A 21st Century CPD Challenge: Patient-Centeredness..

“Learn on Your Own and Leave Us Alone”

Fahad Al-GhimlasOctober 19, 2014

Session 1 : Continuous Professional Development (CPD), Challenges & Evidence-based Approach Merits

My reply

• ‘That’s not the way we do things here. This is part of the education of doctors in the hospital, where all team (including residents or/and students) participate in your care’.

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

My reply

• ‘That’s not the way we do things here. This is part of the education of doctors in the hospital, where all team (including residents or/and students) participate in your care’. If you don’t want all team participating in your care, you should go somewhere else.’

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

My reply

• ‘That’s not the way we do things here. This is part of the education of doctors in the hospital, where all team (including residents or/and students) participate in your care’.

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Mrs. A

• 76 frail lady, in casualty• Known to have “asthma”• Admitted already, waiting for a bed• Cough, febrile, and pancytopenia

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Mrs. A

• She doesn’t want “student doctors” taking care of her.

• She wants “real doctors,” not ones who are “still learning.”

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Today, most teaching hospitals..• Staff nonteaching services (including staff on

locum)• Admit more patients to nonteaching services

(despite large government subsidies for their teaching status)

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

• Staff nonteaching services (including staff on locum)

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Today, most teaching hospitals..

due to..o Restrictions on residents’ work hours tighten, o Caps on teaching census shrink, o Number of federally funded positions for

graduate medical education remains fixed, and o Hospital executives (including many trained as

physicians) value patient throughput more than medical education.

Reilly BM. N Engl J Med. 2014 Jul 24;371(4):293-5

My reply

• ‘That’s not the way we do things here. This is part of the education of doctors in the hospital, where all team (including residents or/and students) participate in your care’.

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Differential “Treatment” for the “Demanding”

• Instead of saying ‘my way or the highway’, I would say..

• ‘Not a problem, ma’am. I’ll make sure I will personally be responsible for your care.’

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Is It a Good Differential “Treatment”?

• Won’t she receive better care in an educational environment?

• Am I not learning myself?!!

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Graduation is Just the Start of A Journey! Yet Should be Good One!

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Junior Staff: they make me look better!

I am a competent clinician but I remember by working with residents and students:

• Mrs. M. (Kuwait) – severe pernicious anemia explained her dyspnea as intern heard the diastolic rumble I had missed.

• Mr. R. (Kuwait) – raging illness stumped me cold until a junior staff taught me about FMF.

• Mrs. K. (Canada) – near-fatal drug addiction remained undiscovered until a medical student made the effort to bond with her family.

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

But who has the time?

Even if..1. evidence of superior quality of care in

teaching hospitals was more convincing — 2. we could explain teaching hospitals’ lower

patient-satisfaction scores

• would it matter in Mrs. A.’s case?

Eviden

ceNex

tSli

de

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

• To compare the performance of U.S. teaching and nonteaching hospitals using a portfolio of contemporary, publicly reported metrics (2006–2009)

Teaching Council of Teaching member (Half-Teaching)Non-Teaching

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

• To compare the performance of U.S. teaching and nonteaching hospitals using a portfolio of contemporary, publicly reported metrics (2006–2009)

TeachingHalf-TeachingNon-Teaching

273852

3,684

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Teaching Non-TeachingHalf-Teaching

Inpatient care

Shahian DM, et al. Acad Med 2012; 87:701-8.‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Teaching vs. Non-teaching: CC

Teaching Non-TeachingHalf-Teaching

Education

Personnel

Shahian DM, et al. Acad Med 2012; 87:701-8.‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Teaching vs. Non-teaching: CC

Teaching Non-TeachingHalf-Teaching

Expense per case

Shahian DM, et al. Acad Med 2012; 87:701-8.‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Teaching vs. Non-teaching: CC

Teaching Non-TeachingHalf-Teaching

Heart Attack

Heart Failure

Process Measure

Shahian DM, et al. Acad Med 2012; 87:701-8.‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Teaching vs. Non-teaching: CC

I P< 0.001-

Shahian DM, et al. Acad Med 2012; 87:701-8.

Teaching Non-TeachingHalf-Teaching

Process Measure

Pneumonia

Surgical care improvement project

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Teaching vs. Non-teaching: CC

I P< 0.001-

Teaching Non-TeachingHalf-Teaching

30-day mortality

Outcome Measure

Shahian DM, et al. Acad Med 2012; 87:701-8.‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Teaching vs. Non-teaching: CC

I P< 0.001-

Teaching vs. Non-teaching: CC

Teaching Non-TeachingHalf-Teaching

Patient experience measure

Shahian DM, et al. Acad Med 2012; 87:701-8.‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

I P< 0.001-

Patient-Centeredness• Patient-centered care supports active involvement of patients and their families in the

design of new care models and in decision-making about individual options for treatment.

• "Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions."

Institute on Medicine. Retrieved 26 November 2012.

• Patient-centered care is also one of the overreaching goals of health advocacy, in addition to safer medical systems, and greater patient involvement in healthcare delivery and design.

Jo Anne L. Patient Advocacy for Health Care Quality.

• Given that non-consumer stakeholders often don't know what matters most to patients regarding their ability to get and stay well, care that is truly patient-centered cannot be achieved without active patient engagement at every level of care design and implementation.

Sepucha, Karen; Uzogarra, Barry, O'Connor, Mulley (2008). Patient Educ Counsel. 73 (3): 504–510

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Patient-Centeredness• “Clinicians’ best, evidence-based professional

judgment must take a back seat to patients’ wishes”.

Dr. Donald Berwick • This idea may have clinical and economic

infeasibility – E.g. misplaced car keys might become an

indication for brain MRI

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Healthcare Professionals Should Gain • In depth background of available diagnostic ‐

tests and therapeutic interventions • Effective search tools • Critical appraisal skills• Ability to define and understand benefits/risks• Ability to understand

patients’ and cultural values and preferences

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Fahad Al-Ghimlas

Should We Adopt Patient-Centeredness?

• Yes. But through a “Mature Dialogue”.• Curiosity is a Requirement. –Why does Mrs. A. want what she wants? –Why rejecting residents and students before

even meeting them?

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Published Research NOT Address..

• Do procedurists in teaching hospitals disclose who holds scalpels, scopes, or catheters in their case?

• Are answers reassuring to patients?

• How faithfully these promises are kept?

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Disadvantages of Work-hour Restrictions

• Patients’ reluctance to serve as “teaching material” pose a similar threat to the quality of our future physicians.

• Might diminish their preparedness for independent practice.

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Overall Conclusions and Take-Home Messages

• Next year will be more exciting.. I promise!• Evidence of quality of care in teaching hospital

environments is superior.• Teaching hospitals may leave lower

patient-satisfaction scores. • Unanswered questions about lower

patient-satisfaction may solve the puzzle.• We should adopt patient-centeredness

but through a “mature dialogue”.

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

It is Not the Start.. It is the Journey!

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Football League Amir Cup

Crown Prince Cup

Al-QadsiaAl-Arabi

Al-Qadsia vs. Al-Arabi Football Clubs

Al-Qadsia Al-Arabi

A 21st Century CPD Challenge: Patient-Centeredness..

“Learn on Your Own and Leave Us Alone”Fahad Al-Ghimlas

October 19, 2014

Session 1 : Continuous Professional Development (CPD), Challenges & Evidence-based Approach Merits

THANKS!

EXTRA SLIDES

• Clinical expertise doesn’t lend itself easily to objective measurement, much less controlled trials.

• (If I could prove it, I would ask patients to give informed consent for the nonteaching service.)

Expertise vs. Updated

I Can’t Prove It

‘Session 1 : CPD, Challenges & Evidence-based Approach Merits’ – Fahad Al-Ghimlas – October 19, 2014

Disadvantages of Work-hour Restrictions

• Patients’ reluctance to serve as “teaching material” pose a similar threat to the quality of our future physicians.

• Might diminish their preparedness for independent practice.

Eviden

ceNex

tSli

de

• 2003: Common Program Requirements established by the ACGME for residency programs.

• 2007: reports of sleep deprivation especially the most junior residents, recommending further limitation of residents’ work hours, increased supervision, fatigue-mitigation strategies, facilitation of care transitions, and increased federal oversight of the ACGME.

N Engl J Med. 2010 Dec 2;363(23):e34.

Past vs. Present

Drolet BC, et al. N Engl J Med 2010;363(23):e34.

Demographic Characteristics

Total = 2,561Drolet BC, et al. N Engl J Med 2010;363(23):e34.

Demographic Characteristics

Total = 2,561

Drolet BC, et al. N Engl J Med 2010;363(23):e34.

What Did They Say?

Drolet BC, et al. N Engl J Med 2010;363(23):e34.

Authors Conclusions

• New rules are designed for “safe and humanistic educational environment”.

• Concerns: should study effect of changes on residents’ education and the quality and safety of patient care in teaching hospitals.

Extra Slides

Extra Slides