Follow-up is now available from a previous post on vigilance and the comment period for new standards. Earlier this month (in the last week or two) the standards approved at the July Council of Postdoctoral Training meeting were posted. The can be found on the AOA's web site at this link.
There is also a link to the email address where comments should be directed. This is: Postdoc@osteopathic.org
The comment period is 45 days - so this should be around the end of September.
There are substantive changes in the Osteopathic Postdoctoral Training Institution standards up for comment. These implement policy changes that have been discussed at multiple forums.There are also re-writes of many specialty standards.
This is the opportunity for the osteopathic graduate medical educators to be part of the process.
All are encouraged to comment!
Friday, August 19, 2011
Tuesday, August 16, 2011
Rested doc + EHR + ACO > tired doc + paper chart + solo practice...right?
The answer is likely not right or wrong. This is the conundrum of patient safety. It is multifaceted. Fixing one thing in isolation may do little. In addition, "fixing" may actually make things worse because of the unintended consequences of the fix.
There are several areas that are great examples of this: duty hours rules and the electronic health record (EHR).
First, a little more on the complexity of patient safety. If it was easy, there wouldn't be a problem. There wouldn't be a Quality Chasm to cross.
One of the better visual schema on medical errors is the Swiss cheese model. This was formulated in England by James Reason. The logic is that we have many fail safes in medicine to keep errors from occurring. Each process is like a slice of Swiss cheese - each has many holes. When the processes are put together - like a block of Swiss cheese - the holes do not line up and all is well. But, every now and then, the holes line up and bad things happen.
Near misses? The hole went almost all the way through, but one or more slices saved the day - maybe a timeout in surgery or a second nurse double checking the label on a bag of blood.
Think of trainees cognitive ability like a slice of Swiss cheese. Pretty solid, but some holes. The duty hours changes made the holes that represented sleepy, cognitively impaired trainees smaller. But they still make mistakes (holes).
The changes opened up big holes on other slices, namely situational awareness. This lack of situational awareness happened because there was a hand-off. This hand-off is generally poorly done. This was an unintended consequence. This is why the changes didn't improve patient safety.
We need to do a better job teaching and standardizing hand-offs!
We can do this - check out several publications and presentations by Vineet Arora. You can also check out her blog. In one recent publication she and colleagues showed that pediatrics interns only handed-off topics well 2/3 of the time - at best. It was about a third for knowledge items. In spite of this, they generally thought they were doing well.
The electronic health record is another mystifier. Again, it seems to make perfect sense that having a legible record that is readily available, and can offer some decision support, should make care safer. But...we all know that there are many unintended consequences. These are so numerous, that we have a taxonomy of EHR unintended consequences.
The EHR has also stifled consultant verbal communication. Why talk, it is in the chart?!?
Finally, the EHR has given us the millennial version of medical cheating: CoPaGA - Copy and Paste Gone Amok. This entails plagiarism of others notes and confirmation bias when erroneous information is carried forward without thought.
Are the holes winning?? It is a neck and neck race from my seat.
So, to bring this back around to osteopathic graduate medical education, it is our job as medical educators to keep the holes from lining up!!
We need to teach hand-off communication, both written and verbal. It needs to be taught formally and tested formally (I see an OSCE in your future).
We also need to teach how to use the EHR and the new professionalism that goes along with this tool. This is not typing 101. It is how to study and implement effective process changes. Another need is professional communication and the roles of each member of the healthcare team.
The alternative is 1 + 1 will equal zero, or, the will be many holes lining up in our Swiss cheese.
There are several areas that are great examples of this: duty hours rules and the electronic health record (EHR).
First, a little more on the complexity of patient safety. If it was easy, there wouldn't be a problem. There wouldn't be a Quality Chasm to cross.
One of the better visual schema on medical errors is the Swiss cheese model. This was formulated in England by James Reason. The logic is that we have many fail safes in medicine to keep errors from occurring. Each process is like a slice of Swiss cheese - each has many holes. When the processes are put together - like a block of Swiss cheese - the holes do not line up and all is well. But, every now and then, the holes line up and bad things happen.
Near misses? The hole went almost all the way through, but one or more slices saved the day - maybe a timeout in surgery or a second nurse double checking the label on a bag of blood.
Think of trainees cognitive ability like a slice of Swiss cheese. Pretty solid, but some holes. The duty hours changes made the holes that represented sleepy, cognitively impaired trainees smaller. But they still make mistakes (holes).
The changes opened up big holes on other slices, namely situational awareness. This lack of situational awareness happened because there was a hand-off. This hand-off is generally poorly done. This was an unintended consequence. This is why the changes didn't improve patient safety.
We need to do a better job teaching and standardizing hand-offs!
We can do this - check out several publications and presentations by Vineet Arora. You can also check out her blog. In one recent publication she and colleagues showed that pediatrics interns only handed-off topics well 2/3 of the time - at best. It was about a third for knowledge items. In spite of this, they generally thought they were doing well.
The electronic health record is another mystifier. Again, it seems to make perfect sense that having a legible record that is readily available, and can offer some decision support, should make care safer. But...we all know that there are many unintended consequences. These are so numerous, that we have a taxonomy of EHR unintended consequences.
The EHR has also stifled consultant verbal communication. Why talk, it is in the chart?!?
Finally, the EHR has given us the millennial version of medical cheating: CoPaGA - Copy and Paste Gone Amok. This entails plagiarism of others notes and confirmation bias when erroneous information is carried forward without thought.
Are the holes winning?? It is a neck and neck race from my seat.
So, to bring this back around to osteopathic graduate medical education, it is our job as medical educators to keep the holes from lining up!!
We need to teach hand-off communication, both written and verbal. It needs to be taught formally and tested formally (I see an OSCE in your future).
We also need to teach how to use the EHR and the new professionalism that goes along with this tool. This is not typing 101. It is how to study and implement effective process changes. Another need is professional communication and the roles of each member of the healthcare team.
The alternative is 1 + 1 will equal zero, or, the will be many holes lining up in our Swiss cheese.
Wednesday, August 10, 2011
I'm so tired, I haven't slept a wink...Duty hours and OGME
July 1, 2011 brought new duty hours rules to OGME programs and their ACGME counterparts. This has led to a significant number of commentaries in the print media (LA Times, NY Times) and on-line in the blogosphere.
It is a common sense (I realize that this is not "common") given that less long hours is a satisfier for trainees. I cannot blame them. While I trained in the halcyon days of 48 hour shifts and minimal supervision, I consider myself wise enough to see the error in those ways. I do not remember enjoying any part of that experience.
I think that there is adequate evidence that less sleep to less cognition. Poorer quality of cognition leads to gaps in patients' care. Patient care gaps are bad.
I am also a pragmatist and realize that duty hours rules are not going away. I also am aware that there are those who feel that they do not go far enough.
Given this reality, what are some of the other unintended consequences of this paradigm shift? Here are a few:
While I do not have the answers to solve this problem, we need to look at #2 for answers. What is the needed education? What does the physician of the future need to know and how to we train this in the new paradigm? Who are our partners on the healthcare team and how can they help solve this dilemma?
Some of solutions are beginning to be developed. We have discussed some of them in past posts. We need to change what, when and how we teach.
We need to train thought not facts.
We need to train leaders not managers.
We need to communicators not commanders.
The solutions will require open minds and innovation.
Rest assured there is no turning back!
It is a common sense (I realize that this is not "common") given that less long hours is a satisfier for trainees. I cannot blame them. While I trained in the halcyon days of 48 hour shifts and minimal supervision, I consider myself wise enough to see the error in those ways. I do not remember enjoying any part of that experience.
I think that there is adequate evidence that less sleep to less cognition. Poorer quality of cognition leads to gaps in patients' care. Patient care gaps are bad.
I am also a pragmatist and realize that duty hours rules are not going away. I also am aware that there are those who feel that they do not go far enough.
Given this reality, what are some of the other unintended consequences of this paradigm shift? Here are a few:
1. If the current residents are not going to be around to care for the patients, who will? This is a significant policy question. The call for 24/7 coverage of hospitals compounds this reality. A recent blog post by Brad Flansbaum, DO for the Society of Hospital Medicine elucidates more issues on this topic.
2. While the QUALITY of education rises with a higher level of cognition, the decrease in hours (and in many instances census) decreases the QUANTITY of education. This may not be all bad as there is some evidence that our current quantity paradigms are flawed. In a competency-based world it is outcomes that matter, not time served. The problem is that we are “not there” yet. There is also a suggestion, both anecdotal and some evidence that time (likely maturity) may matter.
3. See #1 and #2…If we need more physicians to care for the patients and if those physicians are trained in a paradigm of decreasing workload (hours and volume), then we will need even more physicians. It is a self-perpetuating cycle.
While I do not have the answers to solve this problem, we need to look at #2 for answers. What is the needed education? What does the physician of the future need to know and how to we train this in the new paradigm? Who are our partners on the healthcare team and how can they help solve this dilemma?
Some of solutions are beginning to be developed. We have discussed some of them in past posts. We need to change what, when and how we teach.
We need to train thought not facts.
We need to train leaders not managers.
We need to communicators not commanders.
The solutions will require open minds and innovation.
Rest assured there is no turning back!
Subscribe to:
Posts (Atom)