Challenges in Academic Clinical Practice

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Challenges inAcademic Clinical Practice
Michael Howell, MD MPHDirector, Critical Care
Quality Associate Director, Medical Critical
Care
From the Silverman Institute for Health Care
Quality Safety Beth Israel Deaconess Medical
CenterHarvard Medical School
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Grand Challenges in Clinical Practice n 8

• From input to www.aamc.org/academicmedicine
• Develop practice protocols for transplanting
  complex organs
• Set guidelines that allow physicians to prescribe
  treatments that may not be evidence-based, but
  are rational
• Make diagnoses based on communication with the
  patient and critical thinking, rather than
  technology and test results.
• Create a way for physicians to have any-place,
  any-time access to a patients patient record
• Create a system for assessing clinical
  performance in a way that is accurate, unbiased,
  and reliable
• Protect patient privacy of electronic health
  record

• Perverse reimbursement
• Dealing with diminishing resident work hours
• You get what you pay for
• Primary care vs. other work ( for prevention vs
  for CABG)
• Private vs. Academic
• Annoying DRG system
• Academic Clinician / Administrator Quality
• Does academic medicine help or harm patients?
• Defining interventions explicitly enough to
  understand whats tested
• Context as a covariate
• Knowing vs doing
• Methods development research
• What is a team, anyway?
• Place in the continuum of care
• MinuteClinic
• 80-hour attendings
• / Researcher pathway
• PL screenshot
• Dealing with web 2.0

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Three of n 8 Challenges in Clinical Practice

• Improving quality improvement
• How can you drink from the fire hydrant when
  youre already under water?
• What is a team, anyway, and where do physicians
  fit in?

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Improving Quality Improvement

• Academic medicine, as a field, should lead the
  way about getting better at getting better.
• We are behind non-teaching settings.
• We dont have good tools to help understand why
  some interventions that are effective and others
  arent.
• We need to develop methods for this kind of
  research

Time to Complete Remission 13 months
Yellow and green peas vs. The Human Genome Project
Time to Complete Remission 3 months
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Why might this make a good theme issue?

• Need for tools to help evaluate and compare
  practitioners and systems
• Existing ones are inadequate
• Potential methods development topics abound
• New analytic challenges
• Need for being adequately explicit in the
  description of interventions
• An irreducible covariate local context
• How do we analyze interventions that by design
  are evolving during the study?
• Debate about whether an RCT is the ideal model
• Work that is getting started RWJF and AHRQ

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Managing Data, Information, and Knowledge

• Usually discussed in the context of the rapidly
  expanding base of biomedical knowledge.
• I mean this more broadly.
• Managing new discoveries
• Managing new tools of practice
• Managing data about individual
• patients
• Helping patients manage information
• Not only data management
• ... Patients and families clearly have tools for
  self-(mis)-diagnosis that are new, improving, and
  more pervasive

Why should esophageal manometry be used in
managing ARDS?
How can you drink from the fire hydrant when
youre already under water?
What is RNAi, anyway?
What is varenicline?
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Why might this make a good theme issue?

• There is a clear motif
• Data ? Information ? Knowledge ? Wisdom
• This theme has some advantages for a theme issue
• Electronic health record
• Personal health record
• Decision support (for patients, families, and
  providers)
• Cognitive approaches to decision-making,
  information management, and lifelong learning
• But also some downsides
• Potentially well-covered by other journals

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What is a team, anyway?

• Many publications refer to teams.
• Ngt10,000 Pubmed hits with team in the title
• Team-based care is widely and zealously
  advocated.
• Local experiences suggest team-based training has
  effect.
• But most team interventions do not
• Reflect the majority of current practice
• Reflect the patients point of view of who helps
  care for them

What is a team, anyway?
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Radiology resident
Resident
Attending
Radiology Tech
Intern
Urinalysis tech
Medical student
Transporter
Microbiology tech
EMS
Radiology Attending
Phlebotomist
Housekeeping
Triage Nurse
Transport
Night float intern
Coders
UCO
Lab tech
E.D. visit
Admission
Discharge
Dietary
Admitting clerk
Case manager
Cook
Transporter
Pharmacist
Patient Care Tech
Contracting
Floor nurse
Billing
Floor patient care tech
Medical student
Medical records
Intern
Transporters
PGY-3
Attending
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Why might this make a good theme issue?

• This may be a heretical question in the patient
  safety world.
• Two team-based RCTs were convincingly null
• Medical Emergency Teams
• Obstetrical Team Training
• The rigorous thing to do is to re-examine our
  assumptions.
• An AHRQ evidence report concluded The medical
  field lacks a theoretical model of team
  performance
• There are a broad range of explanatory
  theoretical models from sociology, organizational
  development, and other fields that we can draw on
  (Activity theory, Knotworking, etc.)
• Academic Medicine should pull broadly from all
  relevant fields of scholarship.
• Timely in relationship to new models of non-MD
  care

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Three of n 8 Challenges in Clinical Practice

• Improving Quality Improvement
• Managing Data, Knowledge, Information, and Wisdom
• Thinking more broadly about teams

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Thank you.
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Training, as was conducted and implemented, did
not transfer to a detectable impact in this
study.
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• Caveat Ive considered a few things as health
  policy problems rather than clinical practice
  challenges
• Focusing on health rather than disease
• Balance of primary, secondary, and tertiary care
• Industry-academic relationships

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