I think that everyone who wants a leadership role in a residency program should be permitted one.
A residency isn't just a group of doctors in training, it's a group of leaders in training, as well.
These individuals will be faced with challenges and in leading the clinics at which they work.
Academic Chief is a start. Creating roles for leaders who can act independently and who can act to provide honest feedback to influence the course of a residency program are important to fostering a flexible training program.
Initiative in any form should be met with encouragement.
Friday, December 18, 2009
Tuesday, December 15, 2009
Health Care Reform
Health Care Reform
original 7/10/2009, updates are in {RED}
After all of this is over and the dust has cleared, these sites may help to figure out "what just happened?"
#1 http://www.rwjf.org/files/research/chart1.pdf
Non-partisan interactive chart with a comprehensive list of health care reform ideas (Republican, Democrat, and In-between)
*that link doesn't work anymore
Here's an excellent report on controlling costs which notes the benefits of the "episodes of care system":
http://www.rwjf.org/files/research/nrhiseriesbettewaystopay.pdf
#2 http://www.rwjf.org/healthreform/product.jsp?id=40713
Discusses some of the proposals in #1
#3 http://mayoweb.mayo.edu/newsbulletin-rst/documents/PDFPerspective.pdf
Mayo perspective. You might have read it in a recent email from the head office. (and there have been others)
#4 http://healthreform.kff.org/
Non-partisan, non-profit called the Kaiser Family Foundation with analysis of this issue (not connected to Kaiser Permanente)
#5 http://www.kff.org/healthreform/sidebyside.cfm
A really good comparison of all the current legislative proposals out there.
this is still really good and it's updated. when things are this complex, it's nice to have it in chart form.
and
http://www.kaiserhealthnews.org/Stories/2009/July/10/exchangesQA.aspx
Health insurance exchanges explained (kind of a big deal)
#7 http://www.rwjf.org/healthreform/
Non-partisan, non-profit called the Robert Wood Johnson Foundation with analysis of this issue
the best thing on this site is "The Cost of Dying" the 60 Minutes story on this used this article as a source: http://www.rwjf.org/healthreform/product.jsp?id=52311
#8 http://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf
Non-partisan Congressional Budget Office (CBO) report on the issue (it's long, but you could get the gist of it by skimming a few pages)
OK, so you're not going to read that. The most important piece here is that just about everybody (republicans and democrats) agrees that the CBO is coming up with reasonable estimates. The two reasons to reform health care are to increase coverage and to lower the costs of that coverage. Both are important. For more information on cost, this is a great document: http://www.kff.org/healthreform/upload/8022.pdf
#9 http://healthreform.gov/index.html
President Obama's web page devoted to the issue. (Note: his stated aim is to let congress take the lead in developing a plan, but he does list some key principles.)
#10 http://finance.senate.gov/healthreform2009/finalwhitepaper.pdf
Democratic Senate Finance Chair Baucus's proposal for health care (the main Democratic proposal right now)
If you're trying to figure it out from the list on #1, I think it's mostly "Singer/Garber/Enthoven" + the ability to have early Medicare buy-in for those age 55-64.
See also #6
If you'd like to see the House Bill that passed in November, you can. It's here in all of its 2000+ page splendor:
http://thomas.loc.gov/cgi-bin/bdquery/z?d111:H.R.3962:
If you'd like to see the Senate Bill as it is up to the moment, you can. It's also more than 2000 pages: http://www.senate.gov/pagelayout/legislative/b_three_sections_with_teasers/active_leg_page.htm
#11 http://wyden.senate.gov/issues/Legislation/Healthy_Americans_Act.cfm
Democratic Senator Wyden's proposal. (Google: Healthy Americans Act)
If you're looking at the list on #1, this one is mostly "Wicks/Meyer/Silow-Carroll"
Right wing resources
Republican Senate and House of Representative proposal. (Google: Patients' Choice Act)
If you're looking at the list on #1, this one is also (more loosely) based on "Singer/Garber/Enthoven" but it's the states that run the exchanges, not the federal government.
See also #6
N/A
#13 http://blunt.house.gov/HealthCare/DearColleague.pdf
Republican Representative Health Care Solutions Group Chair Blunt's letter outlining goals (there's also an associated web site)
It was a little difficult to find, but I think this is the main republican page for health care reform (includes senate and house and ...)
http://www.gop.gov/solutions/healthcare
#14 http://www.cato.org/health-welfare-entitlements
Conservative think tank called the Cato Institute's ideas on the subject of health care
Here's another interesting article:
http://www.cato.org/pub_display.php?pub_id=11054
#15 http://www.cato.org/pubs/handbook/hb111/hb111-15.pdf
Cato Institute's ideas how to make medicine better, safer, and cheaper (it might make you cringe, or not)
#16 http://www.politico.com/healthcare/
Daily updates on the issue in Washington, DC
#17 http://www.ama-assn.org/amednews/site/topic.htm#reform
The AMA's newsroll.
#18 http://www.aafp.org/online/en/home/publications/news/news-now/government-medicine.html
All doctors aren't the same. The AMA has a tough road trying to represent a varied bunch. Our organization's take on things. (Wouldn't it suck if health care reform screwed us and gave the urologists more Porsches?)
Friday, December 11, 2009
the trouble with email
the trouble with email as a "push" form of communication is ...
...if you send it to everyone you're not sure if anyone is going to read it or act on it {and the race to the bottom of a stack of emails (or to the trash bin) is pretty quick for most people.}
...if you send it to one person you are almost certainly excluding someone who has opinions, knowledge, or a stake in the issue
...if try to go the middle route and pick a few people it seems to both exclude and go unread by those you'd like to read it. {and the serial nature of a thread can really hamper having a robust discussion}
blogging, as a "pull" form of communication helps with this problem. but it can simply go unread.
and that's fine because people have a right and a need to triage all the information flying at them.
but there needs to be a better way (or better use of existing mechanisms) to help people triage the "push" that they're receiving. Flags, marking "priority", and similar are commonly used (and overused) but within organizations (and beyond) it would be nice if there was some convention to it.
We all have our own organization scheme for our inbox (and no organization scheme is still one). It'd be interesting to see what's the most efficient scheme we use to save and retrieve the emails we RECEIVE and tailor some prioritization scheme to the emails we SEND.
this is the kind of thing an electronic resources committee could ponder.
not to try and be a whole new IT department. instead as an organized group to brainstorm, liaison, and advise.
Other issues could be considered:
Departmental and residency web pages
Individual and departmental blogs
Intranet and internet resources for care and patient education
Electronic health record
Webcasting and other ways of disseminating educational information
...if you send it to everyone you're not sure if anyone is going to read it or act on it {and the race to the bottom of a stack of emails (or to the trash bin) is pretty quick for most people.}
...if you send it to one person you are almost certainly excluding someone who has opinions, knowledge, or a stake in the issue
...if try to go the middle route and pick a few people it seems to both exclude and go unread by those you'd like to read it. {and the serial nature of a thread can really hamper having a robust discussion}
blogging, as a "pull" form of communication helps with this problem. but it can simply go unread.
and that's fine because people have a right and a need to triage all the information flying at them.
but there needs to be a better way (or better use of existing mechanisms) to help people triage the "push" that they're receiving. Flags, marking "priority", and similar are commonly used (and overused) but within organizations (and beyond) it would be nice if there was some convention to it.
We all have our own organization scheme for our inbox (and no organization scheme is still one). It'd be interesting to see what's the most efficient scheme we use to save and retrieve the emails we RECEIVE and tailor some prioritization scheme to the emails we SEND.
this is the kind of thing an electronic resources committee could ponder.
not to try and be a whole new IT department. instead as an organized group to brainstorm, liaison, and advise.
Other issues could be considered:
Departmental and residency web pages
Individual and departmental blogs
Intranet and internet resources for care and patient education
Electronic health record
Webcasting and other ways of disseminating educational information
medical student loans and forgiveness
I had a 2 year Navy scholarship when I was a medical student. So I have less debt than I would have otherwise. But I still have more than $100K racked up.
I've been in repayment for the loans since 2004.
In the last few months I found out about a new repayment plan that really lowered my monthly payment. It's called the "Income Based Repayment Plan" and it cut my monthly payment in half.
Also, there's 2 new loan forgiveness scenarios that I wasn't aware of.
The basic skinny is: (1) if you make 25 years of payments, whatever is left gets forgiven and (2) if you make 10 years of payments and you're doing some sort of service, whatever is left gets forgiven.
It's hard not to pay even a big loan off in 25 years (think mortgage), but 10 years is a real bargain.
There is a lot of ambiguity about what would constitute a "public service job" even though they try to lay it out pretty specifically:
you qualify if you...
...are employed by any nonprofit, tax-exempt 501(c)(3) organization;
...are employed by the federal government, a state government, local government, or tribal government (this includes the military and public schools and colleges); or
...serve in a full-time AmeriCorps or Peace Corps position.
--or--
A private organization that is not a for-profit business, a labor union, a partisan political organization, or an organization engaged in religious activities (unless the qualifying activities are unrelated to religious instruction, worship
services, or any form of proselytizing) and that provides the following public services –
Emergency management;
Military service;
Public safety;
Law enforcement;
Public interest law services;
Early childhood education (including licensed or regulated health care, Head Start, and state-funded pre-kindergarten);
Public service for individuals with disabilities and the elderly;
Public health (including nurses, nurse practioners, nurses in a clinical setting, and full-time professionals engaged in health care practioner occupations and health care support occupations);
Public education;
Public library services; and
School library or other school-based services.
here's the fact sheet from the government: http://studentaid.ed.gov/students/attachments/siteresources/LoanForgivenessv4.pdf
From what I can tell in looking over the IRS website (search section 78 for the word "clinic" here: http://www.irs.gov/app/pub-78/) it seems like there's a lot of places that would qualify as employers.
The Cleveland Clinic
Emory Clinic
Johns Hopkins
Kaiser Permanente
Massachusetts General & The Brigham and Women's Hospital
The Mayo Clinic
I may be missing something, but from what I can tell these are all 501(c)(3) organizations.
The implication is that there are a lot of places for a family physician to work which would qualify as a 501(c)(3) organization. And would this work qualify for the 10 year forgiveness?
I've been in repayment for the loans since 2004.
In the last few months I found out about a new repayment plan that really lowered my monthly payment. It's called the "Income Based Repayment Plan" and it cut my monthly payment in half.
Also, there's 2 new loan forgiveness scenarios that I wasn't aware of.
The basic skinny is: (1) if you make 25 years of payments, whatever is left gets forgiven and (2) if you make 10 years of payments and you're doing some sort of service, whatever is left gets forgiven.
It's hard not to pay even a big loan off in 25 years (think mortgage), but 10 years is a real bargain.
There is a lot of ambiguity about what would constitute a "public service job" even though they try to lay it out pretty specifically:
you qualify if you...
...are employed by any nonprofit, tax-exempt 501(c)(3) organization;
...are employed by the federal government, a state government, local government, or tribal government (this includes the military and public schools and colleges); or
...serve in a full-time AmeriCorps or Peace Corps position.
--or--
A private organization that is not a for-profit business, a labor union, a partisan political organization, or an organization engaged in religious activities (unless the qualifying activities are unrelated to religious instruction, worship
services, or any form of proselytizing) and that provides the following public services –
Emergency management;
Military service;
Public safety;
Law enforcement;
Public interest law services;
Early childhood education (including licensed or regulated health care, Head Start, and state-funded pre-kindergarten);
Public service for individuals with disabilities and the elderly;
Public health (including nurses, nurse practioners, nurses in a clinical setting, and full-time professionals engaged in health care practioner occupations and health care support occupations);
Public education;
Public library services; and
School library or other school-based services.
here's the fact sheet from the government: http://studentaid.ed.gov/students/attachments/siteresources/LoanForgivenessv4.pdf
From what I can tell in looking over the IRS website (search section 78 for the word "clinic" here: http://www.irs.gov/app/pub-78/) it seems like there's a lot of places that would qualify as employers.
The Cleveland Clinic
Emory Clinic
Johns Hopkins
Kaiser Permanente
Massachusetts General & The Brigham and Women's Hospital
The Mayo Clinic
I may be missing something, but from what I can tell these are all 501(c)(3) organizations.
The implication is that there are a lot of places for a family physician to work which would qualify as a 501(c)(3) organization. And would this work qualify for the 10 year forgiveness?
Tuesday, December 1, 2009
Consumer reports info on Medicare part d and trazodone
Click here for a mobile version. If you are having trouble viewing images, Click here.
NEWS UPDATE
ConsumerReportsHealth.org/BestBuyDrugs
Dear Mark Morgan,
Are Your Prescription Drugs Safe?
The Food and Drug Administration approved them, your doctor prescribes them, and you see them advertised on TV — so your medications must be safe, right?
More than half of all prescription drugs cause adverse effects — some serious or fatal — that aren't detected until after the FDA approves them, sometimes many years later. In 2008 alone, the FDA received more than 100,000 reports of serious injuries related to adverse drug events, an increase of about 25 percent over the previous year, according to the Institute for Safe Medication Practices.
In addition, the U.S. system for identifying drug risks before approval is flawed — and the one for spotting them afterward is even worse. Take a closer look at why you face these unexpected dangers, and what you can do to protect yourself.
Prescription Drug Insurance
How to pick the best Medicare Part D plan
It's that time of year again. Open enrollment for 2009 for the Medicare Part D drug benefit takes place from Nov. 15 through Dec. 31, 2009. You should enroll by Dec.15, though, to avoid potential coverage lapses and problems filling your prescriptions. Your coverage will be in effect from Jan. 1 through Dec. 31, 2010.
Whether you are enrolling for the first time or considering switching, you might have dozens of private plans to choose from, with differing premiums, co-payments, and levels of coverage — including which drugs are covered. As a result, we strongly urge Medicare beneficiaries to:Premiums are projected to increased by an average of 11 percent next year, with some of the biggest plans charging an estimated six to 22 percent more than they did in 2009. The average monthly premium for basic benefits is estimated to be about $37, according to a Kaiser Family Foundation report, but premium ranges will vary widely, from around $9 per month for some plans to more than $120 for other plans. There are a number of factors to consider in choosing a plan. Read on for more details on how to choose a plan, avoid the doughnut hole and what you can do if you think you may enter it next year.
- Understand the drug coverage you already have, if any.
- Get information on the Part D benefit in advance.
- Set aside time to study your choices and compare plans in detail.
- Seek independent outside information and advice, if needed.
- Pick a plan carefully.
Off-label Prescribing
The most common insomnia drug is one you've probably never heard of
What's among the most widely prescribed drug for insomnia—Ambien? Lunesta? Yes, but there's also another: a nearly 30-year-old generic antidepressant called trazodone, which causes drowsiness as a potentially useful side effect.
Trazodone is not approved by the Food and Drug Administration for treating insomnia (though doctors can legally prescribe it for this and other treatments). There's very little clinical trial evidence on whether it's effective for that purpose when there's no accompanying depression, and only modest evidence when there is. But numerous doctors use it because they believe that trazodone is the best sleep medication for many people.
Here's why trazodone has become so popular—and what to do if your doctor suggests you try it.
For additional information on more than 200 prescription drugs, alternatives to high-priced drugs and Best Buy selections for the most common, chronic medical conditions, visit ConsumerReportsHealth.org/BestBuyDrugs.
About the Consumer Reports Best Buy Drugs™ Project
Consumer Reports Best Buy Drugs™ is an educational and outreach initiative that compares a variety of prescription drugs on price, effectiveness and safety to help consumers and their doctors identify the most effective and affordable medicines.
The project combines evidence-based research on the comparative effectiveness and safety of prescription drugs with comprehensive nationwide data on drug prices. The information on drug effectiveness is derived from the Drug Effectiveness Review Project (DERP), a 14-state initiative. Price information is based on average retail prices paid in cash by consumers at the pharmacy. Every drug report is peer-reviewed by medical experts in the particular drug category.
For information on other drug categories we have examined to date — heartburn and acid reflux drugs, high blood pressure, depression, arthritis and pain — visit ConsumerReportsHealth.org/BestBuyDrugs.
Thanks for visiting,
The Consumer Reports
Best Buy Drugs™ Team
Resources
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Tuesday, November 17, 2009
Study Template
The IRB has released a template (attached) that includes all the elements required for submitting a minimal risk study through IRBe. This applies to the majority of studies done in Family Medicine.
http://bit.ly/2RRxtS
CTSA - Research Resources CReFF Award Program Announcement
CReFF Award Program Applications due March 1, 2010
The Mayo Clinic Center for Translational Science Activities (CTSA) is accepting applications for the 2010 Clinical Research Feasibility Funds (CReFF) Award Program.
CReFF awards support investigator-initiated, patient-oriented pilot/feasibility studies that use CTSA Research Resources facilities and services such as the Clinical Research Unit (CRU) and Translational Technology Cores.
The awards are intended to assist junior faculty as they generate preliminary data to support studies with a high likelihood of gaining future extramural funding. Eligible applicants must have a confirmed faculty appointment as of Jan. 1, 2010 and may not have a Mayo core research budget or more than 20 percent Category I research time.
Applications must be submitted via the IRBe system by March 1, 2010. Awardees will be notified by May 28, 2010 and funding will commence July 1, 2010.
A full description of the CReFF award, eligibility guidelines and application instructions are available online. Direct questions to Bettie Lechtenberg at (77)5-7916.
Monday, November 16, 2009
Family Practice Inquiries Network (FPIN).
Take a look at the November Evidence Based Practice to learn the answer to "Is iontophoresis therapy effective for tennis elbow (lateral epicondylitis)?" Our very own Dr. Alejandro Garcia was the lead author on that Help Desk Answer! FPIN is an opportunity to do research and be published for a "Help Desk Answer" or a "Clinical Inquiry".
Read the article here: http://bit.ly/3BC2FH
Friday, October 23, 2009
Tuesday, October 20, 2009
Worth your time
How could coupons possibly be worsening the health care crisis (yes, coupons)? Is it possible that insurance companies aren't the problem? Is the "public option" debate missing the point?
These questions and more are answered in the this intriguing and entertaining show about health care costs and reform. I think this matters and is relevant. Each part is about an hour.
Part 1: More is less
Part 2: Someone else's money
http://www.thisamericanlife.org/Radio_Episode.aspx?sched=1321
It's relevant to our specialty and to this particular time in the country. We're all at the beginning of our careers and the entire industry is being rethought. right now. by a lot of people who aren't doctors.
If you feel that discussion of health care really breaks along partisan lines, it's this kind of report that cuts through that. And if you're feeling uneasy about the current debate because it seems to be missing the point in some way, that's what this is about.
I think we all want to practice evidence based medicine. It's at the heart of our specialty. All the forces that you haven't really thought about why we sometimes (often?) don't do that thing that all of the evidence supports.
It's relevant to our specialty and to this particular time in the country. We're all at the beginning of our careers and the entire industry is being rethought. right now. by a lot of people who aren't doctors.
If you feel that discussion of health care really breaks along partisan lines, it's this kind of report that cuts through that. And if you're feeling uneasy about the current debate because it seems to be missing the point in some way, that's what this is about.
I think we all want to practice evidence based medicine. It's at the heart of our specialty. All the forces that you haven't really thought about why we sometimes (often?) don't do that thing that all of the evidence supports.
Wednesday, October 14, 2009
link page
Here's that page of links.
http://delicious.com/fmacademics
Advantages:
no log on is required (saves time)
everything in one place
you can search and sort them as you'd like
Disadvantages:
Some links are on the intranet only - hard to avoid this
I actually don't have all the family med links in there (I missed a bunch) - but I'm working on it.
It's another thing to deal with
And:
If you like it and want to create your own account, that's great. I think that's the whole '2.0' part.
If you'd like to edit this list, the user name is fmacademics and the password is @mayofp1
Let me know what you think.
Tuesday, October 13, 2009
Monday, October 5, 2009
Family Medicine Journal Club - Tuesday, October 13
Family Medicine Journal Club: OCTOBER Details
WHEN: TUESDAY, OCTOBER 13 AT 6 PM.
WHO: Dr. Robert Bonacci will be facilitating a discussion of Technology in Family Medicine.
WHERE: Dr. Bonacci's House 910 Folwell Drive SW. Map at http://bit.ly/1IbOzg
ARTICLE FOR DISCUSSION:
Tranform presentation on emerging techonologies at http://centerforinnovation.mayo.edu/transform/index.html. You will need to scroll down to on the “Transform Talks” window and you will find the presentation by Indu Subaiay.
RSVP with Tammy Younge so we can figure out logistics.
Here's a short survey we'll discuss, as well: http://bit.ly/Tq3vf
About Journal Club
Journal club is a monthly meeting the second Tuesday every month. It intends to focus on the evidence that supports the care we provide. Usually we'll be reviewing a single journal article.
To prepare, we ask that you 1) view the video and 2) think of ALL the websites you access while you're providing care and submit the name of one website you use (besides www.uptodate.com and www.mayo.edu) which helps you provide more effective care.
Most of all it's supposed to be relevant and interesting.
Email me if you have ideas for articles for discussion and/or you'd like to facilitate a future discussion.
And remember, contrary to the old Klingon proverb Journal Club is a dish best served warm.
Take care,
Mark Morgan
Thursday, October 1, 2009
Palliation and one other thing
http://docs.google.com/present/edit?id=0Afx385EXJZMyZGdjbW1zZnFfOTYxNnNocnY1aGI&hl=en
From Dr. Matthews on EBM:
...an open-access article from PLoS Medicine.
Nice article from PLoS about bias in clinical trials...
Read the open-access, full-text article here:
http://dx.plos.org/10.1371/journal.pmed.1000152
Tuesday, September 29, 2009
Numbers needed to treat and MORE
Here is my presentation about numbers needed to treat
http://docs.google.com/present/edit?id=0Afx385EXJZMyZGdjbW1zZnFfOTQ3Z3ZzZDl0ZnQ&hl=en
Dr. Matthews's links:
http://nntonline.net/ (smiley faces)
http://www.shef.ac.uk/FRAX/ (fracture risk assessment)
http://www.mdcalc.com/wells-criteria-for-dvt (Wells DVT score)
Geriatric Depression Scale (from up to date)
- The Geriatric Depression Scale — This self-report instrument has been studied in multiple settings [87,88]. A five-item version demonstrated good receiver operating characteristics across the full spectrum of elderly populations [88]. The five items are:
- Are you basically satisfied with your life?
- Do you often get bored?
- Do you often feel helpless?
- Do you prefer to stay at home rather than going out and doing new things?
- Do you feel pretty worthless the way you are now?
Two out of five depressive responses ("no" to question 1 or "yes" to questions 2 through 5) suggests the diagnosis of depression
Edinburgh Depression Scale (for postpartum depression)
http://www.patient.co.uk/doctor/Edinburgh-Postnatal-Depression-Score-Calculator.htm
The List
http://www.medicine.ox.ac.uk/bandolier/band50/b50-8.html
Bandolier
http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/NNT.pdf
AAFP
http://www.aafp.org/fpm/20000500/59unde.html
Businessweek Article
http://www.businessweek.com/magazine/content/08_04/b4068052092994_page_2.htm
New information on working at the prison
Hi everyone,
For those of you who didn't know, there is a prison in town and it is a Federal Medical Prison. It's kind of neat because it is where all the federal prisons in the region send their sick inmates.
I worked there for a year before I came here and I have worked out a few connections. I'm trying really hard to get some opportunities for moonlighting for our residents there. Family med is an obvious fit for that job since we can handle anything.
It's really a very soft gig working there overnight. You get paid at least $50 an hour. Usually you're sleeping. Sometimes it can be exciting. It's never dangerous, though. Plenty of female nurses and staff work there, as well.
They also need people occasionally to do chronic care clinics (can be evenings/weekends).
I have the tentative go-ahead from the firm that does the contracting (this is NOT Enhanced Med or whatever) to put together a pool of people as potential "back-ups" in case the night coverage falls through the cracks, they can't get someone to come in, or they need help for those clinics.
If you're interested in being on the substitute list, let me know.
So far they're working on getting the following people on board:
Sara Oberhelman
Shawn McManus
Ryan Ludwig
They can take at least 3 more people.
It's a first step to getting in to a very lucrative spot. Right now it's mostly fellows because the waiting list is so long. This is a backdoor that will be good for us and good for the prison. I'm just not sure a pediatric subspecialist needs to be working there.
Let me know if you're interested or if you have any questions,
Mark
Sunday, September 27, 2009
Friday, September 25, 2009
Prison Contact People
For doing an elective rotation: mnelson@bop.gov is Dr. Mike Nelson, the Clinical Director there.
For moonlighting: jcpierce@bop.gov (Jim Pierce) is the Prison contact person. cmorgan@neshold.com (Cindy Morgan) is the representative of the firm that schedules and contracts the moonlighters.
There is about a 3 month lead time for this.
Wednesday, September 23, 2009
Precepting Debriefing Sessions
I think it would be a good idea if we had a debriefing session after clinic at least one afternoon per week. This would be a way to collect and discuss cases from the day. It would be a time to run difficult cases by the group. Finally, some discussion could occur regarding possible research projects that could come out of the day's clinical encounters.
I think it would be time well spent.
Beyond research, board review, specific topical discussions, etc. could be discussed. It would be a way to add some education to the continuity clinic experience.
I think it would be time well spent.
Beyond research, board review, specific topical discussions, etc. could be discussed. It would be a way to add some education to the continuity clinic experience.
Sunday, September 20, 2009
Award winning children's books
From the American Library Association:
Updated feed bundle for Google Reader:
Friday, September 18, 2009
Scheduled committee meetings
Curriculum committee last Friday 12:15
Education committee last Wednesday 12:15
Research committee third Wednesday 12:15
Recruitment committee first Wednesday 12:15
Education committee last Wednesday 12:15
Research committee third Wednesday 12:15
Recruitment committee first Wednesday 12:15
Society for Teachers of Family Medicine
http://www.stfm.org/conferences/annual/an/index.cfm
A separate Call for Fellow/Residents/Students Works-In-Progress Posters will take place beginning in early November. Watch for details. [ultrasound study...]
A separate Call for Fellow/Residents/Students Works-In-Progress Posters will take place beginning in early November. Watch for details. [ultrasound study...]
Thursday, September 17, 2009
Notes from the OB ultrasound meeting 9/16/2009
The first session will indeed be on 10/22/2009.
45 minute blocks. 4 people max to a group. 3-4 groups.
Dr. Brost has identified someone outside the department who will work on scripting and materials so that we can be learners/participants and not skew results.
A questionairre will be administered.
questions may include: previous learning in U/S; intent to do OB; Age; Gender; Comfort level (1-5 scale) on AFI, CRL, presentation, etc.; frequency of U/S use, total cummalative OB U/S experience, etc.
Graded exercises, a variety of them.
This will be a Pre-test assessment with a debriefing.
Attendance needs to be high.
***We need to talk to Flinch, Gill, etc.
MFM fellows will supervise.
Pre Test
Thermofill pictures
Deidentified participants (for comparison to post test and other assessments)
Post Test
Will be done after they've completed 3? sessions?
Gold Standard
The OB techs will use the models. Their results will be the "Gold Standard" to which study participants will be benchmarked.
Can mix Pre and Post Test thermofills and have expert panel "read" them/independent review (construct validity).
Validity
Can images from an ultrasound machine be used to differentiate a novice from a competent sonographer from an expert? What other items can help in this differentiation.
Poster & IRB proposal
These should now be set.
Review of literature:
May consider using OB curriculum for U/S as a reference (esp if we're expected to be as competent).
Another source is at http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/rap/curriculum/maternitycare.Par.0001.File.tmp/Reprint261.pdf
I think that's it. Feel free to post here...
Dr. Brost has some pictures for the storyboard.
Review of literature:
another article is at
Saturday, September 12, 2009
curriculum info and Areas of Concentration
http://www.afmrd.org/i4a/pages/index.cfm?pageid=3360 has information for training requirements in general
http://www.afmrd.org/files/public/AOC_Individual_Guidelines.pdf has information about another certification called "Areas of Concentration"
I'm thinking this could be used to motivate OB ultrasound study participants. It really wouldn't be that hard. They would need to be able to attend one (1) US CME, which could be obtained locally (?)
Augmented training called "Area of concentration" are something we can add to our training. I don't know how this documented, though. It might be an incentive to formalize ultrasound, endoscopic, and other training, though.
1. The subject of the AOC should be within the scope of family medicine as defined by the New Model of Practice.
2. The AOC should be individualized to meet the needs of the resident and his/her future practice in family medicine. The needs of the resident’s future practice community may require enhanced training during residency that is above the core training in family medicine.
3. A written program of study designed by the resident with faculty input should be completed, including competency-based goals and objectives. The written program should include how the faculty will determine that the additional competencies have been achieved.
4. The additional training should be sufficient to achieve and demonstrate the desired competencies in the area of concentration.
The time to achieve this competence will depend upon the individual’s goals and objectives.
5. A scholarly project is completed in the AOC. The project is presented and evaluated locally, and a copy of the scholarly presentation and evaluation is kept in a portfolio of materials documenting the resident’s work in the AOC. Presentation at the state and national
level is encouraged.
6. The resident should attend a CME meeting relevant to the AOC, and be expected to disseminate clinically useful, evidence-based information to resident and faculty colleagues.
7. The resident presents a critical appraisal Journal club of an article in the chosen area.
8. Quality outcomes should be demonstrated and documented in the AOC with case logs (if relevant to the AOC), patient outcome data and faculty reviews of resident competency in the AOC.
9. A letter summarizing the training completed is written by the program director or faculty supervisor for placement in the resident’s portfolio to document the training that was completed.
flu trends (google has the flu)
http://www.google.org/flutrends/intl/en_us/
"We've found that certain search terms are good indicators of flu activity. Google Flu Trends uses aggregated Google search data to estimate the current flu activity around the world in near real-time"
-Google
Friday, September 11, 2009
the attendance problem
Some anonymous quotes:
"...attendance has always been a problem at conference, and even more so at grand rounds. Food helps with attendance but then you always have those that just show for the food and leave...which isn't right either I know. There needs to be consequences for not attending unless you are excused for being on call or post call. Even at that, maybe we need to do a better job of telling our residents and the off service rotations they are on that they need to have coverage in order to attend."
"...if you figure out a way to increase attendance and get people there, please let us know - we've been battling that problem for ages! It's unfortunate."
The problem
The problem is poor attendance. It leads to difficulty in getting good speakers. It ultimately results in a poor learning experience during residency. It's impact is not small.
Required conferences include Thursday Weekly Conference, Thursday Monthly Seminar, Friday Monthly Grand Rounds, Quality Improvement, and Balint.
The current policy
Mayo Family Medicine Residency
"The program requires that we maintain 75% attendance at conferences.
"DVD's of all conferences, seminars, and grand rounds are available through me in the Academic Center in Kasson. Beginning January 2009, if on-call, post-call, away rotation or on vacation, you have the option to watch all conferences at workstations to obtain credit. The links for webcasts can be found at: http://mayoweb.mayo.edu/fam-res/WebcastsforCredit.html.
"If you are not away due to the above reasons, you still need to attend "live" whenever possible. Recordings will not take place of your attendance if your schedule permits you to attend in person."
ACGME
"Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care."
"A Review Committee may grant exceptions for up to 10% or a maximum of 88 hours to individual programs based on a sound educational rationale."
Excused absences
For the Family Medicine OB service, it is expected (at date this document was prepared) that the resident begins work at 8 am when taking call. The 30-hour mark for the resident on FMOB, therefore, would be 2 pm the following day. Conferences/didactics, therefore, would only be excused beyond that time period.
For the Family Medicine Inpatient service, the starting time for work is more variable. Assuming the resident begins work at 7:00 am when taking call, the 30-hour mark for the resident on FM-Inpatient, therefore, would be 1:00 pm the following day. Conferences/didactics, therefore, would only be excused beyond that time period.
Motivational strategies
Consequences
The main penalty involved is related to graduation. If we're getting close to graduation then we possibly receive notification that are attendance is below the required level.
There are no other consequences currently in place. These might include a meeting with the program director, chief, or mentor to discuss the issue. I don't think removal of vacation days would go over well and it does seem harsh, but that would probably be a strong penalty for particularly egregious cases.
Inducements
This is where all the possibilities are.
Small monetary inducements work in research and they would work well with residents, too. The cost to the department would be nominal and the yield would be great.
Food always motivates attendance.
I think vacation days are very motivating. One problem with offering vacation days is that it is very difficult to take vacation in the first two years, and by the last year, the yield in motivational strategies for seniors is very small.
One motivating inducement for 1st and 2nd years might be scheduling priority. This would be a very strong motivator.
Public recognition is a strong motivator.
Acknowledgment in a detailed formal performance appraisal can be motivating.
Competition
What we are missing is that this demographic is one of the most competitive groups on the planet. Young doctors have been competing for test scores and academic rank for years. High school, organic chemistry, medical school, etc. It does probably foster a respectful learning environment to remove competition from some of the performance-related aspects of residency training. However, healthy competition with regards to attendance seems to have little downside.
Competition does require a few elements: a desirable ultimate reward (an undesirable ultimate penalty is not suggested), knowledge of ordinal position, and a persistent hope of reaching a goal.
Desirable ultimate reward: outside of inner drive to succeed (which is huge, but is a personal, internal thing), rewards do have the ability to motivate us. Recognition both to the department and in performance assessments could be implemented for the resident with the best attendance for each training year. A gift certificate for a small amount could be used. An additional half-day of vacation could be used. Any inducement from above could be a part of this.
Knowledge of ordinal position: having an idea what your own personal attendance rate is, as well as, where you stand in the pack would help with encouraging participation. This is pretty much common sense. I think that we need to have more frequent updates of our performance. It should either be 1) directly accessible by each resident or 2) provided to the resident with frequency and at a motivating time (such as Wednesday night or Thursday morning).
I've prepared an online spreadsheet which performs attendance calculations and could be used by residents and staff to track attendance. The output could be used in performance evaluations. It also distinguishes between attendance needed to graduate and attendance regardless of excused/unexcused status. It's ready to be used right now.
Persistent hope of reaching a goal: the online video setup is great, however, my gut feeling is that the presence of the video possibility wipes out any chance the excused residents will attend. For this reason, I think the raw number of attended conferences should be the goal that residents work to improve. This is a factor that motivates speakers: speakers like to have an audience. There should be absolutely no reward for simply viewing videos at home since this does nothing for the program and is a distant second to attending and participating in person. The reward for watching the videos is learning and being able to graduate.
The persistent hope of reaching the goal of a high personal attendance rate could be helped by giving more credit to those who attend when it would have been excused for them not to. I don't know the work hours rules behind this, but it would not be patient care, so hopefully this could be formally encouraged. Additionally, partial credit for non-required activities (such as journal club or board review) could foster healthy competition and improve attendance at those activities, as well.
Swipe-n-dash
I don't think this is the biggest part of the problem, but it's worth addressing and it could be addressed in a few ways. It seems to be possible because the device we swipe in to is always outside of the conference room.
Swipe out
Timing the system so that swiping can only occur after half the presentation has passed might help.
Sign in sheet
To the extent that this is a serious problem, maybe temporarily resorting to paper attendance would be helpful. This could be used to verify the swipes. Forging someone's name might provoke a little more cognitive angst than just using their access card.
Simply by beginning noon conferences at noon and by completing them by 1:00 pm, we would improve conference attendance by at least 2 residents for each conference.
By placing the onus on the resident to justify (to some extent) their absence from our (very few) conferences while on away rotations, this may capture some of the absences seen when residents rotate on ICU, cardiology, pediatrics, ER, etc. Formal policy/curriculum should be outlined for each off-service rotation to delineate which rotations have scheduled didactics which should supersede Family Medicine didactics. To the extent that this is unclear, it is a loophole.
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