Monday, September 14, 2015

This game is frequently used in medical education settings to poor effect.

What is "Jeopardy!"?

Confession time: I despise presentations that involve the use of a PowerPoint Jeopardy! game. To be clear, I get uncomfortable when any game-like activity appears in a medical teaching presentation.

Not that I don't think games can have an important role in education - far from it. Heck, I once worked on a presentation that turned our residency conference room into a giant Game of Life board with the residents as life-sized game pieces. It seems to me, though, that most of the time teachers insert games into their presentations just to do it ("They're games! They're fun!") and not after careful thought about using games as an instructional strategy to further their educational goals. Because, at the end of the day, that's what games should be when we use them to teach - a deliberately chosen instructional activity designed to reinforce knowledge and/or skills.

When we did that Game of Life board, for example, it was part of a longitudinal series we created as faculty development fellows on "The New Health Care System."* In preceding sessions, we had taught the residents about different types of practice models, staffing ratios, and even the debate about whether to invest in an electronic health record.** For the game session, the residents had to make a series of decisions about how they wanted to build their "practice," all the while encountering occasional calamities and successes, just like in the original Game of Life.

We used our modified Game of Life to reinforce previously taught concepts; participants had the opportunity to practice knowledge and skills that they had already received. Most of the time, this sequence - first provide new knowledge, then reinforce new knowledge - is the right way to structure interactive presentations. Provide your audience with new knowledge and/or skills, and then let them practice.

The problem with Jeopardy!, most of the time, is that the audience is not provided with the relevant knowledge being tested beforehand. I would have no quibble with PowerPoint Jeopardy! presentations if they followed other presentations providing the knowledge to be reinforced first, but usually that's not what happens. My observations are that medical teachers, instead, use Jeopardy! as a tool to teach new knowledge. I've been told that "the residents can learn from each other when they're wrong" and this game will "reinforce what they already know." Unfortunately, most learners will not learn effectively in this environment.


1. Most people learn best in low-stress, emotionally safe environments. One emotionally unsafe example is "pimping;" most personality types experience a high level of anxiety related to the potential embarrassment of answering "pimp" questions incorrectly. Medical Jeopardy! presents the same risk; while a few residents and students will thrive in this competitive environment, most will internally cringe at the risk of revealing their perceived ignorance. Anxious, uncomfortable individuals do not retain new knowledge as well as calm individuals.

2. Jeopardy! often involves a vast amount of information that may be only loosely related. Most learners will only walk away from an educational session remembering 3-4 key concepts. A typical Jeopardy! board has 30 squares on it; multiply this by 2 if you've also got "Double Jeopardy!" - and remembering 60 facts after any presentation seems unlikely to me.

3. Most of the time I see Jeopardy! played in teams; that is, with 3-6 residents on a team competing against each other. Having observed several of these sessions over the years, very few audience members get actively engaged in these sessions. It's easy for more anxious, less experienced, and/or more introverted residents and students to take a silent role, and observing instead of participating decreases the educational yield even more.

If the goal of the presentation is to teach (and not just "have fun!"), then games should reinforce new knowledge, not provide it for the first time. Every instructional strategy should intentionally reflect the educational goals of the presentation, and the level of problem-solving inherent in the game should align with the presentation's objectives. The Game of Life, which involves a lot of application and analysis, made sense for teaching about decision-making in new models of office practice. Jeopardy!, which is fundamentally a game of information recall, would work better to reinforce basic knowledge such as antibiotic coverage or musculoskeletal anatomy.

But the key word in that last sentence is "reinforce" - using Jeopardy! to introduce new concepts is a flawed approach that will leave most learners uncomfortable, overwhelmed, and unengaged.

* These concepts preceded the Patient-Centered Medical Home model, so I am definitely dating myself here.
** Again, dating myself. *sigh*

Saturday, April 18, 2015

How can social media help Family Medicine?

This post originally appeared on the AFP Community Blog.

I was thumbing through an issue of Family Medicine (the Society of Teachers of Family Medicine's journal) when I came across "Twitter Use at a Family Medicine Conference: analyzing #STFM13." I knew that this article was on its way; its lead author, Dr. Ranit Mishori, had contacted me to ask for some of my thoughts about using Twitter at conferences several months ago.

The study authors examined every tweet with the #STFM13 hashtag related to the 2013 Annual STFM conference from 3 days prior to the conference, during the conference, and for 3 days after the conference. They found that nearly 70% of the tweets were directly related to session content, about 14% were more social, and the remainder related to logistics and advertising. They also grouped the top reasons attendees gave for tweeting into four categories: information sharing, networking and connectedness, advocacy, and note taking.

Several of my comments made their way into the article about why I tweet at conferences. Tweeting allows me to simultaneously take notes and share interesting facts with the Twitter-verse. It's easy to read through my tweets when I get home and review what I learned along with the action steps I need to take. I also enjoy the dialogue and camaraderie that happens during the conference on Twitter; it's great to respond to other people's comments and factoids as well as see their responses to mine. By enabling supportive, meaningful dialogue among conference attendees, Twitter helps us to engage more deeply with the conference content.

Upon reading the article, I saw my Twitter handle (@SingingPenDrJen) named as the top tweeter for the conference. I was both a little proud and a little dismayed; it's nice to be an "influencer," but maybe I'm tweeting too much? Outside of what the article terms "social" tweets (which are not the majority of my tweets), I try to only tweet session content that is new, insightful, and/or practice changing. I'll definitely be more mindful of what I tweet at the next conference I attend.

Only a small percentage of STFM 2013 conference attendees were on Twitter; just 13% of conference attendees tweeted at least once, and over half of the total number of tweets were sent by 10 people. Many of the people sitting next to me in conference sessions asked me about tweeting and why I do it. When I offered to assist them with getting on Twitter, most politely declined, usually with comments about "I don't have the time" and the how intimidating new technology is ("I can't even figure out my EHR!" one person said).

I'd love to see more family docs on Twitter and other social media sites, but I'm not sure how realistic that is. From 2012 to 2013, the number of tweeters at the STFM conference didn't budge much. The diffusion of innovations theory postulates that a critical mass of early adopters have to embrace a change before the majority will follow suit; are we still waiting for that critical mass, or will this particular theory end up not applying to family docs and Twitter, with a significant number of docs not ever using it?

Spreading the word about the positives of an online presence may be a step in the right direction. A recent article in Family Practice Management reviews several social media platforms and discusses benefits of having a robust online presence. The article describes using social media to provide office updates and patient education. Perhaps equally valuable is proactively managing your online presence, so that patients see more than just third-party website patient reviews of you when they put your name into a search engine. At the end of the article is a list of simple, practical starting points for getting online in ways that benefit both patients and docs.

I hope to see more articles exploring how we as family docs connect and communicate online. Keep the replies, retweets, and Facebook posts coming!

Thursday, April 16, 2015

Not like other doctors

I've now been in my new position for about 8 months. (When does "new" no longer apply?) The toughest part of moving for me is having to build new relationships with patients, and over the past few weeks I'm finally looking at my daily schedules and recognizing some names.

I think my patients are starting to feel that sense of comfort as well, and several of them have made a similar comment to me. The context always seems complimentary:

"You're not like any doctor I've ever known!"

One patient followed this comment by saying, "If you weren't wearing a white coat, I'd never guess you were a doctor."

I graduated from medical school in 2003, yet I've never heard these comments before, not until this most recent move. Is there something different about the physicians in this area whom I'm being compared to? Have I changed, somehow, in ways I haven't recognized?

I have gotten a lot more comfortable in my own skin as a doc. I still rely on my doctor-patient communication training to make sure the visit stays focused on the patient's needs, but I worry less about "sounding like a doctor." I feel free to inject some of myself into these interactions, which feels much more comfortable than earlier in my career; I was guilty of imitating how I felt a "good" doctor would act instead of being genuine with patients.

While I appreciate the implied compliments, part of me worries about these "not like other doctors" statements. Perhaps I don't look professional enough, or act professionally enough. Maybe I'm putting too much of my personality into these encounters. Maybe my patient interactions cross that invisible doctor-patient boundary line of appropriateness. Is there some inherent "doctor"quality that I am lacking?

And, if so, how do I figure out what it is?

Monday, February 23, 2015

0.7 + 0.1 = 1.0

I've been looking carefully at my weekly schedule to make sure I'm not committing to projects that I don't have time for. There just don't seem to be enough hours in the day to get things done, and while I know that's a common sentiment, as a part-time worker I'm not sure anyone will empathize with me.

I currently have two employed positions; I work 0.7 FTE with a residency program and 0.1 FTE with a medical journal. I intentionally left 1 day a week open for my writing and volunteer projects; it also definitely de-stresses my marriage for one of us to have a little wiggle room in the week to take care of all of those sniggly domestic tasks that always crop up.

While examining how I've been spending my time, though, I discovered the phenomenon of "schedule creep." 0.7 FTE should leave 1.5 days a week free; 0.1 FTE should only take up 0.5 of one of those days. But I've been working 32-40 hours a week at my 0.7 FTE position; the 0.1 FTE is pretty close to 4-5 hours a week. That adds up to 36-44 hours per week of work, or 0.9-1.1 FTE. Add to that the sniggly domestic tasks that fall to me, and no wonder I'm not writing or volunteering nearly as much as I would like.

Of course, few full-time physicians work 40-hour weeks, and 32-36 hours is close to 70% of the average physician workweek. My husband is a 1.0 FTE physician, and he is regularly clocking 50-60 hour workweeks (which is why I don't begrudge doing my fair share of those sniggly domestic tasks). But seeing just how much time I am spending makes me feel a little better about the non-work activities that haven't been getting done as much as I would like.

That said, I have no regrets about being part-time. Although our dream to have a family hasn't panned out, it still works well for us as a two-physician household to have a release valve in our weekly schedule. I am certainly not getting 8 hours a week (my supposedly leftover 0.2 FTE) to spend on writing and volunteering, but at least I don't feel guilty about the time I do spend on non-work activities.

For right now, it works, and that's good enough for me.

Monday, January 19, 2015

How much should my employer get to know about my activity?

As is true with an increasing number of employers, my new organization provided me with a free fitness tracking device. I sync it daily, and I'm earning incentives (mostly cash) based on my level of activity. If I track what I eat and engage in online health challenges, I can earn even more.

I have to admit that I find this little device (more accurately, a Virgin Pulse Max) motivating. Every morning, my Max greets me with a "Good morning, Jennifer" and a heart symbol on its screen. It's neat to accumulate activity badges and see my Max smile at me when I achieve my goal steps for the day. It's not cumbersome to use, and the cash incentives are nice.

While the jury is still out on the cost savings related to these worker incentive programs, they are becoming increasingly popular. I like the idea of being rewarded for making healthy choices, and it makes sense on a lot of levels for companies to promote health and wellness among their employees.

And yet.

I admit to some hesitancy, at times, with my Max. Adding another item to my daily "to do" list gets annoying; I have to clip Max on my waistband every morning and unclip it at night. It's a small device and easy to misplace (or for a cat to bat off my bedside table). I have to remember to sync Max regularly to earn my incentives. And, I have concerns about who might be doing what with my data. Who, precisely, is getting to see the data I upload? How much should my employer get to know about my activity? What I eat? How much I'm sleeping?

I also wonder how fair it is for companies to be able to punish employees for not engaging in wellness programs. Although some companies only reward desirable behaviors, some also have financial penalties for employees who refuse to participate and/or have unhealthy behaviors (tobacco being the most common). I worry that some employees may feel financially coerced to participate; they may not feel that they can afford to leave incentive money on the table (or pay penalties).

So, these are the issues I wrestle with when I attach Max to my waistband every morning. I enjoy the motivation, I think companies should promote employee wellness, but I'm bothered by privacy and fairness concerns.

I already know, though, that tomorrow morning I'll clip Max on again.

Wednesday, January 14, 2015

Healthcare costs should matter (even to business-adverse docs)

This morning, I had the privilege of attending a grand rounds lecture across town given by Dr. Chris Moriates titled "First Do No Harm: High Value Care From the Front Lines." Dr. Moriates is among the team at Costs of Care dedicated to "transforming American healthcare delivery by empowering patients and their caregivers to deflate medical bills."

Confession time: when I start hearing about finances in medicine, part of my brain tends to shut down. I usually find most everything "business" oriented dull and difficult to comprehend. I have no interest in getting an M.B.A. or even ever being an office medical director; budgets and dollars and numbers are simply not my forte. But bear with me, because even this cost- and budget-adverse physician found Dr. Moriates' presentation highly compelling and actionable.

His lecture centered on these key premises:

1. Tests or treatments that physicians order that do not help their patients' health contribute mightily to wasteful healthcare spending, on the order of around 210 billion U.S. $ a year. This spending not only hurts our country as a whole but hurts our individual patients.

2. Although there are many issues regarding health care costs that physicians don't have direct control over, we can choose to not order tests or treatments that the evidence base clearly tells us are not helpful or even harmful.

3. Just telling doctors what to do (or not) and showing them the evidence base to back it up, however, is insufficient to create meaningful change. Cultures and systems of care have to make it easier for us to choose the right thing than it is to choose the wrong (or even less-right) thing.

I often feel overwhelmed and powerless when it comes to the problems with health-care costs, especially as someone who is not naturally gifted at understanding business and finance. What can I, as just one individual doc, do to play my part in making this gargantuan problem better? Thankfully, a great resource exists to help me play my small part: the Choosing Wisely campaign.

The Choosing Wisely website provides lists of "Things Providers and Patients Should Question," which are divided by specialty. Each specialty has a list of 5 common practices that have a strong evidence base behind them that physicians should adopt in most circumstances.* You can find the list for Family Medicine here.

By incorporating the 5 Choosing Wisely recommendations for Family Medicine into my practice, I can help prevent patient harm and unnecessary healthcare spending. It feels good to know that I do have the power to make a difference after all! I appreciated how Dr. Moriates distilled these complex issues into simple, straightforward concepts that I can apply, both a family doc and a residency educator.

* of course, there are exceptions to every rule. Choosing Wisely isn't, as far as I can tell, advocating "cookie-cutter medicine." Hence the lists are things we should "question," not hard and fast rules. But, most of the time, our decisions should probably fall in line with the evidence base.

Thursday, January 8, 2015

My favorite-est apps, 2015 style

Being in academic medicine often equals juggling multiple projects and responsibilities at a time, and I have come to rely heavily on a small suite of apps to keep me doing what I need to do and going where I need to go. I'm frequently on the prowl for whatever is latest and greatest in that arena, so I thought I'd share a few of my recent and not-so-recent finds in the spirit of New Year's life (re)organization.

I had been a casual Evernote user for much of 2014, but it was only toward the end of the year that I made the time to really learn how to optimize this app. The 2-3 hour investment has paid off nicely; I am enjoying the ability to keep items, notes, and clips related to multiple work and non-work projects neatly filed and organized away. I recommend using Evernote for a few weeks to get familiar with the bases, but then don't wait as long as I did to explore its richer functionality; there are lots of useful articles on the Evernote website as well as free e-books (no worries - they're short!) worth checking out to learn more.

Toward the end of 2014 I was getting fed up with the default iOS Mail app. It wasn't syncing well with my Gmail, not to mention that the gestures just felt more and more clunky. My work institution uses Outlook, and I had to play with several apps before identifying one that worked equally well with both Outlook and Gmail - here 'tis. I'm still learning some of this app's features, but I really like its "cards" feature that lets me quickly send something to Evernote or Pocket.

I am just getting to know Timeful, but I think that we will be BFFs before long. Timeful is like my own personal assistant - I tell it what I need to get done and how long it will take, and Timeful suggests where in my schedule I can plan to do it. Again, with several different projects within my residency faculty position going on simultaneously, Timeful is helping me budget my time wisely and ensure that what needs to get done has a set time to get it done. Maybe not everyone needs that much micro-organization, but I am learning that, without it, I struggle to stay on task.

Pocket Informant
PI (not to be confused with "Pocket" as mentioned above) has been my go-to calendar and to-do app for a few years, and every time I look to see if anything better has come along I realize just how good PI is. I like the seamless integration between calendar and to-do lists, as well as the highly sophisticated way you can personalize both. PI integrates my Outlook and Google calendars seamlessly and lets me organize my to-do lists to my OCD-heart's content.

Any great apps you'd like to share?

Tuesday, January 6, 2015

Inbox zero: look out, 2015!

It's been a while again.
I know you're shocked. ;)

I'm not usually a New Year's resolution type, but I took advantage of some down time at the end of 2014 to take inventory of my current projects and responsibilities, along with trying to figure out where I'm losing time to inefficiencies (Muda, you lean followers might say).

Part of my regaining equilibrium has involved taming the almighty e-mail inbox. I am not normally prone to clutter; my work e-mail inbox is typically quite tidy, as is my electronic health record inbox. But something about my personal Gmail just got too overwhelming, and for the last couple of years I have just let things pile up. I've lost one too many important messages lately, though, so this past weekend I resolved to tackle the great beast and gain control.

Using Gmail's search function, I created tags to identify and sort everything important. After moving all of those messages into their new folders, I unsubscribed to at least a dozen e-mail feeds that I hadn't made time for in ages and knew I wouldn't miss. I created searches again for each of these and deleted them all en mass. Ditto for searches including the terms "reservation" and "confirmation" (all for events in the past - why was I keeping these?).

After setting up some filters for messages I wanted to archive but not necessarily review immediately (bank statements, etc), I was more than 1/2 way through my 1K+ messages. I scrolled through the rest, sorting out a few things here and there to keep, and voila! 19 messages left. I will create tasks in Pocket Informant for those new messages and then get them archived.

I know that taming my e-mail won't solve everything. But it has helped me to regain a sense of control. Now I am confident that what will come into my inbox is important and won't get lost.

So bring it on, 2015. I'll be ready.