On ‘Leadership’ in Medicine

In medicine, there are many buzzwords that are thrown around so frequently and loosely as to lose meaning or purpose. I’m looking at you, ‘patient-centered.’ And you, ‘disruptive innovation.’

Now that it’s August–the season of medical school orientations and white coat ceremonies–there’s another that, as if on cue, is making the rounds: leadership. This time of year, medical students are treated to speech after speech by deans who wax poetic about the physician-leader.

“We brought you here not to be 9-to-5 employees, but leaders in medicine.”

“We’re not just in the business of training doctors; we’re developing leaders.”

At the time, I was a fresh-faced, doe-eyed disciple in my first days of a lifetime in medicine, and I hung onto every word of the sermon–enchanted, captivated, inspired.

In the coming months, though, that inspiration turned to curious inquisition. Inquisition turned over to weary skepticism. One year in, I’ve started to deconstruct and critically evaluate the ambiguous aspiration that is ‘physician-leadership,’ a process that’s led me to these questions.

What’s a physician-leader? A year ago, we were challenged to be more than “9-to-5 employees”–to go beyond the ‘ordinary’ work of doctoring and patient care to advance the frontiers in scholarship, administration, and healthcare delivery.

Since then, though, I’ve seen some sparks of inspiration among the seemingly mundane that reveal a broader sense of leadership. There’s the country family doctor who, as a lone knight, stewards the health and wellness of an entire community. There’s the intensivist who speaks up to oppose medically futile care and guide patients to ‘a good death.’ Does one have to be an Ezekiel Emanuel or an Atul Gawande to be a physician-leader, or can we find and appreciate glimmers of leadership in the day-to-day labors of being ‘just a doctor?’

What’s it mean to train physician-leaders? As orientation became an ever-faint blip in the rear-view mirror, so became the relevance of leadership and transformative thinking in our day-to-day coursework. If we were being trained as physician-leaders, how was our training any different from that of physician not-leaders? I think we learned anatomy the same way. Same for physical diagnosis and pathology, too. A year in, I’m not sure how exactly one trains as a physician-leader, as opposed to a not-leader.

To train physician-leaders is an admirable aspiration, but it would be a little more admirable if there were a little more substance to it.

What’s with the love of leaders? As the old adage goes, if everyone’s special, then nobody really is. Likewise, if everyone’s a leader and trained from the start to think only as a leader, is there anyone left to be led? Students are selected into medical school by leading in the classroom, leading in activities and organizations, and leading in the community. When students who have only ever led arrive at medical school and are instructed to lead, does it compromise the profession’s ability to form hierarchies or collaborate?

I wonder if medical schools ought to teach, along with leadership, the principles of good followership–active listening, influencing from below, knowing when (and how) to challenge a leader. Perhaps then, we’d see stronger cohesion and collegiality, both within our profession and among the health professions.

Don’t get me wrong, now–the importance of effective leadership in medicine by physicians, for physicians is hard to overstate, especially at a time when doctors are facing increasing pressures from changing practice models, shifting payment structures, and growing information technology demands. For now, though, leadership as it’s preached and praised in medical education is a notion without clarity, an ambition without substance.

Speeches and sermons at orientations and white coat ceremonies are good. If we want to do better, though, maybe we should recognize and teach the brand of leadership that happens not only at the highest levels, but in “9-to-5 medicine.” Maybe we should actually think critically about what it means to train physician-leaders as a functional practice, rather than a buzzword not reflected in the curriculum. And maybe, just maybe, we should understand that there are limits and complements to a singular emphasis on leadership that are worth instilling, too.

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The eStudent: Nothing About Me, Without Me?

I recently had the wonderful privilege of being accepted to present at a conference on medical education. I’m excited; this is a first for me!

It also came with a less-than-wonderful ‘first’: the privilege of paying a hefty conference registration fee.

Now, I can appreciate that organizing a conference is an expensive endeavor. Venues cost. Staffers cost. Esteemed keynote speakers cost. I get that.

What I don’t get is how a conference on medical education can accurately reflect interests and engage stakeholders in medical education by pricing out the main recipients of medical education: students.

Sure enough, looking over this conference’s speakers list, students are scarce. Plenty of deans, administrators, clinician-educators, and research scholars, though. It’s a conference about learners, but without learners.

To be fair, this isn’t a new phenomenon. Last year, I was elated to see the AAMC webcast its Medical Education conference. With great interest, I watched. I learned. I chimed in via Twitter when the dialogue called for (more often, presumed) a student’s perception or perspective.

And then I rolled my eyes when the post-conference survey, to the question, “Which of the following describes your role?” failed to include the option, “Student.” That moment spoke volumes, and it said everything about the student’s role in educational innovation and curricular design.

This is the essence of the problem. As students, there has to be a bigger role for us in medical education than taking post-intervention comprehension assessments or filling out satisfaction surveys. There has to be, to draw upon clinical analogies, a shared decision making model that invites students’ values, goals, and habits throughout the design process. Medical education without student engagement makes about as much sense as patient care without patient involvement.

To give credit where it’s due, I’m lucky to attend an institution where the student voice is present from the inception of an educational design process. But my experiences on the national scale imply these are outliers, not norms, and that’s a fundamental flaw.

ePatients, as advocates for access to their clinical records and active involvement in their own care, have in recent years coined the moving message, “Nothing about me, without me.”

That’s the attitude we need in medical education. That’s what we have to aspire to, and advocate for. To be eStudents: learners who don’t just participate in and function within an educational ecosystem, but actively shape it.

On Rounds | 4.26.2015

It’s the weekend after end of block exams, which means it’s time to dig through the 742 links in my Pocket queue. That also means it’s time for another edition of “On Rounds,” bringing you my favorite reads of the week.

On the new MCAT | Forbes
There’s a lot to like about the new Medical College Admission Test; with new content in psychology and sociology, MCAT 2015 acknowledges that there’s more to doctoring than biochemical pathways and physics equations. But are multiple-choice tests the best way to identify humanistic, socially aware aspiring doctors? What more we can do to foster diversity and holistic thinking among medical trainees? Allan Joseph and Karan Chhabra break down the good, the bad, and the path forward.

On quack science and journalistic ethicsVox
When it comes to pseudoscientists and their cults of personality, what’s a better-knowing journalist (or healthcare provider) to do? Speak out, and validate a quack? Or stay silent, and let faulty information rule the airwaves? Julia Belluz is on point with this one, and her insights and advice here ought to be required reading for every journalist, scientist, and clinician with a social media account.

On medical schools as laboratories of health transformationForbes
Esther Dyson once remarked that change in medicine happens one retirement at a time. She’s dead right. If we want our healthcare system to pivot from expensive care and late-stage interventions to systems-based practice, preventive care, and population health, the transition begins with how we train future doctors to think. At UT-Austin, the new Dell Medical School is bringing a ‘re-boot’ to a 100-year old model of medical education. David Shaywitz breaks down their educational approach, and what it could mean for medical schools nationwide.

On the value (or maybe not?) of health apps New York Times
There are two kinds of people. On one hand are those who own wearables and use health applications: the young, the affluent, the health-conscious. On the other hand are those who might often benefit from digital health but can rarely afford it: chronic disease patients, the elderly, and those with limited access to care. Today, the consumer market for health apps and devices is larger than ever. How do we connect tech fads to health outcomes? How do we balance rapid innovation with health equity? This NYT article doesn’t offer all the answers, but it raises many of the right questions.

On restoring the ‘joy of medicine’Medstro
When it comes to physician lifestyle, we keep hearing the same stuff: provider burnout is at a high; satisfaction is at a low; most doctors today wouldn’t recommend the profession to their children. We know all that; now, what are we going to do about it? Medstro and Geneia’s “Joy of Medicine Challenge” invites your ideas to restore joy to the practice of medicine, and they’re offering $1,000 for your thoughts. Instead of talking about how our healthcare system is broken, let’s ideate on how to fix it.

On Rounds | 3.24.15

In recent months, as I’ve transitioned from senioritis to sleep deprivation, I’ve come to appreciate the value of brevity. Goodbye, RSS; hello, Twitter, Circa, and BriefMe.

It’s with this perspective that I’m launching ‘On Rounds,’ a (hopefully!) weekly curation of big ideas, reflections, and byte-sized foods for thought. If you’re finding it tough to keep up with the world beyond the lecture hall or clinic, outsource that task to me.

On sitting with patients | New York Times
We often discuss empathy decline in medical training, and why it occurs; in this insightful, incisive piece, Dhruv Khullar absolutely nails it. Pre-meds don’t aspire to treat medical records and lab values, but people. But in medical school, knowing the patient takes a back-seat to knowing the pathophysiology, creating a rift between expectation and reality.

On MOOCs and medical training | Slate
While the MOOC is no longer a novelty, it’s still an enigma: what’s the place of online education in the knowledge market of the 21st century? This month, Yale raised the stakes by announcing its new online physician’s assistant program. In light of an imminent physician shortage and the ever-rising costs of higher education, one has to wonder: is there a place for online, or hybrid, education in medical training?

On re-designing deathCalifornia Sunday
Ideo, the legendary design firm, has built its brand on challenging assumptions and breaking the barriers of, “Well, we’ve always done it this way.” What happens when the strategies that have driven the design of products are instead applied to processes—say, death? And more crucially, how do we inspire and train clinicians to apply the design framework to the act of doctoring, itself?

On UX designMedium
What are the skills and roles that effective design requires? Irene Au breaks it down here, and spoiler alert—the parallels to patient care are remarkable. If we envision the bedside encounter as a co-design collaboration between a patient and provider, the implications and applications in this piece for clinical medicine are fascinating.

On health tech and how bad it isNew York Times
In most fields, the technologies work for the people; in healthcare, the people work for the technologies. Here, Bob Wachter explains why the transition to electronic health records has been a rough one, then lays a roadmap to realizing the value and potential of digital medicine. It’s a daunting task, but an essential one if we eventually hope to treat patients, rather than “iPatients.”

Medicine, Live-Streamed?

MeerkatAs a health tech optimist, I’m constantly fascinated—and completely stumped—by the science of ‘viral’ ideas. What is it that makes some innovations emerge, ignite, and transform, while others stumble, sputter, and fade?

Take live-streaming, for example. The concept of broadcasting one’s first-person perspective in real-time isn’t a novel notion. It’s existed since the early 1990s, when tech pioneers like Steve Mann strapped on cameras and webcast their lives to the world. And, if you’re a millennial in medicine, it’s how you attended medical school.

So what makes Meerkat, the latest ‘app of the moment,’ matter? The short answer: simplicity.

Until now, live-streaming has been done by big institutions for big events: the State of the Union, Apple product reveals, March Madness games. Sure, casual users have YouTube or Vine, but the real-time element of a live-stream takes engagement a step further.

Meerkat now empowers you, the viewer, to become the broadcaster. Open the app, click ‘stream,’ and cast via a link that’s available on your Twitter feed. It’s intuitive, instant, and inexpensive—it’s Meerkat.

How might we leverage this real-time capacity to share our perspectives to enrich medicine?

To transfer knowledge. Take it from a medical student: conferences cost. A lot. An academic conference is a buffet of food for thought, but learners and patients are often left to catch the leftovers through tweets and news releases. Now imagine a future where every presentation, pitch, and panel is immediately available. Imagine a future where your audience isn’t just a room of conference-goers, but the global Twitterati. And imagine the impact that will have on the time to translate insights from bench to bedside.

To foster empathy. Too often, the communication gaps and patient-provider tensions in healthcare are rooted in a failure to understand the other’s experience. Live-streamers invite their audience to watch the world through their eyes, to witness the challenges they face daily, and to respond accordingly. What if providers could observe the barriers that prevent their patients from adhering to treatments? What if patients could see why their doctor seems distracted, or doesn’t have an answer to every question? With Meerkat, it’s possible, quite literally, to walk a mile in someone’s shoes.

To promote accountability. When the world’s watching, we sit up straight and put on our best behavior. The ability to (broad)cast public scrutiny on any individual is powerful—perhaps, too powerful. Whether or not we should put others under this spotlight, the indisputable truth is that we can. That alone should make hospitals and providers pay attention.

Let’s be realistic: Meerkat isn’t likely to be the next Twitter or Facebook; it’s too ephemeral, too public, and too inconspicuous to replace more established forms of public dialogue. But it does open opportunities to communicate visually and to communicate live. And in a discipline where many of our biggest problems are communication problems, that’s worth thinking about.

White Coats for Black Lives? Prove It.

When it comes to advocacy on matters of race and social justice, medicine’s C.V. is, at best, mediocre. 19th century medical students learned their craft by dissecting the grave-robbed cadavers of African Americans, immigrants, and the poor—the bodies that wouldn’t be missed or spark protest. Decades of translational research relies on an immortal cell line extracted, without consent, from African-American Henrietta Lacks in the 1950s. And, of course, there was that clinical experiment for “bad blood.”

Which makes it all the more fascinating, then, how medical students nationwide responded to the recent controversies surrounding the deaths of Michael Brown and Eric Garner:

On one level, it’s incredible to see medical students taking a stand, making ripples nationwide, and letting all our patients know that we stand with them. The white coat—even a short one—lends reputation and gravitas, and #WhiteCoats4BlackLives proves that if we stand (or die-in) together, people listen. As tomorrow’s doctors, we should be inspired from these events to capture that attention and guide public discourse on society’s leading issues: access to care, women’s health, medical errors, gun control … the opportunities are immense.

And yet, on another level, it feels somewhat hollow to die-in together, to call our campuses to attention with powerful gestures, to feel the pride of a national movement … only to return to clinic or class an hour later, ready to resume our usual routines. We have the public’s attention, but now I’m tempted to follow up with a question I encountered too often as an Indian-American liberal arts major: “What are you going to do with that?” If social media is any indication, we grabbed the microphone for a moment, dropped it, and walked off the stage. That’s not social advocacy; it’s feel-good activism.

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In the days to come, we have to remember that raising awareness is a means to an end, but not an end in itself. It’s imperative that our objective is continuity, not complacency. We’re entering a discipline where our black and white patients’ life expectancies differ by five years. Where blacks have the highest rates of cancer, but the lowest rates of clinical trial enrollment. Where six percent of our colleagues are black. Where 70% of the applicants for NIH funding are white, and 1.4% are black. If we want to take action—to not just “raise awareness” of problems, but solve them—the social agenda practically writes itself.

As medical students, we chose this profession to help others—to make a difference. So let’s challenge ourselves to go beyond the “social activism” of fighting a disease by wearing pink, pouring ice water on ourselves, or sprawling out on a sidewalk. Let’s challenge ourselves to identify matters of race and social inequality within our communities, in our medical institutions, and at the bedside of each patient we meet. Let’s challenge ourselves to not simply “raise awareness” of the issues that are already trending in the media, but to take real, directly measurable actions to make these social inequalities artifacts of history.

A Digital Native’s Open Letter to the Academic Journal

Many of my grayer-haired relatives have recently made the leap to digital. The transition isn’t always smooth. There are the charming, all-CAPS lock emails; the Facebook posts to me … on their own wall; and even the occasional phone call about which app to use for playing a video with a .pdf extension. After the laughs and the face-palms, I remind myself that these fumbles are understandable. To transition from an analog lifestyle to a connected one is no easy task, and on some level, it’s important to respect and appreciate the effort itself.

It’s a similar philosophy that we should apply to the academic medical journal’s search for its place in an information economy centered on social media. In a distant era before I was born, medical journals produced content that was aggregated, validated, and current. Now, content aggregation is as affordable and simple as a well-curated Twitter feed or Flipboard Journal. Validation comes in the forms of shares, RTs, and up-votes by the trusted voices of one’s network. And as for current … don’t even ask me how many blog entries, Facebook posts, and tweets I penned in the nine months that this paper was under review, revision, re-review, final edits, and scheduling for publication. These factors all converge upon the question: how do medical journals ‘do digital’ and stay relevant in the time of social media?

If this week’s “Intention to Tweet” study in Circulation is any indication, the jury’s still out on that one. From Dr. John Gordon Harold at the “ACC in Touch” blog:

The trial, “Intention-to-Tweet,” randomized 243 articles published in Circulation to either receive social media or not and found no difference in median 30-day page views (409 [social media] versus 392 [control], P=0.80). There were also no differences observed by article type (clinical, population, or basic science; P=0.19), whether an article had an editorial (P=0.87), or whether the corresponding author was from the U.S. (P=0.73).

The trial authors noted that these findings suggest “a social media intervention in a traditional cardiovascular journal setting may not increase the number of times that an article is accessed and viewed in the first 30-days after publication.”

In brief: “We’re posting links to our articles, but readers aren’t clicking.” Despite the journal’s efforts, social media did little to boost article traffic. . What’s a journal to conclude—and how is it to respond—after that? If I’m the social media editor for a medical publication (oh wait!) here’s what’s on my mind:

Right message? If there was an antithesis to Buzzfeed or Upworthy’s trademark brand of clickbait, it’s something like this:

I’ve spent the last five weeks of my life living, breathing, and dreaming the cardiovascular system (which is a less hyperbolic system than I’m proud to admit), and I understand about 25% of this tweet. Understandably, the academic’s journal’s charge isn’t to make headlines, but to faithfully report the science. But if I’m allowed to be naive for a second and idealize research as an enterprise that creates knowledge, informs public opinion, and affects institutional decision-making … isn’t step 1 to make sure that research is seen? And isn’t a pre-requisite to being seen to be interesting, or curious, or evocative? When communication happens 140 characters at a time, even the best content may fall flat without a compelling ‘hook.’

Right medium? 75% of Twitter’s users are primarily mobile; for Facebook, it’s 78%. Let’s put the Circulation study’s findings into perspective, for a moment. Realistically, how often do you read any article—much less a full-length academic publication—from start to finish on a mobile interface? Also realistically, how often do you actually get back to the articles saved to Pocket, Readability, Instapaper, etc.? Now think about the last time you struggled with reading a PDF on a smart-phone (as if academic journals use large, easily-readable fonts to begin with …) and it’s entirely logical why social media hasn’t translated to page views for Circulation.

As mobile becomes the new default in how we access and interact with content, academic journals should reimagine how they present content to a society on the move. Podcasts? Short-form news updates? Info-graphics or tweet-embedded media? Perhaps it’s time to repackage the academic paper into formats that fit daily function.

Right audience? Beyond the Circulation study, here’s a real question for journals’ social media editors … who’s the [intended] audience? For most journals, it seems platforms like Facebook and Twitter are another channel for dialogue with providers [Exhibit A: the language of the above tweet]. That’s undeniably valuable; amid busy workflows, clinicians need filters to locate and organize the latest data, and social media is integral to that process.

Still, there’s a deeper conversation here about how academic medical journals can use their social media presence to connect with the real stakeholders: the patients. Patients are not only the key backers of research (read: taxpayers), but its core beneficiaries. A public presence offers an opportunity, perhaps even the obligation, to bring research findings out of the ivory tower and into a broader, community-wide dialogue.

In closing, I’m not too optimistic that social media will disrupt the academic journal enterprise anytime soon. Hands down, a well-curated Twitter feed offers more agile and accessible (not to mention affordable) content, any day. But for now, peer review outweighs social network curation; impact factor supersedes RTs or up-votes; and publication volume, not blog traffic, drives tenure decisions. In the meantime, academic journals would be well-served to think more deeply about how to craft their message and hone their medium for an ever-evolving, digitally-focused audience.