Moving the meat, the hidden curriculum and how to stop it.

By Daniel Cabrera (@CabreraERDR)

Moving Meat.jpg

Moving the meat is medical slang, a phrase I hate. It is derogatory, unethical, amoral, conceptually wrong, dehumanizing and operationally inefficient; yet the term is used every day in thousands of clinics, emergency departments and hospitals around the world. The idea of moving the meat is the concept of trying to be as efficient as possible, focusing on satisfying the system more than the patient, keeping the production line running no-matter-what; the hidden intention is not to pay attention to the patient as a person but only as part of a large Henry Fordesque assembly system.

Boris Veysman made a poignant commentary in his 2010 Annals of Emergency Medicine article Butchers Move the Meat; Doctors Care for Patients”. He tells the story of his grandmother getting poor quality care (the doctor almost missed her acute glaucoma) because of the perceived focus in keeping the patients moving. In others words it is more important to move the meat, than actually do what is right for the patient. In quality process jargon, the (flawed and inconsistent) argument is that the amount of defects in the process is irrelevant as long as the process continues.  This makes no sense on many levels of health care.

As physicians our prime directive is to care for the people trusting us with their well-being (and lives). At the same time we recognize the critical aspect of preserving and expanding the healthcare brain trust (concept by Benjamin Sandefur) by educating professionals who will serve as the next generation of healthcare providers.  Of course, all of this is on the background of “no money, no mission”; we need to efficiently produce to keep the lights on in our hospitals, clinics, and schools.

The divide between a Clinician Eductor’s duty to their patients and learners and operational efficiency is not small. A few years ago, Jim Colletti published a research piece showing that commitment to knowledge and instruction actually decreased the throughput times of the observed faculty. (See here for another example)

Ioannidis recently coined the idea of Finance Based Medicine, as a sort of joke on the extreme influence of funding factors in the creation of medical knowledge, particularly biomedical research. We understand and accept the industry behind medicine, but we need to escape the oppression of finances or cold-blooded algorithms in the face-to-face encounter with the patient and the learner.

I was in despair until I stumbled upon  an ICRE presentation from Victoria Leung, Laura Quigley,Wai-Ching Lam, Rodrigo Cavalcanti and Brian Hodges. They propose a theoretical framework to start narrowing the divide; the structure is based on a fantastic paper by Golden and Martin (Using systems thinking to (re)design Canadian healthcare).

Here is the idea in a nutshell:

Moving Meat.png

The core concept is to incorporate the culture and values of education, patient care and operations into a common matrix.

The education group should be given a voice at the table to participate in the design of the pathways of care, as learners represent a very significant workforce in academic institutions. As part of this, the goals and roles of teachers and learners need to be explicit. Accountability should exist; particularly in terms of dedicated time and benchmarks for achievement.

A key concept is that within the “production line” construct that I hate so much, there is also an embedded education system affecting all aspects of the production system. Focusing on only one group (e.g, the residents or medical students) without investing resources and attention to other groups (e.g., nurses, clinical aides, paramedics) is not only wasteful and impractical, it also creates silos and divide that does nothing more than creation resentment and a culture of “us and them”.

Our learners are extraordinarily smart people, many of the time they are better informed than their supervisors (à la Flynn effect); their opinion and feedback is key to understand how well the system is running and how we can make it better for everybody. Development of metrics and feedback loops including the educational/academic component of practice is of paramount utility.

Last, we forget about the future when we dig too much in the present of our healthcare systems. One of the major reasons current healthcare systems and academic institutions are functional is because of the immense brain trust created by generations of teaching and academic scholarship. This brain trust, composed by thousands of physicians, nurses, scientists, social workers, paramedics is what keeps this machine running. If we focus too much on the machine and not enough on the people, we run the clear and present danger of destroying the brain trust.  We need to invest in our learners (and patients), not simply move the meat.

“Waste no more time arguing about what a good man should be. Be one.” – Marcus Aurelius

References and further reading

Image 1 by JD Hancock via flickr under CC BY 2.0

Image 2 by Leung et al. 2013 ICRE.

#KeyLIMEPodcast 113: After all the work of restricted duty hours… no effect?

The Key Literature in Medical Education podcast has a controversial paper this week.  On the podcast you’ll hear Jason incorrectly interpreting the paper as a poorly done study, while I correctly (I love editorial control) suggest there is a lot of value in the conclusions.  If that statement isn’t click bait for the podcast, then check out the abstract below for more details.

The podcast can be found here.

– Jonathan

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KeyLIME Session 113 – Article under review:

New KeyLIME Podcast Episode Image

Bilimoria KY, Chung JW, Hedges LV, Dahlke AR, Love R, Cohen ME, Hoyt DB, Yang AD, Tarpley JL, Mellinger JD, Mahvi DM, Kelz RR, Ko CY, Odell DD, Stulberg JJ, Lewis FR. National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. The New England Journal of Medicine. 2016 Feb;[ePub ahead of print]

Reviewer: Jonathan Sherbino (@sherbino)

Background

Wait for it… wait for it.. a New England Journal RCT on a #meded topic.  The KeyLIME paper this week is a love child of EBM and education psychology.  Also it’s political.  Buckle up!

Resident duty hours is a hot topic in North America.  The Royal College tackled this issue via a national steering committee report, found here. With an acknowledgement of the dangers of condensing complex topics into headlines, the report states that “traditional duty periods present risks to the physical, mental, and occupational health of residents”, yet, “a tired doctor is not necessarily an unsafe doctor, “ and “there is no conclusive data to show that restrictions on consecutive resident duty hours are necessary for patient safety.”  Yep, pretty bold and contentious statements.

The perception is that a restriction in duty hours leads to less clinical exposure to patients, which impedes the development of experience.  We tackled this perception among general surgery program directors on KeyLIME Episode 55.

Subsequently, Episode 62 suggested that duty hour restrictions had NO impact on written exam scores among US internal medicine trainees.

Despite the FIRST trial label, this is NOT the first trial to look at the effects of the ACGME duty hour reform.  A 2007 study of registry data of 1.2M internal medicine patients found a 0.25% reduction in absolute mortality rates, yet in 240k surgical patients there was no significant difference in mortality.

So, how do we parse the data? How about a multi center, prospective, randomized trial?

Purpose

“We conducted the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial30-32 to test whether surgical-patient outcomes under flexible, less-restrictive duty-hour policies would be no worse than outcomes under standard ACGME policies. Resident satisfaction and perceptions of patient care, resident education, and resident well-being were also assessed.”

Type of Paper

Research: RCT

Key Points on Methods

  • Prospective, cluster-randomized, pragmatic, non-inferiority trial
    • 25% non-inferiority margin **
  • n=117 (of 136 eligible) general surgery residency programs 2014-15
  • Both control and experimental arm
    • Max 80 hrs/wk
    • 1 in 7 off
    • 1 in 3 call
  • Control
    • PGY1 max 16 hr shift
    • PGY2+ max 28 hr shift
    • 14hrs off post 24hrs call
    • 8-10hrs off post shift
  • Experimental
    • None of the above CGME restrictions required
  • Patient outcomes via Am Coll Surg Nat Surg Qual Imp Program database
  • Resident outcomes MCQ survey added to 2015 boards

Key Outcomes

Analyzing ~139k pts, no difference in 30 day rate of death or serious complication (CVA, MI, need for CPR, PE, PPV, ARF, blood tx, sepsis, surgical-site infection, wound dehiscence)

  • 0% standard policy v 9.1% flexible; p = 0.92

Analyzing ~4300 residents with response rate of 84-87%:

no difference between groups regarding:

  • overall education quality
    • 7% standard policy v. 11.0% flexible; p = 0.86
  • well being
    • 0% v. 14.9%; p = 0.10

Residents in flexible policy are less likely to perceive negative impact on patient safety, continuity of care, professionalism BUT more likely to perceive negative effects on personal activities.

Residents in flexible policy were less likely to report leaving during an operation (7.0% v 13.2%; p = <0.001)

Key Conclusions

 The authors conclude…

“As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents’ satisfaction with overall well-being and education quality”

Spare Keys – other take home points for clinician educators

This manuscript is an important reminder to Clinician Educators that the education design we wrestle with has important system and patient implications.  While we may tend to live and think within the #meded literature, our work often has much broader implications

And a quick side note… Northwestern University REB deemed the trial to be non-human-subjects research J

Shout out

Big shout out to the authors for including all of their data. I think. With 30 supplementary tables, they provide an overwhelming look at the raw data of their findings.  Rather than “piecemeal-ing” their data into multiple manuscripts, they provide a coherent and rich narrative.

Listen to the podcast here

ICE Book Review: Grit -The Power of Passion and Perseverance

By Rob Cooney

“If you can keep your head when all about you are losing theirs and blaming it on you…”                      -From “If” by Rudyard Kipling

51gTUhW2u0L._SX327_BO1,204,203,200_Does genius drive success? If not genius, then what does? Angela Duckworth is a professor of psychology at the University of Pennsylvania well known for her work on the concept of “grit.” In her book by the same name, Duckworth explains the nature of grit, its importance, and how to get more of it.

She opens her book with a review of talent. She explains why focusing on talent is a mistake and how the least talented students sometimes are the most successful learners. As she explains,

“the biggest reason a preoccupation with talent can be harmful is simple: by shining a spotlight on talent, we risk leaving everything else in the shadows. We inadvertently send the message that these other factors-including grit-don’t matter as much as they really do (pg. 31).”

She also does a nice job of explaining why effort is essential to success. As she explains:

Talent x effort = skill

The remainder of the book is focused on Dr. Duckworth’s research into the discovery of grit and explaining how you can get more of it.  For starters, take the grit assessment.

To grow grit, Duckworth asserts that a person must first have “interest” in a topic. Once interest is established, an individual must have the capacity to practice. As an individual gets better, they will develop a purpose that connects their interest, often connected to the well being of others. Finally, an individual must have hope. The development of capacity always involves some component of failure. Rising to the occasion promotes the development of grit. The next several chapters of the book explore these four key components of the development of grit.

Particularly interesting was the chapter on practice. Educators will recognize the work of Anders Ericsson and the theory of deliberate practice. Educators may also be familiar with the concept of flow, another theory proposed by Mihaly Csikszentmihalyi.  At first glance, these two concepts appear to be at odds. Deliberate practice is energy intensive and generally not perceived as very much fun. In contrast, flow is a state that is highly enjoyable, where a person can lose track of time.  From my understanding of the two concepts, I came to the same conclusion as Duckworth, “deliberate practice is for preparation, and flow is for performance (page132).”  It turns out, however, that people with a high level of grit actually experienced deliberate practice differently, and more enjoyably, than people with a lower level of grit.

The final chapters of the book involve taking the reader on a conceptual journey of applying the principles of grit development for parenting, coaching or teaching, and overall cultural development.

If you are at all interested in cognitive psychology and its relationship to teaching, you should pick up a copy of Grit and have a read through the concepts. If you’re not certain and would like to learn a little bit more before reading, check out Dr. Duckworth on TED.

#KeyLIMEPodcast 112: Who’s the Boss?  Freud and #Meded

What specialty did you choose in medical school? What specialty did you avoid? Can you feel your counter transference rising?  The Key Literature in Medical Education podcast explores an interesting take on health human resources this week.  The article uses a psychological framework (Social Dominance Theory) to characterize specialty choice among medical students.

Not sure if this topic is for you?  Check out the abstract below for more details.  For a richer debate (and there is lots of it) download the podcast here.

– Jonathan

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KeyLIME Session 112 – Article under review:

New KeyLIME Podcast Episode Image

Lepièce B, Reynaert C, van Meerbeeck P, Dory V. Social dominance theory and medical specialty choice. Advances in Health Sciences Education. 2016 Mar;21 (1):79-92

Reviewer: Jason Frank(@drjfrank)

Background

One important ingredient in an effective health workforce is getting the right type, mix, and distribution of physicians for a population. In most countries, there is a large degree of choice for medical students when they enter residency training en route to specialty certification. The factors that influence future physicians’ career choice are therefore an important topic for medical educators.

Incidentally, there are numerous studies looking at the whole specialty choice enterprise. Few tackle a theoretical psychological model, while most describe a set of influences. The latter papers have previously identified a large number of systemic, intrinsic, and extrinsic factors, including:

  • Perceived future income;
  • Debt load;
  • Difficulty getting a training spot;
  • Work hours during residency;
  • Work-life balance in practice;
  • Length of training;
  • Degree of holism/generalism vs. specialism;
  • Nature of practice setting;
  • Degree of technical vs. cognitive work;
  • Clinical problems of interest;
  • Role models; and
  • Prestige

The literature on this topic continues to grow; the contextual nature of admissions prevents any kind of definitive paper from being published.

Purpose

In this paper, Lepièce et al explore this idea of prestige in specialty career choice in meded with a unique twist: using Social Dominance Theory (SDT). They sought to characterize the relationship between an interest in hierarchy and specialty career intentions.

Type of Paper

Research: Observation Study

Key Points on Methods

For the purposes of this paper, “prestige” was defined as, “…the respect gained from perceived expertise or know-how…” Social Dominance Theory (SDT) describes the psychosocial practices that contribute to social hierarchies. Social dominance orientation (SDO) is the individual’s preference for hierarchy and prestige. SDO varies by environmental factors and institutional norms.

The authors hypothesized that more technical disciplines would attract those with a higher SDO score. So by their construct, they operationalized “medical prestige” as “person-centred” vs. “technique-oriented” to classify disciplines.

The authors surveyed Belgian medical students at a single site in years 4, 5, & 7 of a 7-year med program. The survey included some general demographics, items about career intentions, and a standardized, previously validated SDO scale by Pratto. They used logistic regression to look for relationships between variables.

There was no research ethics review. This is clearly a single school convenience sample. And there was no effort made to validate the authors’ prestige taxonomy.

Key Outcomes

359 students participated across the 3 cohorts. Participation rate was in the 80s% approximately. The authors found no relationship to age or gender vs. SDO. Undecided students tended to be younger. Those interested in technique-oriented disciplines were more likely to be male, and had higher SDO scores, with an OR of 1.56. SDO scores increased with further training.

Key Conclusions

The authors conclude that SDO predicts career choice of one of two broad groups of specialty prestige. They further posit that greater exposure to hospital-based medicine contributes to progressive SDO scores over time.

(Of course, this is all “on thin ice”, to use a Canadian expression: there are many assumptions and threats to validity in this paper.)

Spare Keys – other take home points for clinician educators

  1. This is an example of a study that shows the power of looking at a meded phenomenon through a novel theoretical lens. We should all be grounding our work to existing theory, where possible.
  1. This journal, Advances in Health Sciences, is particularly oriented to psychological-theory-based papers, even when they have–ahem–significant limitations.
  1. MedEd really is a global enterprise, so this topic, admissions and career choice, is ripe for a cross-border study.

Shout out

A shout-out to Stephen Choi (Ottawa) & Ian Incoll (Sydney), who gave a great session on selecting trainees for successful residency training at ICRE 2015.

Listen to the podcast here

Blogging about Blogs: On the Wards

(This is part of the ICE Blog’s “Blogging about blogs” series, edited by Anthony Llewellyn and Teresa Chan. See herehere and here and here for previous posts.)

On the Wards.pngThis blog is an interview by Anthony Llewellyn with Evangelie Polyzos of onthewards.  The onthewards blog, podcast series, and now app was initially conceptualised by a group of #MedEd-ers at the Royal Prince Alfred Hospital in Sydney, Australia to fill a gap in #FOAMed resources for prevocational doctors in Australia.

*Conflict of Interest declaration.  Anthony Llewellyn is also the CTO for onthewards but like most #FOAMers gains no financial profit from such a lofty title.

onthewards has about 10,000 site views per month.  On the site you are able to listen to and download podcasts, read podcast summaries as well as read topical blogs and provide comments.

The onthewards app allows you to download most of the content from the website, and favourite and utilise it on your smartphone even when not connected to the internet (handy when you are trying to save on data or have no access to wi-fi).

The key personnel involved in onthewards are James Edwards,  Evangelie Polyzos and Anthony Llewellyn

Q:  When did you start your blog?

A:  May 2014

Q: How many people are involved?

A: We have a core team of 10 with expanding contributions from over 35 junior doctors from across New South Wales, Victoria and Western Australia.  A number of consultants and specialists also contribute as interviewees for the podcasts.

Q: How would you describe your blog?

A:  A “community of practice” as James would most likely say…  Obviously it’s a medical education site for junior doctors and medical students across Australia.  We focus on and try to ‘tackle’ topical and relevant issues effecting Junior Medical Officers, as well as aiming to encourage audience participation (start a conversation/response/engagement by way of comments).

Our site also offers tips and guidance to medical students and JMOs on available career options and preparation required to follow a selected career path.

Q:  How would you describe your audience?

A: We know through linking to other platforms such as Facebook that we have an international audience of mainly junior medical officers and medical students, as well as nursing and allied health and Consultants and Specialists with an interest in #MedEd.  We find a number of online journals or commercial sites also show an interest in our work.

Q: Can you describe your process for generating content?

A:  We have an editorial team that contribute content – they generate ideas from online discussion. Individuals from the team read current medical literature and this inspires many of their blog topics.

We also identify individuals (internal and external) that may have a story to tell.  One of our current bloggers, a General Practitioner first came to our attention when she posted a comment about the lack of recognition for the role of GPs by ontheward doctors.

The editorial team discusses relevant bloggers and ask for contributions.  We also accept individuals that approach us with an idea for a post and an interest in contributing. The editorial team supports the development of each post by providing feedback/comments and further concepts for inclusion.

Q: What’s your technology stack (i.e. how do you host your site, how do you code it, do you have a CMS, do you use any integrations e.g. facebook, twitter, google etc…?)

A:  In the true spirit of #FOAM we host our own site on a U.S. server because its very cheap to do so (although we are now contemplating bringing it back to Australia).  We use Concrete5 as our Content Management System.  This is now the 4th most popular CMS and it has some benefits that we like over others such as WordPress.  It is particularly good with in-context editing (what you see is what you get).  It’s also the CMS Anthony is most familiar with.  We basically built our own site using a paid-for theme, some add-ons and a little bit of coding in PHP. We mirror our site on our native android and iOS app using the GoodBarber framework. We have integrations with Twitter, Facebook and Disqus (for comments) and we also find web apps like IFTTT and Zapier to be good free services for integrations.

Q:  What’s one interesting thing you have learnt through the process of developing a MedEd blog / website?

A:  I enjoy the collaboration.  I also enjoy the negotiation, and giving an individual a voice, encouraging them to contribute and then observing both their skills and confidence grow. Ask them, don’t tell them and watch as they engage and generate ideas… for free. 

Q: How do you optimize credit or personal recognition for your MedEd blogging activities? 

A:  When a blog is published it is accompanied by the blogger’s bio and photo.  Regular bloggers are credited as ‘guest contributors’ on the about page. The blurb attached to the Facebook posting of the article includes blogger’s name and position (sometimes also on Twitter).  We are thinking about issuing certificates of participation for the JMO’s curriculum vitaes.