calls with them to learn from what they were doing. From there, the CLABSI team went to hospital leadership, who recommended ideal units to pilot the project. And after initial success, they are now rolling these out to other units at GUH.

The eight projects are in various stages – some are just getting off the ground, others are already collecting data – but each one has the same goal: to improve care for patients in the hospital. (Note: Georgetown is serving as one of 20 test sites in the IHI Open School Quality Improvement Practicum. Click here to learn more.)

And, I was delighted to learn, the QI projects are only one initiative within this vibrant Chapter. Faculty advisors Bernard Horak, Professor of Health Systems Administration, and Dr. Eileen Moore, Assistant Dean for Community Education and Advocacy, along with other faculty members are committed to making this improvement work real and permanent. The group is also striving to:

- Engage more students in their Chapter
- Secure funding for Chapter events and activities
- Integrate QI in curriculum

Georgetown University recognized IHI with a certificate of appreciation for their educational contributions! (From left to right: Fischer, Horak, Cervantes, Perlo, Alyeshmerni and Moore).

Thank you, IHI Open School Chapter at Georgetown, for an excellent first site visit. After a day with your group, I am absolutely inspired by our community of healthcare professionals and can’t wait for the next site visit!

- Jessica Perlo, IHI Open School Community Manager