Navigating Medicine's Next Frontier

For those of us in health care, it's an accepted fact that we will spend years and years working towards our goal to interact with patients and make a difference in the world. Given the hierarchical pecking order in medicine, it's not uncommon to allow those immediate goals like passing a renal pathology exam, completing medical school, or making it through a long night on call cloud one's original motivation for entering the field of health care in the first place. We're all running on this rigid track hoping that we won't lose steam along the way. Thankfully, there are plenty of opportunities to refuel.

I took some time this past weekend to refuel by attending the Asian Pacific Medical Student Association (APAMSA) National Conference in Baltimore. Since the conference is organized by medical students, the programming has always been great because it usually addresses and answers a lot of questions that any medical student would have: how to survive third year clerkships, applying for residency, what a career in oncology is like, etc. The APAMSA conference also has several sessions dedicated to Asian American health concerns such as Hepatitis B, which disproportionately affects Asian Americans (more information here). I was particularly impressed by this year's programming because it really spoke to the unique position we as medical students are in given today's changing health care climate.

The conference title was "Navigating Medicine's Next Frontier" and the session led by Dr. Sunny Ramchandani and Dr. Paul Song truly captured the great potential we have although the future of medicine is filled with more uncertainty than ever before. Medicine is no longer just about absorbing every bit of medical information printed in textbooks and journals, and then applying that to care for patients, but also about actively being engaged in our health care challenges and working to shape the future of our field.

The current medical school curriculum does not adequately prepare us for these health care challenges. How many medical schools have time set aside for communication skills, a systems approach to medicine, basics in health care economics, or even to discuss health reform? The field of medicine has evolved to encompass much more than just the individual interactions between doctors and patients. We as a profession need to build an awareness of the health system as a whole and develop skills to allow us to engage in this larger perspective--to better serve our patients.

In order to address this new demand on future physicians, the APAMSA national conference had several sessions designed to broaden our view of medicine. These included a session about applying business skills and concepts to improve our everyday interactions with patients, discussing provisions in the Patient Protection and Affordable Care Act that address health care disparities, implications of the new 80 hour work week, how to start a community clinic, mental health and disability awareness, the physician's role in policy and politics, medical errors and adverse events, and much more.

Moving forward from my experience at the conference, I'll refer to Dr. Sunny Ramchandani's advice (paraphrased): we need to break out of the mentality of mindlessly climbing the medical career ladder and take steps toward becoming more aware of the system that we are destined to be a part of. Health care and it's challenges are spiraling out of control and as future physicians, we have the opportunity to contribute to the discourse on finding solutions.

So, every once in a while, I'd recommend taking a quick glance at Kaiser Health News or another health news source to start developing an awareness of medicine and our future. We can always come back to that pathology textbook in 30 minutes.

Patient Centered Medical Home: An Anchor in the Ocean of Health Care?

The health care system is a ruthless and turbulent ocean. For many patients, even a regular visit to the doctor can be quite unforgiving. With patient safety, effectiveness, patient-centeredness, efficiency, timeliness, and equity concerns, health care visits can feel like navigating the ocean on a flimsy fishing boat. Now that we are transitioning into the phase of implementing and executing health reform, we must push patient-centeredness to the forefront of all our efforts to inform us on how to improve the quality of our health care system.

For example, the concept of the medical home that many say will transform health care into a more coordinated and comprehensive system isn’t just implementing electronic medical records, restructuring care teams that group physicians, nurses, physician assistants and other allied health workers together, redefining scheduling, or figuring out how to pay for these new services. The medical home needs to be a patient-centered medical home—one that actively engages the patient’s needs and concerns. Our system’s struggles with achieving patient-centered care is most evident in how health care providers deliver bad news to patients.

Kris (*all names changed to maintain privacy) is a multiple sclerosis (MS) patient and my longitudinal patient experience patient volunteer. Her experiences of reaching and finally receiving her diagnosis were far from ideal. Not only was her fishing boat almost completely destroyed by the big waves of the health care ocean, but she was also left alone to salvage the pieces. The first symptom she developed was a rapid decline in her vision. A busy nursing student at the time, this was the last thing she needed. She visited an optometrist to increase the prescription of her glasses--that’s all she thought she needed to alleviate this perturbance of age. But, Dr. Ortiz, the optometrist, was worried by what he saw. He explained his concerns of multiple sclerosis, encouraged her to see an ophthalmologist, and offered his kind words and a prayer.

This one good experience was soon overturned when Kris had to battle the sea monsters of scheduling and physicians simply not understanding the gravity of this impending diagnosis. Before Kris’s MS was even confirmed, one physician had told her that there was no rush for her to have an MRI because her diagnosis was not going to change.

The health care ocean is now littered with online resources that provide health care information, good and bad. Kris consumed all of this information and already had a clear picture of the worst case scenario before she was finally diagnosed. As Kris reflects, “You are going to destroy and completely change someone’s life with what you say, but instead of being just the wrecking ball, bring the rescue team with you.” Too often does our health care system see patients as floating vessels of transactions—bait it, catch it, and then throw it back into the ocean. A diagnosis is not the first step towards a pathway of reactive care services. How that diagnosis is reached is life-altering and how it is delivered today allows us to lose the tremendous potential the health care system has to truly help and support our patients.

What Kris needed on her odyssey to her diagnosis was a patient-centered medical home, a supportive health care team that acknowledged and respected her voice in the system. She did not need a physician to tell her to quit nursing school and she could have had more support than the kind words and encouragement of Dr. Ortiz. Our health care system failed to learn and understand Kris’s values and life goals. As a result, she spent years struggling to manage her MS. How could she take daily steroid injections when she was afraid of needles and the side effects were threatening to further derail her life? No one ever talked to her about her fears of becoming completely incapacitated or how the image of her first rotation at a nursing home with a patient with severe MS haunted her. Kris was a patient lost at sea. On her worst days, she would hold onto the knowledge of her ailing mother’s bag of potassium as a source of comfort and control. Where was the health care system while all of this was happening?

As a medical student, I often think about Kris’s story and what I would have done differently. On an individual level, I strive to have the positive impact that Dr. Ortiz had on Kris. He was her sole guiding oar and provided her with not only support, but also empowered Kris to take control of her diagnosis and life. Dr. Ortiz took the time to understand Kris and tailored his medical support to fit her needs. Today, Kris is not just an MS patient. She is a strong woman, a mother of two adopted children, and a NICU nurse, who happens to have MS. On a system level, we need to move away from being disparate objects floating in the ocean that patients can helplessly grab at, and move towards becoming the anchor and compass of their care—a patient centered medical home.

Until patients feel that they can interact with the health care system with the same level of comfort and ease, like on a luxury cruise liner, than we have a long way to go. As a first step, let’s allow our compassion to resurface and start our care with improvements in delivering bad news.

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.