Wednesday, November 23, 2011

Major professorial cringe moment!

This morning, I had the opportunity to address the first year medical student class about Clinical Practice Redesign and our urology office project.  (I told you about last year's visit with the first year students in this post.  By the way, one of last year's students did contact me and we've been working on a practice redesign project since the summer.)   The best part of the presentation (for me, anyway) is the students' participation.  I've presented our practice work to many different audiences over the last 4 years, and first year medical students reliably ask the most probing questions.  Perhaps it's because we haven't yet brainwashed them into thinking about things "our way".

I try to encourage their participation with regular pauses and prompts.  And with a little bribery (Tim Hortons gift cards for randomly selected hand-raisers).  This group of students were enthusiastic with their questions and comments.

About 30 minutes into the session, I realized that we had spent so much time with questions that I was not going to finish my presentation on time.  Two students had their hands up, and I indicated we had time for one question, and then I would move on.

At the end of the session, the course instructor - who had been distributing the gift cards on my behalf - had reserved one of the cards and announced that it was for the student who I had passed over when she raised her hand.

I mentally kicked myself.  I realized that I had "got through the material" and finished showing the slide show I had created, but it was at the cost of stepping on the contribution of the students - the contribution that I had explicitly encouraged at the beginning of my presentation.  These students wouldn't have been worse off if they missed hearing just one of the half-dozen practice redesign examples I brought along.  The questions they asked were insightful enough to spark a discussion that was more enlightening than the slides I had to show.

And, after telling them that it was essential to focus on the patient's needs when redesigning their work, I had been totally "provider-centric" by satisfying my own compulsion to slog through my slide deck.  This is the product I have, and I'm going to give it to you, no matter what you want!

That wasn't the worst part.

After the lecture, I went over to the student to apologize for cutting her off and to hear her question.  She asked how we could tell if our practice's improvement efforts could make us "too efficient".

She illustrated her point with a personal story.  She had waited many months for a consultation with a specialist.  At the visit, the doctor made a diagnosis and gave her a sheet of paper containing information about the condition.  The doctor told her that this would give her the information she needed to manage her problem, and sent her on her way.

The student's comment was that although this was a very efficient way to use the specialist's time, she felt somewhat short-changed by not having adequate opportunity to interact and ask questions.

Her insight is known as "balancing measures".  Whenever we make a change in a system with the intent of improving one aspect of it, there may be unanticipated and unwanted consequences in another area.  For example, if I want to reduce the wait time for cystoscopic bladder examinations, I may decide to increase our daily capacity by 50%.  We'll reduce our wait time, but the nursing staff who assist me in the exam room will be run ragged.  They may take more sick time, or even ask for a transfer.  We could check this balancing measure by doing a staff satisfaction survey before and after the system change.

I reminded the student that her unsatisfactory consultant visit was a reminder that, when implementing system changes, we should always consider our primary goal: Putting the patient first.

That's when the cringe hit me.

In my quest to zip efficiently through my presentation, I lost sight of the real reason I was there: Putting the students first and encouraging a sense of curiosity around different ways of delivering care.

Maybe I'll get it right next year.


  1. Don't kick yourself too hard! All of us at one point in time or another get caught in the "death by powerpoint" slog to ensure we cover all our slides. In fact, it has recently been shown that although presenters like powerpoint, often the people learning, learn better without the overfull slides of too much information. I'm sure everyone of those students felt grateful just to have the opportunity to discuss their comments at all, even if you cut them a little short to ensure they got information you felt important enough to include in your presentation. So, fix it for next year, but don't be too hard on yourself!

  2. You're very gracious, Anon. I got over the angst pretty quickly, but I hope the lesson will stick with me.

  3. Dr. Visvanathan,
    I'm a 4th year JURSI in Regina. You spoke at the Fall Formal a few years ago. I was actually thinking of the fantastic Urology group in Saskatoon just the other day. I've noticed a lot of red tape and politics when it comes to consults in the hospital.
    I'd like to be efficient and collegial in a good practice group as a future General Surgeon (fingers crossed for the CaRMS match).
    Maybe I could ask you questions and ask for advice in the future!
    Thanks for your blog!

  4. Hi Janice,

    Thanks for the comment. Planning now for your future practice is a wise move. You can contact me at kishorev50 if I can be of help.

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