In defense of SOAP notes

Our hospital system's IT department has recently encouraged us all to change our default encounter note template from the traditional "SOAP" format to the "APSO" format.

For those not familiar with those acronyms:
S - subjective - the patient's story
O - objective - physical exam, labs, other data
A - assessment - the identified issues/diagnoses
P - plan - details of how to address issues/diagnoses in the assessment

The argument in favor of APSO, putting the assessment and plan first, is that no one reads the subjective and objective. Readers just scroll through the S and O to get to the A and P, so why not make everyone's lives more efficient by putting the A and P first? From the hospital to our outpatient office, our system is encouraging us to create patient encounter notes in the APSO format.

As residency faculty, I review a lot of resident notes in the process of supervising them, and despite this switch in the last few months, I can't seem to adjust to reading APSO notes. Maybe my perspective is different since I actually have to read the S and O as part of my supervisory responsibilities, but jumping straight to the assessment and plan just feels jarring and out of order.

Documenting those subjective and objective sections can be challenging within the electronic health record (EHR). It's faster to click boxes or use a template than to type out the unique aspects of a patient's story and/or exam. Don't get me wrong - templates and click boxes increase efficiency in documenting simple yes/no responses and normal findings. Reading a subjective and objective that's all click boxes and templates, however, doesn't provide a compelling story. (It can even invite wondering whether everything clicked and templated was actually asked and done.) No wonder busy physicians would rather skip to the end.

I just can't get behind starting at the end with this APSO format. I like opening with the patient's story and the directionality of proceeding from that through the exam to the assessment and plan. The patient's individual story is valuable, both in providing key details to successful care and validating the humanity of each patient. I free text a significant portion of my documented subjective,* and I add any pertinent unique details to the exam template in our EHR.

Starting with the assessment and plan disincentivizes reading those stories. I worry that future physicians, who may learn APSO as the norm, may not appreciate the value of a well-composed subjective and a thoughtful physical exam.

I'm sticking with SOAP.

* In the room, as the patient shares it - and, yes, patients are quite accepting of that practice. Of course, Instant Medical History would be even better, but I've yet to convince any of my employers to adopt that technology.

The 2017 marathon

I had a dream last night that I was running a marathon. At first glance, that might not sound pleasant, but it actually was. The running felt effortless, the weather was beautiful, people were cheering me on as I went, and I crossed the finish line to hugs and happy tears from family and friends. I woke feeling peaceful and content.

In many ways, this last year has felt like a marathon to me, but certainly not as pleasant as the one in my dream. Learning how to juggle motherhood and my career has been a balance that I struggled to find. Supporting our child through her health journey has also been physically and emotionally taxing. Yet as 2017 winds to a close, I can't help but reflect on the many positives along this marathon route. I was blessed by the family and friends who cheered us along the way and did share our celebrations with hugs and happy tears. My family is crossing the 2017 finish line intact and well. I can even look back on some career accomplishments in the last year with pride.

2018 feels full of possibilities. Maybe I actually will run that marathon;* more likely, I'll keep working at being the best family physician, teacher, writer, mother, and wife that I can be. I've never been someone before who sets resolutions, but I'm resolving to be more intentional about how I want to experience this next year. I have some goals, too, related to my personal writing and my faculty development interests that I'm pretty excited about.

Bring on 2018; I've got my running shoes ready.

* I've never actually run further than a 10k in my whole life. This particular dream is definitely a bucket list item for me. :)

Mother's Day 2017

My evening routine ends the same way every night - I tiptoe into my sleeping daughter's room for a final check and view of her for the day. 

Often, I'm coming from a brightly lit area, so it takes my eyes a minute to adjust until I can see her. I stand over her crib, blinking into the darkness, waiting for my pupils to dilate. After a few seconds, I can usually make out her hazy outline. A few more seconds, and the position of her limbs and head is more clear. Finally, I can see her in total, her back* rising and falling as she sleeps, usually with one hand curled up near her head and the other splayed out behind her. I stand there for a minute or two, and let the beauty of the moment consume me.

You'd never know, looking at her peacefully slumbering, what she's been through already. The surgeries, the physical therapy, the medications. You'd never know, frankly, to look at her during the day, as she alternates between joyful glee and serious exploration of her world. In the dark, these are not the thoughts that come as I watch her. That time, somehow, remains reserved for joy. She is resilience personified, and I'm so blessed to be her mother.

This Mother's Day, my first as a bonafide mother, is admittedly bittersweet as I ponder the years of infertility and loss that preceded it. But the gift that is our child provides more than enough sweetness to offset the bitter. And this evening, as I ponder her sleeping form before headed to sleep myself, I'll allow myself a moment again to let the gratitude wash over me.

* We put her to sleep on her back every night, but she's capable of rolling independently and thus safe to leave on her belly when she winds up there - which she does most every night now. But "back to sleep" for infants always!!!

Being the parent of a patient

Over the last few years, I've been frequently been the patient thanks to infertility. Being a patient who is also a doctor has certainly felt unsettling at times, but over the years I got used to it. I couldn't really ever turn off my doctor brain sitting on the exam table, but I tried to listen thoughtfully to my doctors and their recommendations. Infertility treatment involved a lot of discomfort and heartbreak, and over time dealing with those issues almost became routine. Normal.

Then my child had a serious medical issue requiring surgery. And everything I thought I knew about being "on the other side" went straight out the proverbial window.

I'm not going to describe her medical issues; I want that to be her story to tell, if and how she chooses, when she is older. She continues to receive excellent medical care, and I will be forever grateful to the many doctors, nurses, patient care techs, physical and occupational therapists (I'm sure I'm missing someone, but I'm ending the list here for brevity's sake!) who are caring for her. It's certainly true that her surgeries and care thereafter couldn't have gone better. Life is slowly starting to get back to whatever constitutes normal as a working physician parent.

And yet, I can't seem to get back to normal myself. The level of emotional fatigue that I'm still experiencing is outside of anything I've previously known. As much as I'd like to just sweep these feelings away and resume daily life, they don't seem interested in going anywhere. I wish they weren't as demanding of my energy, but they're definitely quite settled in.

Part of me feels like it would be a betrayal to all that has happened to just pick up and get back to "normal." Part of me is afraid to let go of the constant vigilance that accompanies having an ill child. Part of me is unsure that I'll recognize myself in the mirror if I dared to really look, now that we're hopefully through the worst of this experience.

So, for now, I'll just keep plodding along. Maybe this reality is destined to be my new normal; maybe these feelings have taken up permanent residence. I'm just going to allow them the space they need.

Their continued existence would certainly be a small price to pay for my child's well-being.

Inspiring family physicians on social media

In my last post, I mentioned "articulate and inspiring family physicians on social media." I thought I'd take a break from my current post arc and share who some of these amazing people are, both family docs and those who advocate for Family Medicine:

Dr. Mike Sevilla @drmikesevilla http://drmikesevilla.com/
Dr. Ranit Mishori @ranitmd
Dr. Andrew Morris-Singer @AMorrisSinger http://www.primarycareprogress.org/home
Ms. Molly Talley @mollytalley
Dr. Bich-May Nguygen @bicmay
Dr. Carla Ainsworth @SeattleFamilyMD
Dr. Pat Jonas @apjonas http://drsynonymous.blogspot.com/
Dr. Kenny Lin @kennylinafp http://commonsensemd.blogspot.com/
Dr. Mark Ryan @RichmondDoc
Dr. Jay Lee @familydocwonk
Dr. Jen Brull @mrsbrull
Dr. Kim Yu @drkkyu
Dr. Heather Paladine @paladineh
Dr. Emily Lu @dremilylu
Dr. Anne Montgomery @AnneMont
Dr. Glen Stream @grstream
Dr. Reid Blackwelder @blackweldermd
Dr. Robyn Liu @rliumd
Dr. JL Richardson @drjfpmd
Dr. Torian Easterling @KTEGlobalMD

Please check them out! If you're not on social media, please know that Twitter is more than the US president's rants and what your favorite celebrity ate for breakfast. There's a vibrant medical community on Twitter that's well worth a few minutes of your day.

I am 100% sure that I have missed some worthy individuals, so please add them in the comments section below.

My baby's doctor is not a pediatrician

"Who is your baby's pediatrician?"

I was first asked this question 12 weeks into my pregnancy by my OB's intake nurse. I have since been asked it countless times - when I arrived at the hospital for my delivery, as we were leaving the hospital with our new baby, and then every time we have taken her to specialist appointments and hospital admissions over the last few months.

My response has been the same every time: "Our family doctor is..."

I don't think any of the people asking me this question intended any offense. I know that, for many people, "pediatrician" = "doctor who cares for children." And, yes, pediatricians are doctors who care for children.* But family doctors care for children, too. The automatic assumption that my baby's doctor is a pediatrician is part of the image problem that Family Medicine still has. It seems that most of the lay public - and, frankly, much of the larger medical community as well - still doesn't know who we are and what we are qualified to do as family physicians.

I've written about this issue before, but nothing has changed regarding our national specialty organizations' efforts in the last four years. Certainly there are many articulate and inspiring family physicians active on social media, but that channel reaches only a relatively small segment of both the medical community and the lay public.

The US will not achieve an accessible, high-functioning healthcare system that delivers equitable, high-quality care without Family Medicine as its foundation. If people don't know who we are and what we have to offer as a specialty, if people don't know that family physicians' patients live longer and better at less cost, how can we possibly be a part of the national conversation about healthcare?

Maybe each of us, as family physicians, needs to launch our own mini-public-relations campaign. First and foremost, our patients must know that we are family doctors (not just a "general practitioner" or a "PCP"). We need to get involved in local medical organizations and make sure primary care's voice is heard there. We need to share our passion for our specialty with anyone who will listen.

I will start by affirming that my baby has a family doctor.


* Pediatrics is a specialty with board certification and its own rigorous training. I suspect many pediatricians would take some offense at the assumption that any doctor who cares for children is automatically a pediatrician. For the record, I have nothing but the utmost respect for pediatricians.

Pregnancy after infertility and loss

I just about stopped writing while I was pregnant last year. Sure, I kept writing professionally. But this blog, and the fiction I had been working on - nothing. Nothing for 9 months. I didn't mention my pregnancy on the blog, and I barely did so on other social media channels.

When I think back to why that might have been, I remember that writing requires recognizing the truths within yourself. There was a truth within me that I did not want to face during my pregnancy; I was terrified that I would lose my baby. I am a board-certified family physician and intellectually knew better, especially once we passed the first trimester. But I did not trust my body to care for my baby. I kept waiting, day after day, for something bad to happen. Once it was obvious I was pregnant, family, co-workers, and even patients gushed with happiness for me. I tried to match their jubilant tone, but it was always fake. I had trouble bonding with my unborn baby and resented the discomforts of pregnancy.

I can't blame you for thinking that the above paragraph sounds impossibly irrational. Looking at it typed there, it sounds impossibly irrational to me. To be honest, I'm ashamed of those fears. I feel guilty for not enjoying my pregnancy the way I was "supposed" to. After all, pregnancy after years of infertility should be cause for a grand celebration, right?

When I reflect on the five years of reproductive failure that preceded my pregnancy, though, the irrationality begins to make some sense to me. Cycle after cycle, year after year, our hope eroded away. When we did achieve pregnancy, miscarriage followed. I was conditioned to expect failure.

Pregnancy does not cure infertility. I still had to wrestle with feeling defective as a woman; I still had to reconcile those years of disappointment and heartbreak with the reality that a healthy, viable baby was growing within me. It was only when my OB laid my newborn child on my chest that I felt joy and hope again. (And, please know, I did feel and am still feeling a lot of joy now!)

I debated whether to share this post after I wrote it. But I'm certainly not the only person who's experienced these feelings during pregnancy, and it would have helped me to see stories like mine. I also hope that we, as physicians and healthcare providers, will allow our patients the space to experience their pregnancies authentically regardless of our personal feelings or society's expectations.*

I feel a complicated web of emotion around motherhood and how I got here. But I keep telling myself that here is a pretty fantastic place to be, all things considered. Our baby is a miracle and every day with her is a gift.

And that's more than enough for me right now.


* This hyperlink is to a post that contains explicit language. It is a raw and honest piece that includes f-bombs and frank anatomical references. If that won't offend you, please give it a read.

Pregnancy, parenthood, & catching up

It's been a while since I've been here (March to be exact), and much has happened since then. 

I've been thinking a lot about this blog in the meantime, dutifully logging ideas for posts in an Evernote file. Of course, thinking about writing isn't the same as actually writing. I've been intimidated, though, about trying to catch y'all up on what's been going on, as the context will be important for what I want to discuss in the next few months.

So, how about a 60-second summary? 

(Or maybe even less than that if you're a fast reader!)

Thanks to the incredible generosity of a woman we will never meet, my husband and I became parents earlier this year via egg donation. The adage that pregnancy doesn't cure infertility is definitely true, and I think I didn't blog about my pregnancy because I was afraid to acknowledge it in words in case something went wrong. After infertility, I didn't trust my body's ability to do anything, let alone gestate a human.

I never expected that being a doctor would adequately prepare me for pregnancy and parenthood (and it didn't). But I've learned some things in the last year that I think I should have learned at some point in my training. So, those should be some interesting posts. ;)

Unfortunately, not long after our little one joined us, she entered the healthcare system with difficulities of her own. Interfacing with the healthcare system as a parent - and a family doc - has been a *insert cliche here* experience (possible cliches that apply: "eye-opening," "thought-provoking," "roller coaster"). Thankfully, assuming all goes well with her upcoming surgeries, her prognosis is excellent. 

Whew! I think it's safe to say that this blog will be going in a different direction for a while. I've always endeavored to write about topics that I am passionate about, trusting that those same issues will find some resonance. Perhaps this new direction won't be of interest to you - I won't take that personally, and I'm appreciative that you've been along for the ride thus far. Maybe some new readers will wander over to this corner of the internet who are less interested in medical education and more interested in the intersection of medicine and parenting - that's okay, too.

But to whomever might be reading this post today, thank you. Thank you for being interested in my story, for being curious and empathetic, for celebrating our commonalities and exploring our differences. 

Thank you.

What do high quality PowerPoint slides look like?

It might be easier to ask first, what do low quality PowerPoint slides look like?

You've probably seen hundreds of these over the years: too many words, "death by bullets," not enough visual support, overly complex diagrams, boring or irrelevant backgrounds, etc.

Think for a moment about the last time you saw really great PowerPoint slides. They probably:

• had few words
• had fewer bullets
• used vivid, relevant pictures/visual support
• used simplified, effective diagrams/charts
• reflected the presenter's personality

When I teach presentation skills workshops, I encourage participants to build slides without using stock PowerPoint templates; instead, work from the "blank" template and design each slide without any bullets. This feels uncomfortable for some people at first, but I encourage folks to push through and start playing around with text boxes and images. What universally happens is that each participant's creativity begins to take over - no one's slides look like anyone else's, but they are instantly more compelling.

The purpose of your slides is to support you, the presenter. They should not be able to stand alone (though your handout should), and they should not distract the audience's attention away from you as the presenter. Most of the tips and tricks that follow keep your audience focused on you, not devoting precious brainpower to interpreting your slides or letting that brain wander away on unrelated tangents.

With that in mind, here are my favorite tips and tricks for kick ass presentations:

Keep your font at least as big as 28 point and, ideally, 32 point at a minimum. If your audience is straining to read your words, you've lost their focus on your content. (Besides, larger fonts make cramming too much onto one slide much harder.)

Choose sans serif fonts for better readability. Serif fonts make your audience subconsciously work harder to read your projected words. Every scrap of audience brainpower is precious and should be focused on you and your message!

Make sure there's contrast between your font color and background color, either light font/dark background or vice versa - but please don't use the canned yellow font/blue background from vintage 1990's PowerPoint. There's no surer way to make your presentation look old and dated.

One point per slide...most of the time. Exceptions include overview/agenda slides or slides where you are connecting several ideas together - but be judicious with these.

Keep backgrounds simple. None of those stock PowerPoint slide backgrounds are worth your time; in fact, any repeating backgrounds or info on slides (including your institution's branding) is a distraction to your audience. Remember, one point per slide.

Optimize your visual support with PowerPoint tools. Let's face it, those super-cool images you downloaded from Google are probably not a perfect fit for your objectives or your presentation's aesthetic. Use cropping, remove background, and/or adjust the contrast/coloring to make images truly pop on the slide. ("Remove background" can admittedly be a bit time-consuming, but it is the best way to make your images look like they organically belong on your slide - instead of looking like you just pasted it in from a web search engine. Try it!)

Cartoons, pictures, etc must be relevant to your content. Otherwise, they will distract your audience from your content - and once you've lost your audience's attention, getting it back will be one mighty uphill battle.

Finally, this outstanding 10-minute video summarizes many of these points and, simultaneously, provides an excellent example of what phenomenal PowerPoint slides look like.

Ditch those boring, over-bulleted, word-heavy slides and inject your personality and energy into your presentations with short bullet-free phrases accompanied by striking visuals. Your audience will not only thank you, they may actually walk away learning something as well.

Meaningful goals & objectives should drive every presentation

The idea of incorporating goals and objectives into presentations has percolated fairly deeply into medical teaching tradition. Unfortunately, these goals and objectives are often superficial and meaningless, especially when they are not tied meaningfully to the presentation's content. Frequently in presentations, it's hard to tell the difference between stated goals and objectives, even though they should be quite distinct and serve different purposes.

Before I provide some examples, let's review for a moment what the purpose of educational objectives are:

• Educational objectives describe the skills learners should possess after you finish your presentation.
• Educational objectives also serve as the foundation of evaluating your presentation; you measure the success of your presentation based on how well your learners met your objectives.

High quality objectives are, therefore, precise and measurable. Objectives are not the same as goals; goals can be as pie-in-the-sky and impossible to measure as you like! Goals provide the emotional power to your presentation; typically, you won't share them with your audience, but they are the fuel for your presentation.

Here's an example. I gave an hour-long presentation on asthma to our residents recently, and the objectives were:

1. Classify asthma severity using the EPR-3 guidelines.
2. Calculate a peak flow %.
3. Design appropriate treatment plans for your patients with asthma.

My unspoken goal was:

• Train residents to recognize under-treated or undiagnosed asthma so affected patients don't suffer unnecessarily.

It would be very difficult to quantitatively measure the success of my goal; I would need to know, somehow, which cases of undiagnosed asthma they missed along with the ones they caught. That's completely unrealistic, which is okay - the goal provided me with the passion and energy I needed to get my learners excited and interested in this topic. Your learners can tell when you are not emotionally invested in the material you're teaching, and they won't learn as well without your enthusiasm.

On the other hand, measuring my objectives was easy, and I was able to do so by the end of my presentation. I observed all of our residents who were present work through clinical scenarios where they had to (1) classify asthma severity, (2) calculate peak flow %s, and (3) design treatment plans. Having these clinical scenarios (and the space to write out their answers) incorporated into the handout I provided them was essential to both this measurement and the residents' concrete application of what I taught them.

In summary:

Goal = mega-aspirational, pie-in-the-sky ideal result of your presentation that fuels your passion for the topic.

Objective = precise, measurable criteria that both point learners to your most important teaching points and allow you to measure the success of your presentation.

Bloom's taxonomy provides a great starting point for choosing high-quality verbs for your objectives; "understand" and "review" are fine for goals but have no place in a well-written objective (being neither precise nor measurable). Use Bloom's to connect your objective to the appropriate step of the taxonomy (do you want them to remember? comprehend? apply?) as discussed in my earlier post about interactive presentations.

Now, get out there and write some kick ass goals and objectives!

Designing learner-centered presentations

As I discussed recently, too many educational sessions in medicine are ineffective. Most of the educational sessions I've seen aren't true presentations, at least not according to my definition:

A "presentation" is a deliberately planned educational activity that incorporates ample opportunity for learners to immediately apply and reinforce new knowledge.

In contrast, a "talk" is nothing more than a speaker or teacher droning on, typically zooming through far more material than any learner could hope to remember afterwards.

Even if delivered by an engaging speaker, talks don't result in any meaningful information gains for learners. Think back to the last talk you attended; even if it was just last week, I bet you can't recall more than 1-2 facts from it (and if you've got 1-2, you're doing better than most).* Adult learners simply aren't wired to memorize reams of facts without context and/or without the opportunity to apply those facts to concrete examples. Even the most motivated of adult learners will struggle to take away something meaningful from observing a talk.

The solution is to incorporate learning activities into educational presentations. Here's one relatively fool-proof presentation formula (warning: this formula will not work if your presentation objectives are weak):

• Introductions; review presentation objectives
• Teach content re: objective 1
• Learning activity re: objective 1
• Teach content re: objective 2
• Learning activity re: objective 2
• Teach content re: objective 3
• Learning activity re: objective 3
• Wrap-up; questions; evaluations

The learning activity should directly correlate to its learning objective. So, if one objective is to "List the four types of allergic rhinitis," the learning activity might be to identify which of the four types applies to various patient scenarios, thereby reinforcing what the four types are along with their definitions. If a second objective is to "Describe the classes of medications available to treat allergic rhinitis," then the learning activity might be to match various allergic rhinitis medications with their mechanism of action. 

Each learning activity should fit with the objective's place on the Bloom's taxonomy pyramid. Here are some suggested learning activities for each step of the taxonomy, from top to bottom:

Creating: create a new process or workflow, brainstorm solutions, write/paint/reflect on a recent patient/peer encounter

Evaluating: rate the quality of a group of clinical trials, assess the pros/cons of an office/hospital workflow

Analyzing: categorize disease types by severity, compare and contrast different treatment approaches

Applying: calculate sensitivity/PPV/NNT/etc, diagram the pathophysiology of a disease/condition

Understanding: interpret diagnostic test findings, explain a medication's mechanism of action

Remembering: recall the typical patient history of a disease/condition, list common physical exam findings for a disease/condition

As you can see, it's often appropriate for your objective to precisely reflect the corresponding learning activity.

Most of the time, when we are teaching medical content, we're working within the bottom 3 tiers of Bloom's. But I challenge you to consider how your presentations might incorporate some of the top 3 tiers; especially in curricula on practice management, quality improvement, medical humanities, and evidence-based medicine, where infinite opportunity exists for our learners to analyze, evaluate, and even create.

* The exceptions to this fact are those rare individuals with a photographic or eidetic memory. 

Giving a presentation? Avoid these common statements

I've listened to a lot of presentations during my time in medicine. Whether as a learner, a teacher, or an observer, I have heard certain statements uttered innumerable times, statements that, frankly, have no place in a thoughtfully designed presentation.

So, here are the Singing Pen's top 3 things never to say in a presentation:

3. "There's a lot of information here, and we'll go quickly, so please interrupt me with questions if you need to."

Unfortunately, the most common mistake I see presenters make is including too much information. At most, learners will remember 3-4 main points after you're done; decide what those 3-4 main points are (hint: your presentation's objectives should reflect them) and spend the time you have emphasizing them. For example, you are not going to be able to cover every single kind of cardiac arrhythmia or every possible type of shoulder injury in 60 minutes. Focus on the key points you want learners to internalize.

FYI: Letting your audience know your preference about interruptions for questions is a great practice, just not when it's said to mitigate your unfocused, bloated presentation.

2. "I got these slides from..." or "I first presented this at..."

It's perfectly fine to adapt others' slides from past presentations into a current presentation as long as you have the creator's permission. But the key word is "adapt." Plopping slides created for one group of learners into a session for another, different, set of learners is fraught with peril. It's highly unlikely that someone else's slides will perfectly fit the needs of your learners, and you risk distracting your audience by skipping unnecessary slides or going off on tangents. Keeping your audience and your educational goals in mind, edit and adjust those slides so that they meet your learners' situation. And, for heaven's sake, put the correct date on the title slide while you're at it.

1. "This slide is hard to read..." or "There's a lot on this slide..."

You have the responsibility as the presenter to create slides that are not hard to read. Yes, many of the concepts we teach in medicine are complex, but an overly complex slide is not going to transmit that information effectively. Don't try to stuff too many words or diagrams on one slide; usually this problem can be fixed by splitting the information into multiple slides and/or thoughtfully using animation to bring in content in a step-wise manner (to avoid looking gimmicky, the only animations you should be using on a regular basis are "appear," "fade," and "disappear").

Unfortunately, the vast majority of medical teachers have never learned how to create an effective educational presentation. Most repeat what they have seen done by others throughout their career: presentations with too much content crammed into them, slides with zero visual appeal (typically stock PowerPoint headings and bullet points on slide after slide after slide, sometimes with the added "bonus" of distracting background graphics), and a dearth of meaningful activities that reinforce key learning points. Building a presentation that negates the need for these 3 statements is a great first step to giving high quality presentations.

Stay tuned for more on creating engaging, effective educational presentations!

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.

Why?

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*

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!

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?

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.

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.

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.

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.

Evernote
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.

CloudMagic
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.

Timeful
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?

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.