Check a box, Tame a Line

A couple of weeks ago, I met some people who have the power to change Canadian healthcare. And, they can do it by June 2012.

There wasn’t a deputy minister among them.

They were the University of Saskatchewan College of Medicine Class of 2014. That’s right – first-year medical students! Skeptical? I think they were, too.

I had the chance to participate in the first-year students’ “Civic Professionalism and Physician Leadership” course. The course exposes students to aspects of healthcare beyond the traditional, disease-oriented clinical curriculum. I was addressing the quality improvement theme, specifically Clinical Practice Redesign.

I had planned just to tell the story of Saskatoon Urology Associates’ Advanced Access/Clinical Practice Redesign (CPR) journey. Essentially, the presentation is a distillation of this blog. The story starts with the reason why we started the project: Frustration over the wait times our patients experienced. Then, I talk about some of our most successful initiatives: pooled referrals, shaping demand/referrals, and reducing recalls.

Usually, I’m giving this presentation to a group of physicians who have recognized an access problem in their practices, as evidenced by long wait times and frustrated patients. They are already motivated to seek solutions, and the discussion centres around how to implement CPR in their practices.

However, medical students in their first few months of training are years away from the challenges of clinical practice. Their perspective is informed by their own or their family and friends’ experiences with health care, media reports, and opinions from authorities. The message they hear: Long wait times are caused by inadequate resources. The solution: More resources. More doctors. More MRI machines. More OR time.

But, our successes with CPR indicate otherwise. There are plenty of opportunities to improve access, quality and value for patients by rethinking how we use current resources. That’s the message I wanted to get across to the students.

But, after recently reading Check a box, Save a Life, I thought that my presentation might be an opportunity to do more than just tell our story. I thought that these students had the potential to drive change, rather than just bear witness to it.

Check a box, Save a Life tells the story of a international group of medical students who launched an initiative to lead implementation of surgical checklists at their respective institutions. After attending the release of the safety checklist at an IHI conference, the core group used their existing organizations and social networks to promote uptake of the checklist. Some students actually participated in, or lead, the use of the checklist in the operating room.

They were sparked by their realization that, even as medical students, they had the power to effect change that would have an immediate and significant impact on patient care. What an amazing story of leadership and activism!

That story convinced me that the U of S first-year medical school class could do the same. Actually… they could do more. While surgical safety checklists promise the more dramatic result of saved lives, implementing CPR nationally could improve access to care for many more patients, improve work-life balance for physicians, and ensure sound stewardship of our healthcare system’s resources.

Whew! That sounds pretty daunting. But once you hear what these students bring to the table, you’ll agree with me that they’re up to this challenge.

First of all, they get it. They understand CPR, and the problems it tries to address. I don’t mean that they listened to what I had to say and understood the techniques of pooling referrals and shaping demand. Certainly they understood the technical part, but that’s the easy stuff. I mean that, from the questions they asked, it was obvious that they understood the deeper issues. They wondered about how reducing specialist recall rates by returning care to family physicians would affect the FP’s workload. They asked whether there was any resistance to introducing CPR into our practice, and how we managed that. They realized that the current fee-for-service payment system was a disincentive to some CPR changes.

These questions showed me an impressive degree of analysis from people completely lacking in clinical exposure. And that’s the next thing they have going for them.

They have no exposure to medical practice. We haven’t brainwashed them yet. Their minds and eyes are open. I’ve posted before about a junior medical student who challenged me to reconsider one of my office practices. An elderly man drove 3 hours for an appointment to discuss a test result. The student asked why that discussion couldn’t have been done over the phone. A more seasoned student would likely already have been indoctrinated into our system to the extent that the visit wouldn’t have raised an eyebrow. They would already know that that’s the way we do business. But the new ones spot our foibles. (Classic: The Emperor’s New Clothes!)

Next, they have powerful social networks. They attend clinical rotations in groups of up to 5 people. That’s a great opportunity to share their impressions of what they’ve seen, and collaborate on solutions. I spend most of my day doing my work the same way I’ve done it for years, without comparing notes with colleagues on how they run their office practice. On the occasions when we do compare our practices, the results have been startling. When we measured our internal demand/recall rates, we were surprised to find the degree of variation in our practices. Once we recognized the variation, and began to explore the reasons behind it, as well as possible solutions, our recall rates dropped. Two (or five) heads are better than one.

Plus, electronic social networks expand that interaction far beyond the physical confines of the U of S. (One thousand heads are better than five!)

Finally, medical students are everywhere. Their rotations take them from the operating room to rural primary care clinics. And they’re observers. They rarely have clinical duties, so they are free to be flies on the wall. Once they understand they type of problems CPR tries to fix, they will see examples of those problems everywhere.

And, as their questions during my presentation convinced me, they will be able to create solutions to the problems they identify.

I would love to be part of this initiative, but as I’ll explain below, it’s important that I stay out of it. But, that doesn’t stop me from giving my version of how I see it developing!

Imagine this: While on their clinical rotations, students from across Canada apply the insights they have gained from CPR advisors to identify potential areas for improvements for individual clinicians. They collect their observations in an online database. Via social networks, they brainstorm solutions. The next students who spend time with that particular clinician ask to try out the solution, and then submit the results to the online community for refinement.

They would harness the curiosity, creativity and energy of hundreds of their colleagues for the benefit of thousands of patients. And for the gratitude of hundreds of clinicians whose practices would be made more efficient and effective.

A project like this, if conceived at the government or national medical association level, would take years to produce results. The Class of 2014 can produce tangible results by June 2012. Their first significant clinical rotations start in their 2nd year – the fall of 2011. By using the rest of this academic year to organize, develop a network, and recruit mentors, the students would be ready to collect data by the time their first rotations start. Small tests of change could start almost immediately.


But, if this initiative is to succeed (in whatever form it eventually takes), it must be conceived, driven and executed by students. They should struggle with recruiting participants, fret about how to engage physicians in the effort, and worry about keeping up their enthusiasm once the initial excitement of a new project dies down. They must fail, and learn from their failure. Their achievements will be even sweeter for all of their sweat.

On the surface, this project is about implementing Clinical Practice Redesign across the country. That will be the easy part. The real work in this project will be harder, but will be much more valuable for the students. The real work is in becoming leaders.

And you can’t do that in a classroom.

Come on, Class of 2014. Show us what you’ve got!