Cheat sheet: What I ask during residency interviews

Ah, interview season.  I barely knew you.

We've had some great applicants this year.  I'm continually amazed by the caliber of medical students considering our program.  At some point I'll dedicate a post (or five) to all the great reasons why future family physicians should consider our program, but first I'd like to reflect on this year in interviewing.

I think I'm an okay interviewer.  I have my standard list of questions I like to ask (which I'll get to later), but it's quite a challenge to balance all the conflicting goals - I need to asses if they'd make a good fit with our program, while probing their intellectual and emotional maturity, while putting them at ease.  All within 20 minutes.  It's quite the juggling act.

Some people are naturals at this.  I am not.  I just want to avoid awkward pauses.

Which brings me to my list questions.  If you had the distinct pleasure (and how can it not be a pleasure) of having me as your interviewer for the PGY1 class for the O'Connor-San Jose Family Medicine Residency program you probably were asked a variation of one of these questions:

1.  If you had a magic wand, what would you change about family medicine to make it more attractive to medical students?

When an interviewee answers 'money', I know they get it.  If a student can't answer why the majority of their classmates chose to ignore your specialty, then they probably haven't been paying enough attention during medical school.

Bonus points:  The student mentions the secret cabal known as the RUC.

2.  Would you support independent practicing of nurse practitioners?

Know what?  None of us are wearing pants right now.
That's right... you heard me.
Now lets start your interview.  

This is a hot button issue, which makes for a great interview question.  The AAFP is adamant in their support of the team model of care, with supervision of physician extenders like NPs and PAs by... physicians.  Their position is that if you wish to practice medicine, make diagnoses, write prescriptions and order tests, then you should go to medical school.

I try to be opaque about my feelings on the subject.  I don't wish to offend anyone who may have a spouse or a family member who is a PA or NP.  I generally take the view that there's a lot in medicine and nursing that can be done by lesser trained (and less expensive) individuals.  There are certainly things I do that can be done just as well by an NP, similarly I believe there are many nursing tasks that can be delegated to a medical assistant.  Heck, if the data shows that it's safe and effective, let's forgo scope of practice restrictions and just hire some high school students to do our doctoring.

But I think this question gets at the very root of what it means to be a family doctor.  Patients, nurses, our government (and even other doctors) are all telling us that our jobs can be done just as well by people with up to a fifth of our formal training.  I want our residents to be advocates for our specialty.  They should know the value we bring to patients and their families.  And they should know what differentiates us from nurse practitioners.

Bonus points:  They can tell me who many hours of clinical training a recent graduate from your average NP program has compared with a freshly minted family medicine grad. [Answer: 2.5-5k hours for NPs vs 20k hours for FPs]

3.  What's the best part of the Affordable Care Act?  What's the worst part?

At the very least, medical students should know what the ACA is and can give a one sentence summary.  I get worried when they are unable to describe at least one good thing about the law.  I'm not as worried when they can't come up with a negative... especially if they belong to AMSA.  I kid.  I kid.

Bonus points:  When I ask the student who's going to take care of the 30 million newly insured patients, they look around the room and say, "You mean they expect us to take care of them?!"  It works on so many levels.

So there you have it.  For all you medical students applying in family medicine next year, study up... theses are high yield questions... and let's avoid those awkward pauses.

Self-tracking at the doctor's office. Not yet.

Happy new year!  It's 2013!  Time for us to embark on ambitious health and fitness resolutions we have no intention of keeping past March!

Here to assist us with our resolutions are a collection of fitness devices and apps that will help track our heart rate, sleep cycles, calories burned, steps walked, mood and much more.  Data from these devices can be stored, displayed graphically, shared with friends, and if we were really determined, shared with our physicians.

As a primary care physician, I'm very excited about the self-tracking movement.  I love the idea of people being enthusiastic about their health and using technology (or just a pen and paper) to gain insight into their behaviors and habits.  You can't change what hasn't been measured, right?

However, now there's talk of bringing that self-tracking data into the exam room and having it stored in our electronic medical record.  Self-tracking evangelists see the movement as integral to the future of personalized medicine and patient engagement.  They tell us we're on the cusp of a revolution in patient empowerment, allowing physicians to use data about our bodies to help us liver healthier and happier lives.

Whoa.  Let's slow down.  I can see how people in the self-tracking movement would be enthusiastic about "medicalizing" their data, but I see a few reasons to temper expectations:

1.  There's not strong data to support self-tracking.  We can make some inferences about how self-tracking would work in a clinical setting by looking at the studies done on telemonitoring, which also generates a large volume of attribute-rich data.  Some studies have shown benefit in outcomes, especially for diseases like diabetes, COPD, and hypertension.  However, hard measures like mortality have not been improved by telemonitoring devices.  Data on hospitalization and ED visits, especially in the elderly, have been mixed.  People (especially the engineers who created these wonderful devices and apps) love to think that more data points are better. But to date, we just don't have a robust set of well controlled studies telling us what self-tracking is useful for, what devices or apps to use, how to interpret the data, or how to integrate it into medical care.

2.  Physicians may not want the data.  Imagine that a 45 year old man who had just started exercising after years of inactivity gives their doctor all of their heart rate measurements from the past month.  All 5000 measurements.  There's no way their physician is going to want to touch that data.  Buried inside those data points will be erroneous and clinically meaningless measurements which, without review and context, will be fodder for trial lawyers when something bad happens.  It's data overload to the Nth degree, because let's face it... anything can be tracked.  Once data gets put into the medical record, it's assumed the physician has reviewed the data and acted on it accordingly.  No one wants something in the patient's chart that not only has limited medical use but carries substantial legal risk.

Finally, we need to pay physicians to analyze and counsel about the data, similar to how we pay for EKG interpretation or reading an x-ray.   Fee-for-service still rules the roost, and nothing gets done unless someone pays for it.   Any thoughts on why so few physicians use email, even though it's been around for decades?  Wanna guess how much Medicare or any other major insurance provider pays for email use?

My new years resolution is that I'm going to keep my self-tracking data to myself.  No posting on Facebook.  No sharing with my doctor.  Self-tracking has the potential to increase mindfulness of our body and our reactions to the environment.  And what's great is that this can be done in a very private and nonjudgmental way.  At some point in the future, self-tracking in medical practice will be ready for prime time.  But until then, let's not medicalize this incredibly reflective process just yet.  

Patient portals associated with increased hospitalization and ED visits

  An article in this month's JAMA from Kaiser Permanente Colorado showed that patients who used their online portal, "MyHealthManager", utilized the hospital and emergency department at a higher rate than than patients not using their online health portal (Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services, JAMA)

 While this was a retrospective study (maybe those who signed up for the patient portal were more likely to use the ED anyway), let me illustrate how this would work in a very real-world sort of way: 

Sample patient email sent through "MyHealthManager":

 "Dear doctor,
I've been getting that weird feeling/pain/numbness in my left arm/upper body again. I know it's almost 6, but can I make a visit with you tomorrow morning to get this checked out?"

 Physician response:

 "Dear patient, 
 While this is something we have discussed many times in the past - and it's probably your rotator cuff, you have now permanently documented in your medical record vague yet concerning symptoms. If you were to have a heart attack tonight, I would be screwed. For that reason, you must go to the emergency room... now. Even if you go to our after hours clinic, you'll probably be sent to the ED anyway because they don't know you like I do. Just save yourself the time, and head straight to the ED." 

   This needs to be studied more, but I suspect that when there's a digital paper trail left by a patient with symptoms that could be construed as signs of badness - say an MI or brain bleed - more CYA medicine will be practiced. With a patient portal, it's now much easier for patients to inject all sorts of symptoms into the permanent record. And when the physician loses the ability to appropriately filter and edit the history, as they do with a progress note, it's hard not to be ultraconservative with the recommendations.

Just FYI, if you are over 40 and the words "chest" and "pain" appear anywhere
 in your email,  I will be obligated by my malpractice insurer to send you to the ED!

Teenage Gamers Better At Simulated Surgery Than Medical Residents

A neat study from UTMB Galveston found that teenage gamers were better at simulated surgery than medical residents.

From Techcrunch:

The study used machines that simulated live surgical techniques, such as needle passing and suturing, and found that high schoolers who played an average of two hours of video games a day did “slightly better than our physicians in training,” said UTMB Dr. Sami Kilic.

I'll give them that teenagers probably have better eye-hand coordination and visual-spacial skills than their surgery resident counterparts, but lets not forget that most teenagers have no fear.  Have you seen some of the crazy stuff they do?  They have a level of confidence in their skills, and thus perform better b/c they have no concept of what can happen when things go wrong.

I propose as a followup study, we have old-school attending surgeons supervise the teenagers during their simulated tasks, and randomly yell out things like,  "If you screw up here, I will break your hands.... ha ha.  Just kidding.  I will break your legs."  Or harass them with twisted pimping questions like, "Where did DeBakey go to medical school?" and then say "What? You're just going to stand there and give me a pregnant pause!? WHERE DID MICHAEL DEBAKEY GO TO MED SCHOOL?!" (all true quotes)

Let's see how well those teenagers do their little simulations then.  There's nothing like an old-school surgeon to put the fear of god into you.

White House Health Design Challenge

Wanna make a difference in healthcare?  Fire up your Helvetica font and submit your best patient portal design to the White House Health Design Challenge.

The challenge calls on designers to take a clunky and confusing patient health summary that is currently being used by the Veteran Affairs health system (sadly, this kind of design-travesty is rampant in EMRs these day) and create a clear interface that can be read by patients and their caregivers.

The best designs will get a cash prize and will elements of each will get incorporated in the entire Veterans Affairs medical system - which is huge.  

I think it's a great idea and a chance to meaningfully impact the medical system that cares for our veterans and their families.  

HealthTap's new 'publications' feature

For the past few months, I've had the privilege of working as a "Fellow" at HealthTap - one of the most exciting and promising mobile health startups out there.

I can't rave enough about their mission, their technology, and their ability to engage physicians and consumers alike, but it's their most recent release that really set the bar high for the future of mobile health apps and e-patient engagement.

Have you ever done a google search on something health related, and one of the returned results was a complicated-sounding research paper abstract displayed through PubMed?  Ever have you ever thought to yourself, "Wow.  This is great - and I would really love to know what they're talking about because I have this disease and this could possibly pertain to me.... but what the heck does this mean in normal, non-doctor words?  And what the heck is a confidence interval?"

Well, with HealthTap's new publication feature, physicians now have a place to write an easy-to-understand summary of their paper, free of jargon and complicated terms.  HealthTap has matched each of their 15,000 (and growing) doctors with their research publications through PubMed and given them the chance to comment on and answer questions about about their research and connect with patients (and other physicians) in amazing new ways.

Sure there have been attempts to facilitate sharing of physician-scientist research through social networks - Academia.edu and Mendeley come to mind, and Doximity to a lesser extent.  But those are relatively closed networks.  With HealthTap, there exists the potential for someone in one of the smallest and (most charming) rural towns in Texas - let's say my hometown of Weimar - to ask a question of the medical expert network and get a response from a physician at a major university who has just published a paper on that particular disease.  I think that's amazing.  There are very few forums in which something like that can happen.  But it can happen through HealthTap because of the size and quality of their doctor network, and the smart optimization of their publications feature.

For all of us who love the idea of open-access journals and having transparent, accessible research, this is a great step in the right direction.  When my wife (who is infinitely smarter about these things than I am), decided to publish in an open-access journal during her M.D-Ph.D, I was proud of her.  All that NIH money, those federal research grants - that money comes from us, the taxpayers.  And even if the abstract's available on PubMed, you shouldn't necessarily have to have a M.D, Ph.D to have some idea about what your tax dollars are going to.  Although many studies aren't amenable to a distilled, easy to understand summary... many of them are.

So if you're a published physician, I encourage you to take advantage of HealthTap's new publications feature and share your research and expertise with the world.

Growing consolidation is pushing up prices of medical care... so what else is new.

Breaking news.

California's attorney general, Kamala Harris, has recently discovered what every other person with a high deductible plan has known for a while: Large multispecialty medical centers can drive up medical costs.

The office of the attorney general has sent subpoenas to several big multispecialty groups and hospitals, including northern California's 24-hospital Sutter health system.

You can check out the WSJ article for the details, but here are my thoughts:

1. Encouraging consolidation among hospitals and providers (looking at you ACA) without single payer, explicit payment caps, or bundled payment can be turn out to be very stressful on the pocketbook.

2. When large multispecialty hospital groups charge us higher prices, we should demand higher quality care with better access.  We need web visits, crowd sourcing of medical knowledge, open access scheduling, proven hospital discharge programs, strong primary care teams.  Valet parking, marble floors, pretty fountains aren't going to cut it.

With a fountain like this, how can you NOT be considered a "Center of Excellence"?