Friday, April 15, 2016

Readmissions, quality and medical education

Finding the way through understanding quality improvement, and most importantly to hardwire the concepts and best practices can appear difficult and cumbersome to the novice. 

But it is not. 

Quality improvement is, as a matter of fact, a fascinating field where you can gain insight and perspective on your own performance and opportunities to improve. In addition, this has been the reason behind the expansion and growth of all the industrial and technological movement in the past century. 

From Taylor to Deming to the creation of the IHI, and now with well established quality health research institutions like Intermountain, Dartmouth, Harvard, etc. we now have formal training and education of a whole generation of health care scientist and providers. This has rapidly changed the culture, and all new trainees and students are intensely getting exposed to terminologies and practices that I barely had any during medical school and my first residency.

I had the honor an privilege to write this guest blog post  at the SHM Blog "The Hospital Leader". I had the opportunity of having direct mentorship from Dr. Brad Flansbaum who helped me tremendously to put the ideas together to obtain the final published piece. 

I hope you are able to read the guest post and more importantly that it yields into motivating curiosity to explore the fascinating world of quality improvement and patient safety. Remember, primum non nocere...

Friday, February 26, 2016

Musings of a Medical Educator - Reflections of the Philosophy of Teaching

I love medical education and teaching in general. Now that I've been a father for 2.5 years, I have appreciated the incredible beauty of curiosity, of the genuine motivation to know and learn - witnessing it on my son. This has been very refreshing - and has made me a better person and professional. 

I was appointed as an Associate Professor in July 2014. Yet I submit my application in 2012. I had now a recent conversation with a colleague about applying for academic promotion. He asked me for the statement I wrote. 

Reflecting on this - the request from my friend, and the everyday fascination I feel from seeing my son growing and learning, I decided to delve into my archives and search for the statement I wrote for my academic advancement regarding my philosophy of teaching. I wrote and signed in August, 2012. Here it is and I'm happy to share:

PHILOSOPHY OF TEACHING / PERSONAL DEVELOPMENT

As an adult learner myself, involved in the complex world of medical education, I have a strong awareness of the different ways of learning that people use.  People use the senses in different ways: some individuals require a persistent memorization effort and may appear bright in terms of factual information recall yet may be unable to develop a critical and analytical perspective of things. Others may have a more practical way of learning by solving problems and putting analysis and reflection into practice yet may not have the ability to retain factual data.  Yet others may need to visually appreciate a concept or idea in order to create a visuospatial relationship with previous concepts.  And finally, some individuals achieve better understanding by listening on a repetitive basis.

The most important consideration is that the educator be aware of the different methods of learning people have and is creative enough to be able to deliver the information or ideas in an efficient way to each individual learner. Creating an environment that fosters learning is essential so that the learner feels motivated – this is done by matching the teaching technique with the learner’s own best learning style.

First of all, I’m a clinician – a hospitalist – I work in the inpatient wards, where seeing acute patients is the norm. Patients are very sick, families are distressed, and most health-caregivers are under significant emotional and professional pressure. My teaching scenario is the patient bedside. I need to teach medical students, residents and fellows. Each of them has a different level of training in addition to their own learning style.  Although the most experienced learners have had more exposure, may not necessarily have more plasticity toward different learning methodologies.

My responsibility as an educator is to ensure all my trainees feel motivated, inspired, and committed to provide excellent patient care. They must come every morning with a great desire to be here. This is done by fostering a team spirit – we all together as a team see all the patients, and the patients belong to all of us.  We all know about each patient, we all discuss about and learn from each individual patient, we all enjoy taking care of patients. The second thing I do is to have the learners acknowledge their own knowledge gap – they shall not feel embarrassed about it, but rather feel a compelling need to close the gap – I make them read about it and give the team a concise and brief presentation usually accompanied by a handout and /or a journal article. This allows me to understand: 1) the ability of the learner to review and synthesize the literature, 2) the ability to frame and write his/her ideas in the handout, 3) the ability to orally deliver a presentation (clarity, structure, length, sequence, etc.), 4) the creativity involved in putting ideas together (presenting the information in a test format, in a clinical vignette format, in a slide presentation, etc.), 5) the interaction with the other learners answering their questions and delivering the information.

My particular method is to teach while rounding and seeing patients – make them observe carefully the patient at the bedside, and first of all, understand that the patient is in a delicate situation and maybe be suffering – have them empathize and be compassionate; know to talk to the patient, provide comfort and hope. This is perhaps the single best teaching we can do at the bedside: good bedside manners. Everything else follows naturally.  The next thing while providing comfort is to enhance the awareness of clinical signs and symptoms: have the trainees to use their senses and enhance their observation and auscultatory skills; then we discuss a differential diagnosis. I put in play the Bayesian approach using pre-test probability of disease and we define a diagnostic and therapeutic approach based on the likelihood of a given pathology.  I use the electronic health record as a teaching tool as well.  We review the bloodwork and analyze the abnormalities with immediate “on the fly” teaching, associating given laboratory values with the patient’s clinical diagnosis or physiologic condition.  This allows the visual learner to make a visuospatial relationship; my explanation allows the auditory learner to understand the process; the whole clinical experience (seeing the patient, reviewing the labwork and imaging, discussing the case) allows the analytical learner to understand the process of disease. In addition, we have the fortune of being in a technology rich environment – this allows me to do literature searches in PubMed at the bedside and look at the literature in the point of care to help facilitate the medical decision making. I show them how to download podcasts especially for the auditory learners.

Once my trainees have written their clinical documentation, another opportunity arises to help them further reflect into the process of disease as well as medical decision making by reviewing their “Assessment and Plans” and discussing with them about the reason for adjusting or changing it allows them to obtain further feedback and reinforce previously taught concepts or as well identify new teaching opportunities.

In addition, at the end of the day, it is important for them to realize how much they need to know and how much they have already learned but perhaps not been quite aware of it. I send them links to articles based on our patient’s diagnosis, diagnostic pathway or treatment, then ask them to choose one article each to present later on the week.  I send these emails on a routine basis – almost daily throughout the rotation – to foster the need to read and appraise the literature in order to provide the best patient care; in addition motivates them to search for the literature on their own sharing their readings with the rest of the team. The advantage of this is that at the end of the day, the learners not only get “live” teaching during rounds, and close their knowledge gaps on their own, but they learn to become self sufficient to search the literature and start building their core of knowledge.

My main satisfaction comes at the end of a rotation when I witness an impressive learning curve, as well as an enhanced level of comfort and ease for medical decision making. My patients express satisfaction with the degree of thoroughness my learners put in every morning during rounds for both assessing the patients as well as explaining to them the results of the diagnostic pathways. I enjoy seeing the degree of satisfaction that my learners show when we are able to successfully discharge a patient who came very ill and is able to look into the future with hope, renewed strengths and desire for recovery. Most importantly I enjoy when my learners actively demonstrate that critical directive, primum, non nocere.


M.A.
Cleveland, OH, August 2012.

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