The Power of Social Networks to Change Health Behavior

Nicholas Christakis and James Fowler, co-authors of Connected: How Your Friends’ Friends’ Friends Affect Everything You Think, Feel and Do, have been studying the power and influence of social networks for a large portion of their careers. The concept of ‘six degrees of separation’ took on a whole new meaning thanks to Kevin Bacon, but Christakis and Fowler turned this party game into a science and have shown through peer-reviewed research that social networks can also influence the health status and behavior of the group.

Using the Framingham Heart Study data set, Christakis and Fowler found health and related behavior reflects ‘three degrees of influence,’ meaning your health behavior can indeed be influenced by a friend of a friend. As Christakis puts it in the following TED talk, “If a friend says, ‘let’s go have muffins and beer,’ and you do…and more friends join you, a new norm of what an acceptable body type begins to look like within your social network spreads–literally and figuratively. See Christakis’ Ted Talk below:

Wired Magazine interviewed the researchers in a 2009 article, The Buddy System: How Medical Data Revealed Secret to Health and Happiness, and the New England Journal of Medicine published the duo’s work in 2007, in the journal’s first piece on social media in medicine, The Spread of Obesity in a Large Social Network Over 32 YearsWhile this may be old news, it is once again gaining momentum as thought leaders in healthcare become increasingly aware of the need to target disease interventions at populations versus individuals alone.

Healthcare as an industry is becoming more and more social media savvy, as the fear of the unknown is overcome by a little education and the knowledge that crowdsourcing almost anything can provide the needed push for a new idea or intervention to take hold. Social networks not only influence health, but are now also being used to find patients for clinical trials–often a rate limiting and time-consuming step to study completion (see Health Data Management, Putting Social Networks On Trial). PatientsLikeMe, out of Boston, MA and led by Jamie Heywood, has built an entire business model around bringing groups of patients together, in their own disease-based social networks in order to share what works and what doesn’t related to treatments, and life in general. The team collects meaningful data to move research forward faster, and now has the ability to match participants to clinical trials they may never have never considered because they were unaware a trial was even being conducted.

By tapping into your own social networks, health or otherwise, you can expand your reach and exposure to more and more information. Knowledge truly is power–it opens doors and provides options that may not have existed before a new discovery is made. But choose those social networks wisely–just like Mom, and now Christakis and Fowler have said–especially when it comes to making health decisions. You are not only what you eat, but what your friends eat!


#mlearning In Medical Schools: How the iPad is Changing Medical Education

When Stanford announced they were supplying iPads to their medical students in 2010, they become one of the first medical schools to begin the transition to mobile learning. But now, the number of medical schools across the US handing out iPads with stethoscopes to their first year students is increasing, as the cost to supply the device is becoming far less of an obstacle once students and educators experience the doors that open with the device in hand.

The Yale School of Medicine now provides iPads to all their medical students after a successful pilot program last spring. In a Medical News Today post last March, Yale’s Assistant Dean for Curriculum shared that “it costs about $1,000 per student to provide paper copies of course materials. This is about the same cost as providing an iPad and supporting apps.”

“We pretty much break even,” said Schwartz, “but the iPad is better for the environment – and as an information delivery system, it’s much more versatile.”

At Yale, students and physicians are using the tablet in both the clinical and educational environments. They have found the benefits are far exceeding the initial goal of note taking in class — instant access to the global library of online reference material, video streaming, the ability to collaborate in real-time and the built-in mobility–are just some of those benefits. Textbooks themselves come to life, and become increasingly interactive when loaded to the iPad, and educators are able to change and update curriculum, delivering it to students digitally, in real-time.

In a September 2012 post on eWeek, iPad Program Launches at University of Pennsylvania Medical School, writer Brian Horowitz shares how The Perelman School of Medicine not only gave iPads to their medical students, but also redesigned the white coats with pockets to fit the device. Putting iPads in the hands of students and educators is changing the way content is delivered, shared and used during class, as the device is changing how students learn. Neal Rubenstein MD, professor of cell and developmental biology at Perelman, comments:

“The iPad is bringing a new dimension to my teaching,” said Rubinstein. “By getting rid of the limitations of paper notes and books, I can teach students how to think critically and act on their curiosity in a way I couldn’t before. The textbook no longer defines our students’ educational experience.”

According to iMedicalApps in a post earlier this year, Top 10 free iPad Medical Apps, the ability to capitalize on what the iPad offers health science education will be only as good as the apps available. Currently, there are over 2500 free medical related apps available for the iPad, and the number of medical apps overall is projected to grow 25% per year over the next five years. Today, apps allow students and physicians to view human anatomy in color, 3D-images, take handwritten notes and create .pdf documents, download a New England Journal of Medicine subscription directly to their iPad and look up drug interactions in comprehensive drug dictionaries–and that is just scratching the surface of the informational power apps deliver to the user.

Did Steve Jobs have any idea how this device would change not only medical education, but the way the world interacts with the growing amount of information available to us? Please share how you are using the iPad, or related technology, to enhance medical education.


Disruptive Innovation Moving Into Medical Education

I was hoping it was only a matter of time before medical education made its way to Coursera. For those not yet in the know, Coursera enables the best universities to put courses online at no cost to students. As of September 2012, Coursera claims a student body of 1.5M from approximately 196 countries around the world, and offers 195 courses from science and technology to the humanities to health policy. Course enrollment ranges from 10K to 130K students per class, and the company’s goal is to deliver high quality content at the lowest possible cost to anyone, anywhere that desires to learn something new. Daphne Koller, co-founder of Coursera and a Stanford professor of computer science, doesn’t see their model replacing brick and mortar higher education–just forcing its hand in order to kick the quality up a notch or two.

Recently, Mount Sinai Medical School began offering three courses through Coursera’s MOOC (massive open online course) format:

  1. Dynamic Modeling Methods for Systems Biology
  2. Introduction to Systems Biology
  3. Network Analysis in Systems Biology

(Additional Mount Sinai’s offerings can be found here, and all of Coursera’s biology offerings can be found here.)

How will this format benefit, or detract from, a medical education? What format yet to be made mainstream would best fit medical training? Educational technology catch phrases like “blended learning” and “1:1 technology” seem like two elements that would easily enhance any learning environment without too much trouble, but how quickly are these new learning methodologies being accepted, implemented and adopted in medical schools? For more information on educational trends–see the Edtech Digest blog, and for the related new vocabulary, see this recent post, Trends–Infographic: Edtech Cheat Sheet.

In an earlier ETY post, The Changing Educational ParadigmMOOCs had just recently been opened up to a mainstream audience and I promised to report back on my own exploration. I highly recommend without reservation trying it out firsthand, as there is a topic for everyone, and being able to access the site 24 hours a day allows for flexibility. I only wish I needed fewer hours of sleep than I do to function! My first course, Fantasy and Science Fiction: The Human Mind, Our Modern World, required students to read a classic work of literature each week, and as such, held more content than my current work-life could balance. The video lectures I viewed, however, were entertaining, insightful and provided in-depth analyses of some of the very best literary works, such as Dracula, Grimm’s Fairy Tales, Frankenstein and The Martian Chronicles.

The consummate student, I’ve since explored a second MOOC, Gamification, offered by Kevin Werbach Associate Professor, The Wharton School, Univ. of Pennsylvania. This course was much more manageable than my first exposure to this exciting new educational format, and as a result a record 8,280 students earned a certificate of completion. The Gamification class had 80,000 students from around the world, with one of the most active self-application rates of all Coursera courses, and a very active Twitter stream to accompany the discussions and meetups–see #gamification12 for more information. A short explanation of the course follows if interested:

On Tuesday, the Coursera servers were down according to their Twitter feed. Quite honestly, I’m surprised it doesn’t happen more often given the number of users accessing this site on a daily basis. The speed with which this educational model was adopted around the world is amazing. It speaks to the hunger we have for knowledge, and the need for high quality content. Regarding the collaboration and global networking opportunities? They are endless, and have only just begun to play out. In fact, if anyone knows how to get in contact with the decision-makers at Coursera, please contact me. I know a great Patient Safety & Quality elective that should be added to their offerings!


How Do Great Storytellers Create Empathy?

There are many gifted storytellers and teachers of the craft. Robert McKee (aka The Script Doctor) is one. Having attended one of his Story Seminars in Vancouver, BC, I can share firsthand that McKee is indeed a master, with an ability to captivate an audience. For 9 hours a day, over his four-day seminar I sat in the silence he demanded of every student from the outset, soaking up every detail as he deconstructed, then reconstructed, the anatomy of a story.

According to McKee, and along the lines of yesterday’s post, Using Storytelling and Narrative to Develop Empathy In Medical Students, it is critical that the protagonist of a story evokes empathy in order for the audience to have an emotional involvement in the outcome. McKee instructs students to create characters audiences care about–characters that appear to be “just like, or somewhat like, me”. His Storylogue, a paid service that provides daily writing lessons, and his Story Seminars given around the world are (in)famous for producing Hollywood caliber scripts, and published authors across all genres. One last parting bit of storytelling wisdom — McKee believes good storytellers have:

  1. Insight into life–a concept or idea no one else has
  2. Depth of knowledge around that unique insight into life–do the research!
  3. Wit–a little wit goes a long way and can be a saving grace
  4. Passion for perfection–write, rewrite and rewrite again
  5. Taste–taste is a gene–know what’s good and what’s not in your own writing

A second example of masterful storytelling has one of the most unlikely empathetic characters. Of late, I have been watching the multi-Emmy Award-winning (plus others) Showtime series, Dexter. I came to the series late–actually six seasons into it–as I am not a fan of horror, crime stories or murder/mayhem of any sort. Not to mention, I was having a hard time understanding how a show based on a serial-killing lead character could have the universal appeal it does. Rumor has it there are even Dexter bobble-head dolls for sale! It remained one of the “mysteries of Hollywood” in my mind. However, I was convinced by a writing colleague to download the sixth season from Amazon and did so under duress. To my surprise, I was quickly hooked. Here is an excerpt that hits at the heart of the series:

How can a serial killer evoke such universal empathy? Yes, the script may be formulaic, but the story backbone is one of the great ones, with a skillful twist on good vs evil better than any I have read or watched in a very long time.  The brilliance of the writers as they dance at the core of self-worth is inspiring. Are we good or bad? A combination of both? Aside from social norms and laws that guide us, what makes us good or bad, and how do we measure up when comparing ourselves to others? How does that self-assessment hold up to the expectations of who, and what, we are and should be according to significant people in our lives? All this from a serial-killing lead character–who knew? I wonder what Robert McKee thinks!

Man (or woman) versus the self is one of the seven great plot structures. I would put our struggle with ourselves at the top of the list when trying to create narratives that evoke the empathy needed to create change in medicine or anywhere else. How does this knowledge apply to a medical school lesson plan? How can medical professors remind students that each patient, and colleague, has their own story or inner struggle? There exists both beauty and power in developing a connection to those pieces of another human being, and if medical education is failing to make a space for that connection to flourish, it’s no wonder empathy in medical students falls off over training.

How can medical professors allow their students to share their own inner struggle within the profession they are about to take on so that those struggles do not take away from a patient encounter? As new skills are being required of practicing physicians, so too are that of medical educators. How are you preparing for this shift? Please share your strategies–and favorite stories!


Using Storytelling & Narrative to Develop Empathy In Medical Students

What is occurring during medical training across the country that would make students feel increasingly less empathy for the patients they will soon care for? A recent study out of Boston University by DC Chen et al, Characterizing changes in student empathy throughout medical school, added to the growing body of knowledge showing a decrease in medical student empathy over the course of their training. Helen Riess MD posted a piece on the October Massachusetts Medical Society’s Vital Signs blog, Teaching Empathy Can Improve Patient Satisfaction, referencing the decline in student empathy over time, but also a Mayo Clinic study that reported 60% of practicing physicians show signs of burnout. If it’s true that so many physicians are this disenchanted with the practice of medicine, is it any wonder that providers need to be reminded to put patients at the center of care?

As medical educators, helping students develop empathy versus lose it over time, can have a positive effect on both patient satisfaction and outcomes. According to M Hojat et al in Academic Medicine in March of 2011, patients working with physicians reporting high empathy scores were significantly more likely to have good control of hemoglobin A1c (56%) & LDL-C (59%) vs those working with physicians reporting low empathy scores (40%, 44%) p<.001. The level of physician empathy was also found to have a “unique contribution” in predicting patient outcomes.

So how then, do you develop and reinforce empathy in your students? Today, many industries are turning to various forms of storytelling to connect the head with the heart, personalizing cold hard facts in a way that evokes emotion and elicits connections to the self and others–something data often fails to accomplish. Many medical educators are catching on to this trend, and programs in Narrative Medicine are growing across the country. Rita Charon MD, PhD, who developed and leads the Program in Narrative Medicine at Columbia University, defines the program’s mission below:

Narrative Medicine fortifies clinical practice with the narrative competence to recognize, absorb, metabolize, interpret, and be moved by the stories of illness. Through narrative training, the Program in Narrative Medicine helps doctors, nurses, social workers, and therapists to improve the effectiveness of care by developing the capacity for attention, reflection, representation, and affiliation with patients and colleagues.

Margaret Cary MD teaches an elective in Narrative Medicine at Georgetown University School of Medicine, where students are encouraged to write about their experience of medical school in order to better understand their place within the world of medicine. Cary has teamed up with Patricia Salber MD, creator of the well-respected healthcare blog, The Doctor Weighs In, to showcase her students’ reflections.

The ultimate goal of a writer is to create characters that evoke empathy so that the reader will invest in the character’s plight, and take part in his/her journey. If medical educators can teach students the skills necessary to uncover and invest in their patient’s plight in a similar way, perhaps that investment will make the joint journey through a healthcare encounter take on new meaning–with the patient’s needs at the center of care.

More on developing the skills of a storyteller to follow…


Brake Repairs and Healthcare – Misdiagnosis versus Pure Incompetence

A few months ago, my car needed repair work so I took it to a neighborhood auto mechanic shop. Over the last two weeks when I applied my brakes, there was a rubbing noise that became worse each day I drove the car. The mechanic listened to my story and after looking at the brakes, explained the pads had worn down almost to the drums, and would need to be replaced. He and his team seemed confident and competent – he said he would get the brakes back to new again.

When I picked up my car and was driving away, I noticed the brake problem seemed to be worse. The noise I now heard was even louder than before.  I returned to the mechanic’s shop–another unplanned stop in a busy day for a problem that was supposed to have been addressed. The mechanic acted surprised, and said I would need to leave my car at the shop another day so he could see what his “younger” mechanic had missed. Frustrated, I left the shop thinking about the inconvenience this incompetence had now caused me.  But what happens when incompetence like this occurs in healthcare….

Which brings me to this next story. My youngest daughter, who is finishing her last year of college, called me yesterday. She was very upset about something that happened this past week. Being her Dad and also a physician who has spent a career working in quality and safety, I was a reasonable target for her to vent her frustrations since they stemmed from what appears to be, at best a friend’s misdiagnosis, and at worst, pure medical incompetence. The ripple effect of a medical error unfortunately no longer surprises us, but pure incompetence by a caregiver is also too common and I share this story because all of us should demand better from our profession.

A few months ago, my daughter’s good friend went to see a physician because she had missed two periods and then had an episode of abnormal bleeding. The physician explained that my daughter’s friend had been pregnant, but had experienced a spontaneous abortion. He told her that she would return to a normal menstrual cycle in the next month or two. Two months passed and she continued to feel “not quite right,” and when her cycle did not return to normal she returned to see the same physician. After an examination, the physician now told her there was a grapefruit-size cyst on her ovary, and that she needed to see a surgeon. The young girl was finally able to see the surgeon after another month of waiting. This time, however, the examination resulted in a very different finding. The surgeon sat down with my daughter’s friend and explained that what the first physician had thought was a cyst, was really a baby. He had heard a rapid heartbeat during the exam, and by his estimates, she was over six months pregnant.

In the matter of one short conversation, this young girl’s life had drastically changed, as did the lives of her family, my daughter and a child yet to be born. If she had known she was pregnant four months earlier, she would have had choices–stop drinking with her friends on the weekend, take vitamins, eat healthier…all things she had not been doing but immediately began once leaving the surgeon’s office. She also has decided to drop out of college with less than one year left so she can prepare as best as possible for the changes that will now be coming her way. She moved out of her apartment and back home with her parents, knowing finances responsibilities are much different than just a day earlier when she was enjoying being young, hanging with friends, working a part-time job, and trying to finish her last year in college so she could get the degree she had been working so hard to complete.

The healthcare system exists for many reasons–but at a bare minimum, physicians are required by an oath to “first do no harm.” Here is a glaring case that has the potential to harm at least two people, and has changed the lives of many in this girl’s inner circle. As 20-somethings find their way in the world, mistakes are common and often the way in which many learn lasting life lessons. I know I made my share of mistakes growing up. Safeguards like healthcare are supposed to be in place to help mitigate some of those mistakes–not compound them–and seeking help from a healthcare provider should not result in greater harm as a result. In this case, because of what appears to be pure medical incompetence resulting from one physician’s inability to follow standard of care practices, this young girl’s life, and possibly that of her unborn child, will be changed forever. We do have a medical error crisis, and many caregivers are working very hard today to make care safer for our patients but we also need to address competency and critical thinking issues. To do this, it will take more than teach-backs, checklists and timeouts…


MedStar Health Institute for Innovation (MI2) Invites Associates To “Think Differently”

“Discovery consists of seeing what everybody has seen and thinking what nobody has thought.” Albert Szent-Györgyi

Last week, Dr. Mark Smith, Director of MedStar Health’s Institute for Innovation (MI2), and his team, invited ~250 MedStar associates to “think differently,” during a day of inspiration and thought-provoking presentations meant to catalyze innovation in healthcare. The foundational premise at MI2 is that there exists a tremendous amount of untapped creative capital at MedStar and healthcare in general, and by encouraging all to “think differently,” solutions to yet unsolved healthcare challenges can be uncovered. Smith designed MI2 to thrive in the thinking space, reframing existing healthcare challenges by aiming intentional thought from new directions, changing altitude–literally and figuratively–as needed. The Institute’s tag line keeps them in the company of easily recognized game changing organizations such as IBM’s “Think” and Apple’s, “Think different”.

The Innovations Day “Early Bird” session kicked off the day’s agenda with Steven Johnson’s TED Talk, Where Good Ideas Come From (see below). The basis of Johnson’s talk is that good ideas take time to grow, and need to be nourished and built upon by others. Those Eureka! moments aren’t reality, according to Johnson, but the process can be accelerated by tapping into the liquid networks of knowledge that surround us–and why the MI2 team was encouraging all in their audience to celebrate the individual expertise in the room.

Dr. Ed Tori, aka The Patient Whisperer, followed with his talk on influence, Seduction Artists, Con Men & Cult Leaders, and How They Can Save Healthcare. Tori uses his growing mastery of influence to connect the head, heart and gut–not only with his patients, but his colleagues and kids as well. “Who wants broccoli?” takes on a whole new meaning in the Tori household when suggested with enthusiasm, authenticity, and a “go first” attitude. Influence, Tori shared, is about managing states and emotions. If you can change the mood, the mind will follow, but connecting on an emotional level is a must and the way to build the rapport needed to engender a following. While this may be a new skill set for many who studied the sciences, it is one that can be learned if the mind and the heart are willing.

Each encounter with a patient is a gift and an opportunity to connect, Tori also reminded the audience. Don Berwick has spoken on this very topic more than once (Google Don Berwick Yale Medical School Address). Care providers are often thrust into their patients’ lives at a time they are most vulnerable. As such, a patient’s authenticity detector is on high alert, per Mark Smith. The words you choose during these highly charged moments of opportunity can make all the difference–whether the patient leaves with a burden lifted, a mother’s concerns are gently eased, or a grandfather returns home with heightened anxiety because he never asked the question weighing heavy on his heart. As a writer, the following YouTube video shared by Tori last week, was a splendid reminder of the impact words can have–simply by altering their order or emphasis. Written, spoken or withheld–words have the power to create meaning that previously did not exist, turn strangers into those with a common purpose, and improve the well-being of others. Which words will you choose to change healthcare for the better? Please share them.


Learning Put Into Practice Through Relationship Building: One Student’s Reflection

By Kristin Morrison

Kristin Morrison is a Telluride Patient Safety Student and Resident Summer Camp Alumni, an MD candidate at the University of Missouri School of Medicine and an MPH candidate at the University of Missouri. See additional reflections by Kristin on patient safety & quality efforts through the eyes of a medical student at the Transparent Health blog: M2-Metaphors and Mindfulness and Why Not Put Adverse Events Right In Patient Charts?

Being a patient safety and medical education site, ETY is delighted to share student and resident research and reflections with you, as they represent the next generation of caregivers. Additionally, the issues discussed and educational materials shared by students on ETY are aspects of healthcare infrequently included in today’s medical curricula. Sharing them with other students and residents will help future caregivers better understand the issues and challenges facing healthcare in the years ahead.

When I think of Telluride, I think of one thing: a catalyst.

I went to Telluride with some experience in patient education and health literacy, and I believed that the topics of patient safety and quality improvement would fit nicely with my other interests. I was pleased to discover that these elements weave together beautifully, and that they’ve expanded my views on patient care while inspiring me to look at medical school as the perfect time to explore what entering this profession means to me.

Telluride was incredible because it provided me with a nurturing environment to discover both the fundamentals and nuances of patient safety and quality improvement. Armed with a stack of books by Pronovost and Levy and Gawande, a bunch of new contacts in my iPhone, and a flashdrive of more information than I originally realized, I left Telluride invigorated to do something to improve both patient safety and the experience of medical education at my school. One thing I noticed while there was that the human connection makes all the difference: whether it was talking in small group sessions, jamming to classic rock on a hike or listening to a mom who lost a daughter talk about how much she wished someone cared about her–building relationships seemed like the foundation to improving health care to me.

So, when I returned, I set out to build new relationships. I spoke with our Associate Dean of Education to tell her about Telluride and ask for ideas about who to talk to next. Then I met with our Patient Safety Coordinator to learn about what our hospital is doing in regards to patient safety, and I was so pleased to discover that we are actually doing quite a lot. I noticed she had Sorrel King’s “Josie’s Story” on her bookshelf, so I asked to borrow it; I offered her Pronovost’s “Safe Patients, Smart Hospitals” in exchange, and she has since ordered more copies for her department. I recently talked to the doc who coordinates our interprofessional curriculum, and will provide student input for future curriculum development meetings. In October, I’m attending a Crew Resource Management training at our new orthopaedic hospital and meeting with the medical director of our Office of Clinical Effectiveness. Given the human nature of medicine and patient safety, I thought it made the most sense to start by forming new relationships.

I also recently had a chance to work on building relationships with other med, nursing, and pharmacy students. We had an interprofessional session (based on one done at another university) about disclosure that involved a talk by our CMO followed by small-group breakout sessions. In the small-group sessions, teams of med, nursing, and pharm students practiced disclosing an error to a patient’s family member (portrayed by a standardized patient). The patient’s family member was aware that something had happened but not of the details, so the first question I asked her was “Can you tell me what you understand about what happened to your grandfather?” It gave my group a frame of reference for building the rest of the conversation because we had a better understanding of where she stood. One of our follow-up questions was, “What are you most worried about for your grandfather?” and we were surprised to discover that her worries were not the same as ours. We quickly shifted gears to address her concerns, and during the debrief she mentioned how glad she was that we were able to “meet her where she was” during the conversation.

One common thread I’ve noticed through working in health literacy, going to Telluride, meeting with folks at my school/hospital, and participating in that interdisciplinary session was that even though patient-centered care seems obviously correct and intuitive, it is still challenging to achieve. I can tell that providing safe, effective, patient-centered care will require diligence, flexibility, and teamwork from a variety of health professionals–and in doing so, I believe we can honor patients for the giving us the privilege of being a part of their lives.


Culture of Respect In Medicine is the Responsibility of All Caregivers

In an excellent article, Darrell Kirch MD, President of AAMC, recently reminded all practicing physicians of the examples we set, and therefore responsibility we have, to our students when it comes to modeling a culture of respect in medicine. In his September post on the AAMC website,  A Word From the President: Building a Culture of Respect, Kirch shares not only his own memory of being disrespected as a student, but also the results of the AAMC 2012 Graduation Questionnaire which shows that 33% of respondents confirm being humiliated by those in a mentoring role. Kirch comments:

When things like this happen, we compromise the learning environments of medical students and residents. Tomorrow’s doctors must be able to learn in a safe and supportive culture that fosters the respectful, compassionate behavior we expect them to show their future patients.

As physician educators, we have an opportunity to shape the culture of medicine. The disservice we do to our profession when we choose to break-down versus build-up our students, and one another for that matter, are missed opportunities to lead and provide a positive role model for those we are enlisted to enlighten. I remember a faculty member at one of the Telluride Summer Camps reinforcing that it’s not just disrespect down the power gradient, but peer-to-peer disrespect that also occurs in medicine. As such, it’s truly going to take educating the young on the “right way” to interact with colleagues, but also re-educating “the old” on tenets of professionalism and the impact disruptive behavior has in creating toxic safety cultures. And it’s going to take all of us to create the change needed and to challenge our peers who believe intimidation is part of the medical education learning culture. As Kirch points out:

As educators and leaders in the medical profession, we have an obligation to eliminate any mistreatment of medical students. The solution starts by addressing the  culture and climate at each institution… at UCLA’s David Geffen School of Medicine…implementing stricter policies and faculty workshops were somewhat effective…not sufficient by themselves. What is needed to eradicate medical student mistreatment is, they concluded, “an aggressive, multipronged approach locally at the institution level as well as nationally across institutions.”

In the end, no work environment should include humiliation and bullying. Other industries do not tolerate the disrespect medicine has been willing to accept for many years. Darrell and I  have both referred to Dr. Pauline Chen’s piece in the NY Times, The Bullying Culture of Medical School  and here on ETY, Bullying In Medicine: Just Say No, about how this negative sub-culture exists during training. Why would we accept this disruptive behavior by a few of our peers in a profession where caring and compassion is at the core of why we chose to pursue it? It’s counter-intuitive and, in the end, always reaches the patient–the person we have sworn to protect. Patients and families see this disruptive and professional behavior and wonder why it exists. Sometimes we have to hit bottom, look in the mirror, and say enough is enough. We need to acknowledge that the disruptive behavior of a small minority of our contemporaries reflects on all caregivers and our profession as a whole. I applaud Dr. Kirch and  the AAMC for continuing to bring this unprofessional and unproductive behavior into the open–this is how change begins and care becomes safer for our patients.


TEDMED’s 20 Great Challenges – Eliminating Medical Errors Also Requires Educating the Young

I have really enjoyed following the progress and discussions related to the TEDMED 20 Great Challenges program to be held in conjunction with TEDMED, next April 16-19 in Washington DC. TEDMED is working to increase awareness and develop a deeper understanding of these Great Challenges to Health and Medicine, defined as persistent problems that have medical and non-medical causes, impact millions of lives, and affect the well-being of all Americans. During this past year’s 2012 TEDMED gathering in Washington, DC — also streamed simultaneously to hundreds of auditoriums nationwide allowing as many as 50,000 offsite Delegates to participate via a remote simulcast called TEDMEDLive — the TEDMED community defined, discussed, and voted for, these 20 Great Challenges of Health and Medicine. For the coming year, the Great Challenges Program will generate a lively national dialogue around each of the Challenges chosen by the TEDMED community.

I was excited to see that “Eliminating Medical Errors” was one of the 20 Great Challenges, as this is a problem that persists despite the hard work of many of us who have dedicated our careers trying to prevent. As I navigated through this category on the TEDMED site, I noticed a “fill-in-the-blank” question posed by the event organizers in the discussion section:

–To eliminate medical errors we must…

As so often happens when I get that type of prompt, I instinctively blurt out the same thing I said many years ago – a quote that has literally followed me around the world, and was the inspiration for this blog. If you want to eliminate medical error “Educate the young and regulate the old,” I repeated. The story behind my statement is the basis of my premiere ETY blog post of the same phrase, and can be found here.

As someone who has spent his entire career in safety and quality, it has not been an easy road. For years, the incentives were horribly misaligned. Even when caring and compassionate caregivers spoke up for change, sharing evidence-based work that demonstrated new ways to reduce risk to patients, financial leadership would push back citing decreased reimbursement and lack of funds to support quality and safety efforts. It was frustrating to argue with the “bean counters” who saw bottom-line dollars and financial capital more important than human capital. So in the heat of my frustrations that day while participating on the closing panel of an Australian patient safety conference, I instinctively replied “Educate the young and regulate the old”.

But think about it…this is exactly what is happening in healthcare today. Rules and regulations driving value-based purchasing, decreased reimbursements for hospital readmissions, and incentive-based core measures are just a few examples of the new medical-financial lexicon. The Triple Aims of care – highest quality, sustained wellness, at the greatest value where patients are true partners in their care, is now the preferred framework for delivery of care. All collectively represent the medical language of the 21st century…long overdue in the eyes of many at the frontlines of patient care, but now understood by those in the financial suites trying to balance budgets using healthcare’s “new world accounting”.

In addition to these new regulations, educating the next generation of caregivers to meet these needs and speak the new language is critical in order to achieve the success we are striving for, as well as address the new requirements of healthcare. Health science curricula can no longer remain in the dark ages, and will need to design educational models and coursework that address the changing needs of healthcare, such as:

  • Patient-centered care over physician-centered care
  • Quality of care provided instead of volume of procedures done
  • Outcome measurements and transparency instead of denial and ego-driven beliefs of quality
  • Open and honest communication instead of “deny and defend” tactics when unintentional patient harm occurs

By training students and residents on these newer, safer and higher quality models of care, evolution to highest-quality, lowest-risk care at good value will become a reality. The next generation of caregivers needs to hit the ground running if we are to accelerate achievement of these goals. I hope educators and student leaders are included in the TEDMED 20 Great Challenge discussions next spring–not only to educate the next generation on these issues, but also because they will provide a fresh outlook to problems that continue to challenge all of us in the delivery of safe care.