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.
Showing posts with label medical students. Show all posts
Showing posts with label medical students. Show all posts
Wednesday, November 23, 2011
Sunday, December 5, 2010
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!
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!
Sunday, October 24, 2010
Canadian Patient Safety Week - Welcoming our second-degree guests
Canadian Patient Safety Week is next week, but its theme – Ask.Listen.Talk - was on my mind a lot this week. And it made me think about a party we held last New Year’s Day.
We invited several friends over for brunch. At the last minute, one family called and said they wouldn’t be able to come. Weather conditions had prevented their visiting relatives from returning home, and they didn’t want to leave them alone. Of course, they were welcome to come to the party, so we set a few extra places at the table.
If you’ve ever been a “second-degree guest”, that is, accompanying someone who was invited by the host, you know it can be awkward. You may not know the host. You would rather suffer in silence rather than put the host out by asking for something. You don’t feel comfortable.
We recognized that our second-degree guests felt that way. All the other guests had been in our home previously and knew their way around. They felt comfortable with helping themselves to cutlery or serving themselves drinks. They made themselves at home, and we invited our new friends to do the same.
But that wasn’t enough.
If I’m visiting someone’s home for the first time, and am told to make myself at home, I won’t. Because I don’t know what “making myself at home” means in that home. Can I poke through the fridge looking for leftovers? Can I flick on the TV and watch the game? I don’t know what their micro-culture accepts, and so I will err on the side of sitting quietly on the couch.
Recognizing that our second-degree guests felt the same way, we did what any host would do, and made sure to pay extra attention to their needs. Would you like another drink? What do your kids like to eat? Like any host would, we wanted them to feel welcome and comfortable.
CPSW’s theme - “Ask.Listen.Talk.” - suggests that communication between patients/families and caregivers, and among caregivers, improves patient safety. No argument from me. But I think we need to consider how we implement Ask.Listen.Talk. in our practices.
Patients and their families are like second-degree guests visiting the healthcare system. Everything from our facilities to the language we use is unfamiliar and intimidating to them. While healthcare workers bustle about around them, visitors worry that even a wrong turn in a hallway may take them into an unauthorized area. They feel awkward.
And then, next week, we want them to “Ask.Listen.Talk.” Maybe we’ll put up some posters, or hand out a brochure. That will be the equivalent of saying “Make yourself at home!” Patients/families won’t know what is acceptable in the healthcare culture. Is it OK to ask the doctor whether or not she washed her hands before examining my mother? Will she be upset with me for asking? I don’t take a red pill at home, but I’m sure it’s OK here at the hospital, because the nurse must have checked it before she gave it to me. She looks too busy for me to bother her.
It’s nowhere near enough just to publicize our belief that communication improves patient safety. We need to actively seek out patient and family comments and participation, like we would for second-degree guests in our home. And when those comments arrive, we need to receive them positively and consistently. A sour look in response to a voiced concern speaks much more loudly than an Ask.Listen.Talk pamphlet on a bedside table.
Last week, I spent some time with a medical student, and we observed what we considered to be a breach of a patient’s dignity. We talked about it after we left that care area, and I asked him how he would address that with the caregiver responsible. He laughed. I laughed too. We both realized that I was being absurd. It would be a rare medical student who would comment on a breach of patient privacy, dignity or safety. At best, they would be ignored. At worse, they would be excoriated for their impertinence. How dare you…
He felt – undoubtedly correctly – that the caregiver would not accept such a comment from someone who was without standing in their culture. But we did explore possible approaches. I thought that he would need to test out – role-play – some options with like-minded colleagues before “going live”. Perhaps the old just-trying-to-be-helpful gambit: Would you like me to pull the curtain around the patient’s bed while you examine him?
I used a similar approach with our second-degree brunch guests. I wanted my 10-year-old son to find out if our guests needed anything, but I realized that giving him that vague instruction would be useless. It wasn’t that he didn’t want to help, or that he is unfriendly. It’s just that it was a new situation for him, and he felt uncomfortable. He needed some coaching and a specific script.
“Ask them ‘May I get you something to drink?’”, I suggested.
“’May I get you something to drink?’”, he repeated.
And off he went.
Coaching and scripting to encourage dialogue around patient safety will help us demonstrate to patients and families that we are serious about engaging them as active participants in safe care.
The day after my student and I had discussed impediments to his commenting on the breach of dignity, he joined me in the operating room. As I introduced him to the personnel in the room, the anaesthetist said this to him: If you see anything going on in here that you think is unsafe, please speak up. We value your eyes on what we’re doing.
That was a big step in the right direction.
Friday, March 6, 2009
Awkward
The problem with first-year medical students is that they haven’t yet learned which questions not to ask.
Two weeks ago, I had a student spending the afternoon with me at my office. We met a patient and his wife, and talked with them about the results of a CT scan he had done earlier in the day. After the visit, the student asked me "Why did he have to come to your office today?" Her concern was that the man had difficulty walking and had recently moved into a care home an hour away from Saskatoon. It was a significant effort for them to travel, both to get to Saskatoon and then within the city.
My staff is diligent about scheduling CT scans (and other tests) on the same day as an office visit, so I can review the results with the patient. I pointed out to my student that this saves people an extra trip into town.
Then she got really impudent.
Two weeks ago, I had a student spending the afternoon with me at my office. We met a patient and his wife, and talked with them about the results of a CT scan he had done earlier in the day. After the visit, the student asked me "Why did he have to come to your office today?" Her concern was that the man had difficulty walking and had recently moved into a care home an hour away from Saskatoon. It was a significant effort for them to travel, both to get to Saskatoon and then within the city.
My staff is diligent about scheduling CT scans (and other tests) on the same day as an office visit, so I can review the results with the patient. I pointed out to my student that this saves people an extra trip into town.
Then she got really impudent.
Subscribe to:
Posts (Atom)
Posts
