Thursday, May 31, 2012

Writing Meaningful Evaluations

In medicine, especially in academic medicine, you write a lot of evaluations.

You evaluate each resident after each rotation you've worked with them on.
You evaluate each resident procedure you've supervised, each delivery, each injection.
Each medical student that rotates through.
Educational presentations and lectures - yep.
Summative evals for your resident advisees twice a year - check.
CME conferences, hospital conferences, online CME.

Sometimes these evaluations are of high quality and are useful to the student/ resident/presenter.  Sometimes they're not, and the student/resident/presenter misses out on the opportunity to make improvements and solidify what's working well.

So, here's The Singing Pen's Guide to Writing a Meaningful Evaluation:

1. You should have spent adequate time with the evaluatee* to write a fair and balanced evaluation.  If not, decline the eval.

2. Yes, circling the numbers and filling in the checkboxes is important.  But of equal importance are the comments that you write.  For medical students, the positive comments may end up in the student's Dean's letter; for residents, in letters of recommendation for future jobs.

3. Speaking of those circles and boxes - find out what the grading institution's definition of "average" or "competent" is...and resist the urge to grade inflate.  (Grade inflation is rampant in American medical schools.**)  One rule of thumb is that only the top 5-10% of your evaluatees should be given  "exceptional" or "honors" grades.

4. Not sure where to start with your comments?  Focus on the circle/checkbox attributes that you ranked either lower or higher than "average."  Provide specifics about why you felt the evaluatee was above or below what is expected.

5. If your evaluatee is deficient in some way, say so. (Medical schools, residencies, etc should be thoughtful about keeping this information confidential.)  This axiom should go without saying, but most medical evaluators do not like to give corrective or negative feedback.** Medical students should not arrive at residency, for example, with deficiencies that should have been addressed in medical school.

6. When you need to give corrective feedback, make sure it is objective (about observed behaviors or skills).  Again, sharing your specific observations is very helpful.

7. Balance your corrective feedback with positives that you observed.  An evaluatee early in his/her medical career may lack knowledge and experience but may still demonstrate compassion, eagerness, and team spirit, all of which deserve recognition.

8. If possible, give informal feedback in the middle of the rotation/year/etc to your evaluatee.  This gives the evaluatee the opportunity to improve shortcomings while building confidence regarding what he/she is doing well.  (If your evaluatee improves - or doesn't - that is also valuable info for your final eval.)  #5 issues should never be a surprise to evaluatees when the final evaluation arrives.

Remember, high quality evaluations provide specific feedback about behaviors or skills that the evaluatees are either doing well or should improve.  If it's the latter, provide specific advice regarding the steps needed to improve that skill.

*And, no, "evaluatee" is not a real word.  But it should be!


Tuesday, May 29, 2012

FM, IM, peds & the state of primary care in the US

In general, most people don't understand what Family Medicine is, maybe because family docs tend not to share who they are and what they do as much as other specialists.  For example, have you seen the ads touting the importance of having a skin exam by a dermatologist?  Yet there has been no such widely recognized campaign by Family Medicine.

Yet family docs toil on, unaware that our failure to share the value of our specialty, and of primary care in general, is leaving a sizable gap in the conversation happening around health care reform in the U.S.  I am frequently asked by patients "what exactly is family medicine?" and "aren't you the same as an internist?"

So, the Singing Pen presents the lay person's guide to primary care specialties:
(For a general overview of medical training, see my previous post on that topic.)

Family Medicine: family doctors complete a three-year residency in Family Medicine. Family doctors see themselves as physicians for the whole person across the lifespan.  We take care of newborns, octogenarians, and everyone in between.  We receive comprehensive behavioral training which comes in handy, since so many of the diseases that we deal with are related, at least in some way, to lifestyle.  The vast majority of graduates from Family Medicine residency programs will go on to practice Family Medicine, though a few will go on to fellowships for more in-depth exposure in topics such as sports medicine, obstetrics, adolescent medicine, geriatrics, and faculty development.

Internal Medicine: internists complete a three-year residency in internal medicine. Internists care for patients age 18 and older.  Most internal medicine residency programs are quite hospital-intensive; residents spend most of their time in the hospital setting rotating through the Internal Medicine subspecialties along with doing general internal medicine.  Although internists used to make up a sizable percentage of the primary care providers in the U.S., those numbers are dramatically dropping as most (80% [1]) internal medicine residency grads choose fellowships to subspecialize in fields such as cardiology, GI, endocrinology, nephrology, etc.

Pediatrics: pediatricians complete a three-year residency in Pediatrics. Pediatricians typically provide care from birth to age 18, though there are some who will see patients in their early 20s.  Pediatrics residencies are varied regarding the amount of time spent in the hospital versus in the outpatient setting, but most lean more heavily toward the inpatient end of the spectrum.  Similarly to Internal Medicine, fewer Pediatrics residency grads are choosing to practice general pediatrics, choosing instead fellowships in many of the same categories as Internal Medicine (cardiology, GI, endocrine, nephro, etc).

We need all three of these specialties in the house of medicine.  I am grateful that training programs exist to accommodate those medical school grads interested in primary care, but only at one end of the lifespan.  And, despite my frequent exhortations about the importance of Family Medicine, we need those subspecialized folks, too.

The balance is just off.  The U.S. probably needs at least 40% of its doctors to be providing primary care (2); the current percentage is a little under 30% (3, 4).  Last year, though, only about 15% of medical school grads chose a primary care specialty (4), and we already know that most of the Internal Medicine folks, and quite a few of the Peds, will choose subspecialties and not practice primary care.

Where are all of these future primary care providers going to come from?  Well, unless the proportions of internists and pediatricians choosing primary care change dramatically in the next few years, most of them will come from Family Medicine.  We need more family doctors if we're going to get that percentage up to 40%.  So, how do we bolster medical student interest in Family Medicine?

Yes, payment reform is important.  Yes, the big high-faloutin' medical schools need to stop closing their Family Medicine departments and telling their students that primary care is "a waste of your talent."

But maybe, too, the dermatologists shouldn't be the only ones with fancy ads in women's magazines.  Maybe it's time for Family Medicine to speak loudly and persistently until we are heard.  We need to supply an image of Family Medicine and primary care to our nation that reflects all that we do and how we can help the nation's health.

Primary care providers, speak loudly and with pride.  Share with your patients, your families, your politicians - anyone who will listen! - why you chose primary care. Together, we can reverse the fallacies that primary care isn't for smart people and isn't rewarding.

Together, we can change the conversation about health care.

(4)  Also great stats in this article about the income gap between primary care and the case there was any doubt about why most medical school grads don't choose primary care.

Monday, May 21, 2012

One person can make a difference - will you?

Not too long ago, I wrote about my Big, Hairy, and Audacious Goal ("BHAG") for Family Medicine.  I want every single human being in the United States to understand what Family Medicine is and why it's so valuable.  If that were so, I believe that more of the people who make decisions about health care in the U.S. would bring Family Medicine, and our health- and cost-effective care, to the head of the table.

I don't know about you, but when I hear about important and lofty goals like that, I feel like I'm too small to contribute in a meaningful way.  Sure, there's a part of me that wants to stand on the rooftops and shout "Family Medicine is a huge part of the answer!" but, then again, I'm a little on the introverted side, and I'm incredibly busy, and how would I get up on a rooftop anyway, and....

You get the idea.

I am here to tell you that there is a really, really easy way to help one piece of the Family Medicine universe.

With just 2 clicks, you can support the Family Medicine Education Consortium.

I'm currently on the board of the Family Medicine Education Consortium (FMEC), a not-for-profit corporation that incubates ideas, connects people, and catalyzes health care change in the NE region of the US.  We...

  • Support programs and services that promote medical student interest in Family Medicine
  • Stimulate the recruitment and development of Family Medicine faculty
  • Facilitate relationships that lead to scholarly efforts relevant to Family Physicians 
  • Create coalitions among those who wish to increase the number of Family Physicians in the U.S. 

(How's that for "important and lofty?")

I am so incredibly proud to be a member of the FMEC.  Yes, the AAFP and STFM are important, too.  But the FMEC has its own unique identity outside of those two organizations.  The FMEC isn't an official Academy, and it's not charged with supporting the educational efforts of an entire nation of FM faculty.  Because the FMEC does not have those responsibilities, it is free - free to be a little "crazy," as our CEO, Larry Bauer, likes to say.  

We encourage the innovation, the crazy ideas that won't all be successful, the forward-thinkers whose visions are so imaginative that no official organization, understandably, can yet sanction and support them.  And yet, without support, those ideas will wither and die, ideas that just may have the potential to change health care.  The FMEC fills that gap.  We are the home for the dreamers, and we connect the dreamers to partners who can help make their dreams come true.

When Dr. Jeffrey Brenner had the crazy idea to spend more resources on those "super-utilizer" patients (which, it turns out, really does save some serious cash in the long run), he found a willing partner in the FMEC.  The FMEC now facilitates a whole network of "super-utilizer" projects, health systems and insurance companies who are sharing best practices on reducing the health care costs - and improving the care - of the sickest, most challenging patients.

We also sponsor an annual meeting every fall where over 1000 individuals interested in FM, or affiliated with FM programs, gather to network, present curricular innovations, and share these crazy dreams.  Last year, over 300 medical students attended and witnessed Family Medicine’s vibrancy first-hand.  Supporting this meeting is a tremendous opportunity for you to give Family Medicine a step up.

Maybe you're passionate about preventing pre-term labor?  FMEC has an initiative for that.

Maybe it's ensuring high quality teaching and initiatives regarding the care of the disabled and those with special needs.  FMEC has an initiative for that.

Maybe it's improving the care of people struggling with addiction and chronic pain.  FMEC has an initiative for that.

Maybe your fire is to get more medical students to consider Family Medicine as a career.  The medical students who attend our annual conference do so for no cost except transportation, and the vast majority of them will match in FM (and, yes, many attend unsure of their specialty choice).  Maybe you'd like to help fund a student scholarship; $500 = one student's conference fee, meals, and shared hotel room.

At the risk of sounding like a bad infomercial, just a few of your $$$ can make a tremendous difference.  It's tax-deductible.  It goes directly to support the annual meeting, medical students, and the initiatives above.  (You can even earmark your funds to one of those projects if you like.)

It's a way for you to contribute in a hugely meaningful way toward those "important and lofty" goals above.  Do you have sixty seconds today to:
  1. Click here,
  2. Click on "Make a Contribution" in the upper left hand corner,
  3. Pop in your credit card number and whatever donation you'd like.
  4. Please type "SingingPen" into the "Enter description" box on the contribution screen so that we can track the folks who gave because of this blog.  (No, I don't get a kickback.  But it'd be nice to demonstrate that social media is a useful fundraising tool for us.)

No donation is too small.  If each of the people who've ever clicked on this blog site gave just $5, we could fund over 130 students to attend this year's meeting.

None of us is too small to make a difference. 

Tuesday, May 8, 2012

Late spring chaos

Hello, blogosphere.  Sorry I've been absent of late.  I still really like you and all - I'm just really busy these days.

I know, I know, I'm the one who volunteered to give a precepting workshop to kick start some faculty development around here.  And, yes, I'm the one who said "okay" when they asked for two nights to give all of the faculty the chance to attend.

I take full ownership for saying "yes" to giving a talk on social media to a prominent local physicians' group last week...and also for submitting a presentation to STFM that was two weeks ago.

Oh, about the evidence based medicine curriculum here...I knew I'd have to build it as I go.  It'll be easier next year.  But we still need to prepare that 50-minute teaching session that's one week from today, not to mention the talk on hyponatremia that the residents requested for the inpatient service next week.

Meeting with the statistician team tomorrow?  Check.  Need to finish draft of research proposal before then.

Somehow, every spring, things collide like this for me.  Now that I think about it, I'm not sure exactly why.  After all, this is the "down" season for most residency faculty: after the match and recruitment season, yet before graduation, new intern orientation, and the transitions of July.

I could have said "no" to most of the above.  I feel an overwhelming need, though, to build relationships here.  I've been in this job for six months, but I still feel like a lost newcomer most of the time.  I need some grounding, some familiarity.  I need to feel like people here understand my skill sets.  Otherwise, opportunities to use them may not materialize.

Blogging has had to fall by the wayside. Having lived through this cycle before, I know that the chaos of late spring will eventually evolve into the easier pace of early summer.  Orientation isn't one of my responsibilities, and July is languid heat and relative calm for me.

Please don't despair, blogosphere.  I'll be back soon.