From the Editor – AM Rounds http://academicmedicineblog.org Beyond the pages of Academic Medicine, journal of the AAMC Thu, 22 Jun 2017 09:40:49 +0000 en-US hourly 1 https://wordpress.org/?v=4.4.10 Beyond Our Walls http://academicmedicineblog.org/beyond-our-walls/ Tue, 14 Mar 2017 14:52:16 +0000 http://academicmedicineblog.org/?p=3313 AM Rounds Slider Master-07

Editor’s Note: This blog post complements a collection of articles in our March issue that explores physicians’ and trainees’ understanding of how social structures and structural competency influence health. Check back throughout the month for additional perspectives on this topic.

Within our hospitals and clinics, it is easy to focus on the crowds of patients, the remarkable new technology, and the numerous resources that have to come together to care for patients with increasingly complex health care needs. We assemble teams to manage the most challenging problems–the multisystem trauma patient, the patient with sepsis and an organ transplant, the patient who is pregnant and the premature infant who may be born. We train our students to understand the pathophysiology of these conditions and to provide the lifesaving care to alter the trajectory of these illnesses or injuries. And we make a difference in many cases.

What we don’t do well is understand why the trauma patient was injured, why the woman in early labor did not receive prenatal care, or how the organ failure might have been prevented. These problems are beyond our walls, beyond our control. In many cases, there are structural conditions within the environment or the patient’s life experience that have contributed to these medical issues. In the March issue, Hansen and Metzl introduce several articles related to the concept of structural competency and explain its importance for medical education. Structural competency addresses the social conditions and institutions that affect health and lead to inequalities in health and health care. They encourage educational experiences for our students to deepen their understanding of these structural issues and to teach them how to overcome these structural barriers to health and health care.

This work reminds me of a recent patient who came to my hospital with a rash. She lived in her car and had no access to running water. She lived in her car because she had lost her job, she had no family, and the resources for people who are homeless in her town were inadequate. She also felt that a life in shelters and on the streets was dangerous, and she described past experiences with assaults and arrests. She felt safer living in her car. As the intern and I performed our history and physical, we discovered that the woman had severe hypertension, which wasn’t being treated and was already causing renal damage. While our medical education system might emphasize the differential diagnosis of the rash and the pathophysiology of the hypertension and renal insufficiency–making her “an interesting learning case”–it likely wouldn’t teach how to address the homelessness that was complicating her health problems. Providers have access to medications to treat rashes and hypertension, but they feel powerless to change the social structures at the root of her illness. We did try to connect our patient to social services, but the barriers were substantial.

In his blog post, Martin describes his personal experience as someone living on the street attempting to navigate the health care system and how difficult and frustrating that can be. I worry that his experience is not an isolated case. While the expansion of Medicaid under the Affordable Care Act has increased access to health insurance for people who are homeless in many states, proposed legislative changes could reverse these improvements.

While it is sometimes frightening to venture beyond our walls as physicians, we must do so to fully understand the health problems of our communities. Training in structural competency and in physician advocacy, as Geiger encourages in the March issue, could provide our trainees with the understanding and compassion for patients like Martin and help us see beyond our walls to better the health of all.

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Faculty Procedural Supervision and Expertise: An Endangered Species http://academicmedicineblog.org/faculty-procedural-supervision-and-expertise-an-endangered-species/ http://academicmedicineblog.org/faculty-procedural-supervision-and-expertise-an-endangered-species/#comments Tue, 06 Sep 2016 11:00:16 +0000 http://academicmedicineblog.org/?p=3133 AM Rounds Slider Master-07

Editor’s Note: This post is one of two pieces on the topic of procedural competency. Read the other piece here.

A few days ago I was working with a new resident and she came to me for help with a procedure. She had a patient with a severe headache and fever and she wanted to do a spinal tap. We had previously discussed the differential diagnosis and the possibility of meningitis. Now it was clear the resident was not at all confident in her ability to do the procedure and that I might have to do it. I took a deep breath. Although there had been a time when I was confident about doing a spinal tap, that was long ago. I had not done one myself in over a year though I had supervised a few. I watched as the resident prepared her supplies, positioned the patient, anesthetized and cleaned the area, and inserted her needle. Unfortunately she was not able to get any spinal fluid and after two attempts, she asked if I could try. I put on sterile gloves with some trepidation and explained to the patient that I would be taking over the procedure. “My head hurts,” she said. “Please help me.”

“Yes,” I said. “I understand that this has been the most severe headache you have ever had and that the CT scan you received was normal. Now we have to make sure you don’t have an infection,” I said. “That is why you need the spinal tap.”

“Will you be able to do it?” she said. “I can’t go through this another time.”

“I have done many of these,” I said avoiding the implication of her question. “Let me feel your back.” I palpated her lumbar vertebrae and the spaces in between them where I would put my needle. Everything felt normal. “I think I should be able to get this,” I said hopefully. I looked at the needle in the tray and it did not seem that the equipment had changed from the last time I had done the procedure. I proceeded to follow all the steps I still remembered and fortunately was successful with the spinal tap, and the clear fluid flowed out into our collecting tubes. The resident seemed both relieved and embarrassed that she had not been able to do what I had apparently done easily. As we let the patient know that the procedure was over, I gave a sigh of relief because I realized what may have looked easy was probably partly a stroke of good fortune considering how infrequently I had done this procedure over the past year. I began to think about my competence to supervise and perform other procedures.

Increasingly over the past year, I had noticed myself becoming uneasy as a procedure loomed. While success on most procedures was not a question of life of death, in some cases it was, such as for patients needing intubation. If we paralyzed a patient and the resident could not successfully complete the procedure, I might be thrust into the spotlight and have twenty or thirty seconds to visualize the key structures of the throat and neck and manipulate a tube into the trachea. It was something I had done many times but the equipment had been changing and my own experience was diminishing as more and more of my time was taken up with administrative meetings, research, and educational activities, and the residents got to perform most of the procedures.

In a recent Academic Medicine article, Vaisman and Cram discuss the important question of faculty clinical abilities to supervise trainees. They describe the case of a faculty member from internal medicine supervising a thoracentesis under ultrasound guidance. This attending internist was not trained in the use of ultrasound and was in the difficult position of supervising a resident who was more familiar with the equipment and procedure than she was. They raised the question about what the attending should do in such a circumstance and the risks to patient safety and to the relationship between resident and faculty member in case of failure. I suspect the situation is far more common than we might like to believe as many faculty who used to work in the hospital have been replaced with hospitalists. In addition, for many of our procedures the techniques and equipment have changed over the past five to ten years. Ultrasound guidance for many procedures allows for direct visualization of structures that used be reached through “blind” needle placements. While residents are getting the training in ultrasound use, faculty either have not gotten trained or have not had enough experience to maintain competence.

Vaisman and Cram suggest that we need to have conversations about faculty clinical supervision for procedures and find ways to address it—either through retraining of faculty or identification of other faculty to assist with supervision. I agree. I suspect that with increasing specialization it will be very difficult for generalist faculty in many fields to maintain expertise. There may need to be a designated proceduralist—a hospitalist, critical care specialist, or other designated expert in the procedure available to teaching hospitals and clinics to supervise resident procedures, provide feedback, and intervene themselves when necessary.

I applaud Vaisman and Cram for bringing this elephant out from under the table and encouraging frank discussion about how to ensure the safety of our patients in academic institutions with appropriate supervision by faculty who have current experience and expertise to assist and educate a resident particularly when the procedure does not go smoothly. We cannot always depend upon good fortune.

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Why Patient Voices Are Important http://academicmedicineblog.org/why-patient-voices-are-important/ Tue, 22 Mar 2016 18:17:14 +0000 http://academicmedicineblog.org/?p=2987 AM Rounds Slider Master-07

Editor’s Note: Be sure to check out the collection of articles in the March issue and our new blog content for more on the patient voice in medicine.

I used to live on a short dirt road where everyone knew everyone else. We recognized each others’ children and would often share childcare responsibilities. A part of our extended neighborhood family for me included occasional medical consultations. I would hear about a neighbor’s call to his doctor to be seen for a cough and fever and the appointment that could not be scheduled for a week. I would bring my stethoscope over to the neighbor’s house to see if he really could wait for a week. And when it became clear that the fever and cough were most likely from pneumonia, I would either order antibiotics or send the neighbor to an urgent care center or emergency department. I would hear about good, bad, and strange encounters with the medical system–odd advice over the telephone, long appointment delays, doctors who did not communicate with each other. Over time it seemed that every one of my neighbors had encountered the medical system in one way or another. One had a fall from a roof, another a basketball injury, a third had a case of hepatitis, a fourth cardiac arrest requiring CPR. Then there were the less serious but more chronic problems–back pain, headaches, allergic rhinitis, rashes, and mental illness. While my physician skills were valuable in helping my neighbors sort out information that was often confusing, my understanding of how to navigate the health care system was probably more important–which doctor to call for what problem, how to explain a problem over the phone, which hospital was best for head injuries, which doctor not to see for a particular problem. While I did not realize it at the time, I was hearing the patient voices that I never heard at the hospital where I worked. Somehow the hospital blunted the nuanced sounds of the patient voices and, by the time I heard them, they fit neatly into my preconceived notions of what a patient history should sound like. I based what I taught in my medical school courses on the stories I heard in the hospital rooms and corridors. It was only later upon reflection that I realized how much I had been missing, how much more patients could have told me. I think the same can be true of our medical education journals and what we publish.

In our March issue, we provide two patient perspectives. One is by Jeannine English, president of AARP, and the second is by Bev Johnson, president and CEO of the Institute for Patient- and Family-Centered Care. I also interviewed Donna Cryer, a woman who had a liver transplant and who is president and CEO of the Global Liver Institute, and a blog post from Martina Rosenberg, a biochemistry faculty member who was recently a patient. I felt that it was important that we hear directly from patients because their experience often contradicts what we believe is happening in our academic health centers. While we teach about core competencies, such as communications skills and professionalism, our patients, particularly those with multiple chronic diseases, often experience a health care system in which specialists do not talk to each other and no one seems to be in charge. This leaves patients who are already burdened with serious illness to make sure that their doctors understand the possible side effects of the treatments they are advocating and communicate with each other to plan a course of action.

The voices of our patients contain a mix of gratitude, concern, and advice for improvement, and we must listen to them. We all went into medicine to help people, and perhaps we assumed that we knew what that meant. But our patients want to participate in the decisions that will affect them, and they want to help us help them. The only way we can do that is if we are open to hearing their voices and learning from their stories. I hope these patient stories will enrich our understanding of the goals of medical education, and I look forward to reading your patient stories in the comments below.

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Good to Great in Graduate Medical Education http://academicmedicineblog.org/good-to-great-in-graduate-medical-education/ http://academicmedicineblog.org/good-to-great-in-graduate-medical-education/#comments Thu, 03 Sep 2015 18:26:06 +0000 http://academicmedicineblog.org/?p=2782 AM Rounds Slider Master-07

My last evening shift was an example of all that is right with our current graduate medical education (GME) system. In spite of spending a Friday night in the hospital, the residents all seemed enthusiastic, engaged, caring, and collaborative. The surgeons treated a prisoner with a pneumothorax as if he were a VIP donor to the hospital, and the internal medicine residents whisked a patient with hyperkalemia to the ICU for aggressive treatment and monitoring without complaint. A pharmacist helped the nurses and the emergency medicine residents speed the preparation of the antidote for a rattlesnake bite. The attending trauma surgeon gave an impromptu lecture about the treatment of burns to assembled medical students, EMT students, and interns after two burn victims arrived. All the patients received outstanding care, the residents were learning and teaching, and the interdisciplinary and interprofessional teams were working well together. It was one of those days when I leave the emergency department thinking that we had been able to turn patients’ bad luck into good luck, that good deeds could overcome bad, and that our future doctors would go out into the world better trained and prepared for what might come their way. And I could take joy in my participation.

But it does not always go like that. There are days when everyone seems exhausted, the computers are not working, the patients are complaining about the long waits, and in the midst of it all, a catastrophe occurs–a wrong medication is given, a patient stops breathing after a procedure, an innocent child arrives by ambulance after a motor vehicle crash and cannot be saved. On those days, we wonder what is wrong with medicine, GME, or the world in general.

Fortunately there are far more days when things go well than when they don’t. But that is not to say we cannot strive to improve our health care system through better GME. The entire September issue of Academic Medicine is dedicated to GME. Our hope is that these articles will stimulate our thinking about how to improve the GME system and create a strong and stable infrastructure for the future. I have provided a summary of the key issues and articles in my editorial and described my vision of how to make every day a good one.¹ In this issue, our authors ask how training will need to change to prepare our graduates for new care delivery systems in which teams will augment the skills of individual physicians, and how GME will be situated along the continuum of lifelong growth and development. Certain questions will continue to be debated–how many and what kinds of doctors will we need in the future, how should we finance GME, what skills will the future workforce need, and how will we know that they possess the needed knowledge and skills. In some cases, the articles in this issue suggest answers, and in others they describe the complexity of the questions and possible ways to find the answers in the future.

I hope the presentation of ideas for improving GME in our September issue will influence the education of our future clinicians, just as I attempt to do so at a personal level with individual residents caring for individual patients. For each of us, our personal experience informs, validates, and provides the inspiration for finding and implementing the best solutions possible to the questions facing our GME system. I invite a vigorous discussion about the articles published in the September issue as well as the current proposals for GME reform presented here, in letters to the editor, and in new submissions to Academic Medicine, so that we can go from good to great in GME.

1.Sklar DP. A vision for graduate medical education. Acad Med.2015;90:1177-1180.

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The Most Influential Medical Education Articles http://academicmedicineblog.org/the-most-influential-medical-education-articles/ http://academicmedicineblog.org/the-most-influential-medical-education-articles/#comments Tue, 16 Jun 2015 17:00:21 +0000 http://academicmedicineblog.org/?p=2691 AM Rounds Slider Master-07

When we review and ultimately select articles for publication in Academic Medicine, we always hope that they will influence how we think about an important issue and perhaps improve our thinking in a useful and meaningful way. One of the ways that we gauge the value of our articles is by the number of citations each receives in the medical literature. So, I was very interested in the review by Azer (1) that identifies the top-cited articles on topics related to medical education published since 1979. Azer looked both at articles published in medical education journals and at medical education articles published in general or specialty journals. While I was gratified to see how often Academic Medicine was the home for these top-cited articles, I was a bit surprised to see how many of the articles were reviews, opinions, or concept papers that did not contain original research. Perhaps this indicates the importance of such articles that integrate research from many sources in a way that helps to answer questions of importance to our communities. For example, the most-cited article published in the medical education literature, by Albanese and Mitchell (2), was a comparison of the features of problem-based learning and traditional medical education strategies, using a literature review. Problem-based learning was also the topic of other top-cited articles in medical education journals. Also in the top ten most-cited articles were two articles on the nature of expertise in medicine, one by Schmidt et al (3) and the other by Ericsson (4), which discuss the literature on expertise from a variety of areas and apply them to medicine. A third topic represented in the top ten most-cited articles was clinical competence and assessment (see the conceptual articles by Harden and Gleeson (5) and by Miller (6)). Other well represented topics were professionalism, simulation, and communications.

What can we learn from Azer’s article? First of all, I believe that the list of top-cited articles suggests that medical education scholarship draws on knowledge developed in a variety of social science areas, such as psychology, sociology, and philosophy, as well as the basic sciences, and that articles that can bridge these areas of knowledge can significantly influence medical education scholarship. Second, the area of cognition, expertise, and decision making has been a fertile area for investigation as it can influence curriculum design related to how students gain the skills in diagnostic decision making that they need to move from a novice to an expert. Of note, among Academic Medicine‘s top-cited articles in 2014 were two on diagnostic decision making processes, one by Norman et al (7) and another by Croskerry et al (8). Based on the central role of cognition and decision making in medical education, I would expect this area to continue to be well represented among top-cited articles. Similarly, assessment of competence will likely maintain its prominent place among our top-cited articles, particularly as outcomes-based medical education gains steam. An area that I would expect to show continued growth is simulation in medical education because of the technological advances in simulation models and the need to ensure patient safety in training for procedural competence.

I believe that the article by Azer can be a useful starting point for anyone wishing to develop a broad familiarity with the most influential articles in medical education published in the past 35 years. It also provides an opportunity to identify those areas with high potential for future scholarship to address current gaps in knowledge. We should congratulate those authors who made these important contributions and encourage our future scholars to learn from their success.

 

References

  1. Azer SA.The top-cited articles in medical education: A bibliometirc analysis. Acad Med.2015;90.
  2. Albanese MA, Mitchell S. Problem-based learning: A review of literature on its outcomes and implementation issues. Acad Med. 1993;68:52-81.
  3. Schmidt HG, Norman GR, Boshuizen HP. A cognitive perspective on medical expertise: Theory and implication. Acad Med. 1990;65:611-621.
  4. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79:S70-S81.
  5. Harden RM, Gleeson FA. Assessment of clinical competence using an objective structured clinical examination (OSCE). Med Educ. 1979;13:41-54.
  6. Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990;65:S63-S67.
  7. Norman G, Sherbino J, Dore K, et al. The etiology of diagnostic errors: A controlled trial of system 1 versus system 2 reasoning. Acad Med. 2014;89:277-284.
  8. Croskerry P, Petrie DA, Reilly JB, Tait G. Deciding about fast and slow decisions. Acad Med. 2014;89:197-200.
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Should I Stay or Should I Go? Retirement, Identity, and the Workforce Implications http://academicmedicineblog.org/should-i-stay-or-should-i-go-retirement-identity-and-the-workforce-implications/ http://academicmedicineblog.org/should-i-stay-or-should-i-go-retirement-identity-and-the-workforce-implications/#comments Thu, 16 Apr 2015 10:41:10 +0000 http://academicmedicineblog.org/?p=2542 AM Rounds Slider Master-07

On March 3, 2015, the Association of American Medical Colleges released new physician workforce projections. To me, one of the most striking findings was the potential impact of changes in retirement on the projections. Of the 767,200 physicians under the age of 75 currently in active practice who completed graduate medical education, 10% were between 65 and 75 and 26% were between 55 and 64. Physicians in these age groups have a high likelihood of retirement within the next ten years. In the projections, a delay in the average age of retirement by two years would result in an additional 27,900 physicians in the overall supply. However, should physicians retire two years earlier, the number of physicians would decrease by 33,000. Considering that the projections are for a workforce deficit of 46,100 to 90,400 physicians, the impact of changes in retirement could be extremely important.

When I recently discussed retirement decisions with some senior colleagues, I heard a mix of arguments–some pushing toward retirement and others pulling back toward continued practice. The arguments for retiring included anxiety and unhappiness with the current health care delivery system, frustrations with the electronic medical record, reductions in income, and the physical and mental problems that affect the ability to practice. I also heard many positive reasons for retirement, such as the desire to explore other interests, investigate new work opportunities, and the chance to slow down, enjoy family, and participate in community activities. Those who wanted to continue in practice feared what might happen to their various projects, patient panels, or students when they retired; some also had financial concerns. Some of these colleagues had never developed outside interests and did not know what they would do with their time. In their recently published research report, which will appear in the June issue, Onyura et al present findings from focus group interviews with late-career academic physicians who were contemplating retirement. Their study helps to move discussions about retirement from the realm of anecdote to a more scholarly level. They note that, for late-career physicians, their occupational identity as physicians was central to their overall personal identity, and that retirement represented a threat to that identity. In addition, these physicians experienced an institutional attitude of indifference to aging within their work environment with a lack of institutional structures to support aging physicians, leaving them to cope with the transitions to a different set of activities on their own.

With the clear need to address a future physician workforce deficit, we have an opportunity to enlist our late-career physicians to be part of the workforce solution through the creation of incentives that could keep them practicing two years beyond the traditional retirement age. The work of Onyura et al demonstrates that physicians are deeply dedicated to their occupational identity and would probably be responsive to opportunities to maintain it. We should consider developing options for part-time practice, research mentorship, and teaching that would be attractive to our senior academic physicians if some of the current impediments to clinical practice could be addressed. As we continue to study workforce needs, we should not ignore the attrition side of the workforce equation. Academic medical centers could provide leadership by developing work models for aging physicians, and in the process they might improve flexibility and the work environment for all our faculty.

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Questions, Answers, and New Conversations http://academicmedicineblog.org/questions-answers-and-new-conversations/ Mon, 12 Jan 2015 09:40:08 +0000 http://academicmedicineblog.org/?p=2402 AM Rounds Slider Master-07

As physicians, we are constantly seeking the answers to questions. What do these symptoms mean? What are the best options for the patient? Do I know enough about the problem or should I seek the advice of another doctor? The answers we find often lead to more questions and stimulate our curiosity to learn. Over time, most of us have developed a healthy skepticism about accepting what appears to be a simple answer to a complex question. We know that life does not usually work that way. Our journal has become aware of challenges to answering complex questions briefly and succinctly  through our Question of the Year, an annual competition to respond to a question of importance to academic medicine. Some of the responses were published in the journal, and authors of a few of the published answers participated in presentations at the AAMC annual meeting. Most recently, the questions explored identity (What is a Doctor? What is a Nurse?), or graduate medical education  (How can we ensure that our graduate medical education system will prepare trainees for practice in new systems of care delivery?). Over time, we have realized that the Question of the Year format could not do justice to the complex issues that we posed to our community. Most thoughtful, scholarly responses to complex questions require analysis of the question and development of a foundation for the answer, which was not generally possible in the space provided. In addition, in some cases rather than an answer, we might benefit from a pursuit of more questions that could lead us on a journey of scholarly discovery.

It was with these limitations in mind that we decided that, starting in 2015, we would attempt to engage our communities in a different way. We will be sun setting the Question of the Year and initiating a new feature, New Conversations, which will encourage thoughtful dialogue around a topic of importance. My January editorial introduces this new feature and lays out the first New Conversations topic. In the coming years, we hope to use New Conversations to examine in depth many important topics of interest to our community, and we plan to announce new topics periodically. For this coming year, we have chosen to explore the influence of health reforms, including the Affordable Care Act, on health care delivery, medical education, and research. We believe that through New Conversations we can help our communities to become informed about the options for health reform in the years ahead. Over the next two years, it is likely that health care will become a major topic for political campaigns. I am hopeful that New Conversations will help our communities to be successful participants in the discussions about the future of health care in our country and in the world. We are seeking New Conversations submissions from a wide array of contributors–anyone is welcome to submit an article for consideration at any time, and we also are working to invite submissions from thought leaders representing a variety of perspectives. International submissions are always welcome, as sharing experiences with health reforms in different settings is an important part of this conversation. The first New Conversations contribution in our January issue is from former Senator Tom Daschle, who provides a broad view of the critical issues facing academic medicine and our health system in the coming years. He identifies five transformational forces–big data, transparency, new payment systems, emphasis on wellness, and scope of practice– that will have critical impact on our academic health centers. I encourage our community to read his article and share it with colleagues.

We look forward to receiving contributions from all members of our community. Submissions should be scholarly contributions; they must follow the journal’s regular submission criteria for Commentaries, Articles, Perspectives, Innovation Reports, Research Reports, or Letters to the Editor, depending on which of these formats you use for your submission. (For more information about those criteria, please see the journal’s Complete Instructions for Authors). We will carry on the conversation outside the pages of the journal as well. This blog will feature a series of roundtable discussions related to the New Conversations contributions that are published in the journal. I also encourage you to discuss New Conversations on Twitter using the hashtag #AcMedConversations by offering your opinions, posing questions, and responding to the questions posed by your colleagues. We will be using the journal’s Twitter handle, @AcadMedJournal, to do the same. Our goal is to keep the New Conversations going throughout the year by using these channels.

We seek the best thinking and creativity of our communities as we consider the effects of health reform and the Affordable Care Act and what messages we would like to give to our political leaders as we look toward the challenges and opportunities of the future.

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A Look Back at AM Rounds in 2014 http://academicmedicineblog.org/a-look-back-at-am-rounds-in-2014/ Mon, 29 Dec 2014 14:45:15 +0000 http://academicmedicineblog.org/?p=2383 journal club2

As 2014 draws to a close, our editorial staff chose a few posts that represent the best of AM Rounds this year:

  1. Eradicating Medical Student Mistreatment: Why Are We Still Playing A Game of Whac-a-Mole? by Joyce Fried
  2. Author Reading: Thanksgiving by Matt Neal
  3. 10 Tips for Men with Questions About How to Excel as Mentors of Women by Janet Bickel
  4. A Peek Inside the 21st Century Doctor’s Bag: Mobile Health Technologies for Medical Education by Shiv Gaglani
  5. Accepting Undocumented Immigrants: How We Became the “Medical School of Dreams” and Dreamers by Mark Kuczewski and Linda Brubaker
  6. Editorial Board Q & A: J. Michael Homan, the first post in a new get-to-know-you series introducing our editorial board members
  7. Back from Africa by editor-in-chief David Sklar
  8. Can Engineering Metrics Help Pave the Way for New Learning Opportunities in Medicine? by Carla Pugh
  9. Part-Time Faculty Member: Lightweight or Leader-in-Waiting? by Sue Pollart

Our goal is to offer compelling complements to journal articles to expand the conversation on the most important topics in academic medicine. We’re excited about continuing to provide these unique perspectives in 2015. And we hope you’re excited about the discussions to come. Thanks for your loyal readership. Best wishes in the new year.

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We Still Don’t Know What’s Wrong http://academicmedicineblog.org/we-still-dont-know-whats-wrong/ Mon, 17 Nov 2014 08:03:20 +0000 http://academicmedicineblog.org/?p=2274 AM Rounds Slider Master-07

A few years ago, I was talking with a medical student who had just finished a shift in the ED. He was an excellent student, but today he had a string of patients who left him frustrated. The 40 year-old woman who presented with abdominal pain left the ED with a diagnosis of “abdominal pain.” We discharged the 35 year-old man who presented with a severe headache with a diagnosis of “possible tension headache.” A five year-old girl with a fever left with “fever of probable viral etiology.” We had gotten blood tests and a CT scan on the woman with abdominal pain, the results of which were normal. We had treated the man’s headache with analgesics, and he got better. We had given the five year-old some Jell-O when she stopped vomiting, and she was playing happily with some toys. The student said, “These people came in bent over in pain or crying. We put them in a bed. We talked to them and examined them. We ordered some tests. A few hours later, they felt better, and we sent them home. They walked out standing up straight and smiling. But we didn’t really do anything. We never figured out what was wrong with them.”

I had to smile because, in many ways, the student was right. He had been learning about the dangerous causes of headache–subarachnoid hemorrhage, meningitis, brain tumors. But he had not learned much about tension headache, or migraine–the causes of most headaches that often improve on their own. He had learned about pancreatitis, appendicitis, ulcers, and colon cancer as causes for abdominal pain, but not abdominal pain of unknown etiology, a common problem that typically gets better without treatment or knowing what caused it. He had learned about fever in a five year-old caused by strep throat or meningitis but not about the various self-limited viruses that caused a fever and vomiting in that same five year-old.

When he had interviewed each patient, his differential diagnosis had included a list of the most serious causes of the problem, as it should. But he had no idea how frequently they occurred or what clues might tip him off as to how to recognize the more common and less serious causes of the same symptoms. His frustration was a function of the emphasis in his education of various specific causes of pathology, which populated his problem based learning cases but did not align with the real world of problems that often are not connected to any pathological condition or given a diagnostic name beyond the symptom the patient described–headache, abdominal pain, fever.

When I read the study of ambiguity tolerance in medical students by Caulfield et al I flashed back to this medical student. Was he frustrated by the lack of certainty in our diagnoses and the ambiguity surrounding our treatment decisions? He chose radiology as his residency, a specialty in the middle range for students’ scores on the Tolerance for Ambiguity (TFA) scale. If I had known about this test, I might have discussed it with him. However, as Caulfield et al noted, many questions still exist about what the results on the TFA test mean and how changeable they are over time. The two blog posts by Luther and Caulfield provide different perspectives on the TFA test.

Our tolerance for ambiguity in medicine also changes with experience. In the cases I described earlier, I expected that the woman with the abdominal pain would have a negative CT because her presentation suggested that her problem was not serious and would likely improve on its own. I ordered the CT scan to lower the probability of a serious condition below my threshold of concern. I could tolerate the remaining uncertainty about the diagnosis. But the student had no such threshold in his mind. The entire spectrum of possibilities swirled around him, and he could not understand why we stopped our work up with the negative CT scan. Even more perplexing for him were the other cases for which we did virtually no tests, and I decided to send the patients home. While I was relatively confident because I felt the risk was low, he was anxious because he had no base of experience to estimate that risk.

Whether the TFA test will be helpful for advising medical students about career choice or even evaluating their suitability for a career in medicine is not clear. I applaud Caulfield et al for their efforts to bring the TFA test to our attention as medical educators, but I urge caution in applying it. I look forward to further work in this area. In the meantime, I suspect the list of specialties ranked from lowest to highest tolerance for ambiguity will likely be the topic of discussion at meetings of medical school department chairs. Perhaps they will decide that when the chairs of dermatology and otolaryngology (low tolerance for ambiguity) and the chairs of emergency medicine and  neurosurgery (high tolerance for ambiguity) can agree on a decision, it is likely that everyone else will  agree, and they can adjourn the meeting.

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Attending Learn Serve Lead 2014: The AAMC Annual Meeting? http://academicmedicineblog.org/attending-learn-serve-lead-2014-the-aamc-annual-meeting/ Fri, 07 Nov 2014 06:03:07 +0000 http://academicmedicineblog.org/?p=2287 AM FB REG Promo-01

Stop by Booth #306 in the Hyatt-Riverside Exhibit Hall to pick up a copy of the latest issue of Academic Medicine and to chat with our editorial staff.

Attend our 2014 Question of the Year session, “How Can Our GME System Prepare Trainees for Future Practice?”
9:30 – 10:30 AM, Hyatt – Regency C
Because of GME’s critical role in the overall education of physicians, Editor-in-Chief, David Sklar, collaborating with the journal’s associate and deputy editors, asks our community to consider how rapidly evolving health care systems will require physicians to have an expanded set of competencies beyond those fostered by our current educational programs. The session will feature several responses to the Question of the Year, and participants will discuss their own ideas and recommendations. Panelists include Eric Holmboe, Ken Ludmerer, Andy Levy, and Rebecca Brienza.

Don’t forget to tweet us at @AcadMedJournal. See you in Chicago!

To learn more about Learn Serve Lead 2014, visit the meeting website.

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