#HoustonStrong

For the last few days I’ve been part of the amazing “ride out” crew of doctors, nurses, and support staff covering Texas Children’s Hospital during Hurricane Harvey and the overwhelming aftermath of flooding in Houston.  Since I live in Houston, I have been asked by many, in person and on Twitter, what they can do to help.

Please let me know via Twitter (@drmlb) or in the comment section below if you have recommendations to add to the list below.

 

Houston has an amazing mayor, who has established a fund which will be distributed to groups by the Greater Houston Community Foundation.  To donate to this fund:  https://ghcfdisaster.kimbia.com/hurricaneharveyrelieffund

Houston Food Bank   A marvelous charity that provides food to anyone who needs it.

Plant It Forward  This wonderful organization provides urban farmland for refugees to grow food for themselves and to sell.  

 

Texas Diaper Bank . It’s amazing how this is always a big need in crisis situations. This group does a great job keeping baby bottoms covered!

 

 

Houston Coalition for the Homeless A group dedicated to caring for the homeless in Houston.  Unfortunately, there is little doubt that we will be seeing an increase in homelessness after this disaster, so their work will be even more important. 

 

Houston Humane Society . There are always lost and frightened pets after a flood.  This group takes care of them.

 

Hospital chaplaincy programs are always in need of resources and provide important spiritual support during times of crisis.  You can donate to spiritual care or other programs for the hospitals in the Texas Medical Center here:  

Texas Children’s Hospital

Ben Taub General Hospital

Michael E. DeBakey VA Medical Center

Baylor St. Luke’s Medical Center

Houston Methodist Hospital

Memorial Hermann Hospital

 

 

If you live in Houston, you might think about volunteering by registering with Volunteer Houston or  giving blood.

What’s for dinner? How to eat well if you are too busy to cook….

I wish someone had taught me this when I started medical school.  Seriously, I would have loved it…  Let me walk you through what I did today to prepare for my week, and I think you will understand.

So, first… it’s summer… In Houston.

The weather makes a difference in how this unfolds, since I’m talking about cooking… i.e. (usually) adding heat.

So here’s what I did today..

  1. I spent about 20 minutes looking through what is my current favorite cookbook for three recipes that a) I liked b) were easy and c) were summer appropriate.

2. I entered all the ingredients I needed into GroceryIQ, … plus stone fruit (that is so ripe and delicious right now), a watermelon (because it’s summer and I love them), bread and ingredients for sandwiches for lunch.

(how can you not love a cookbook that says “Heat a big glug of olive oil in a skillet”?)

3. I went to the grocery store and bought everything on the list. When you have a list, it’s really fast, so you make up the time you spent looking up the recipes and making the list. Also, you are much less likely to buy more than you need (which leads to interesting microbiology experiments in your refrigerator) or things you really don’t need (i.e. junk food).

4. I took a nap. (I was on call Friday, up all night, so I’m still catching up). Plus, Sunday          naps are amazing… so don’t think you EVER have to justify them!

5. I spent about 20 minutes preparing the ingredients for Joshua McFadden’s recipe for the tuna melt “casserole” and for one of my summer favorites, ratatouille. Every time I make ratatouille, I think of Maryvonne, Monique and Maddy, my French “mothers” who taught me this recipe when I lived in France as an undergraduate.

6. Here’s where the Houston weather comes in. To minimize stove top and oven time, I roasted the squash for the tuna melt and the vegetables for the ratatouille at the same time – while they were cooking, I sautéed the onions and garlic for the ratatouille and added the tomatoes (canned). (In case you were wondering, the sweet potato is for snacks or something else TBD.)

So, we’ll have the tuna melt tonight, with some store made coleslaw (Brussel sprout and kale), and there is enough for the same meal another night, or lunches if we choose.  The ratatouille can be sides to our sandwiches, or can be another meal with a protein (we are mostly “pescetarian” so probably fish… but you can choose what you want).  Ratatouille is also delicious cold on it’s own or with cottage cheese, or you can add it to broth with chicken meat and make a great soup/stew.Bottom line… maybe an hour today for a week’s worth of amazing food… which is what I wish I’d been taught when I started medical school.

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 p.s. Since you were wondering…  The other two recipes for this week are cooked seafood salad with fennel, radish basil and crème fraiche (p115) and crunchy mixed bean salad with celery, tarragon and soft boiled eggs (p260).

p.p.s Do not get intimidated if you don’t know how to cook. YOU CAN LEARN.  (and you should).  Find someone to help you.

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Good advice I have gotten over the years…

Dr. Jennifer Dietrich, who is the Chief of Pediatric Gynecology in the Department of Obstetrics and Gynecology at Baylor College of Medicine recently showed me a list of advice she’d been given in the past. It’s a great list, so I thought I’d share it! 

  • Give important emails 24 hours for a well thought out response.
  • Say yes to the things you want to do and that make a difference in your career.
  • Find time to protect yourself.
  • It is ok to say no sometimes.
  • Ask for help if you have reached your limit.
  • Try not to bring work home or at least confine work to the weekdays and weekends you are assigned to be on call/on service.
  • Make an appointment with yourself to exercise, relax, go out to dinner, etc.
  • Plan each year to go to the dentist, doctor, address medical needs and protect that time.

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Applying to Residency: Tips for Medical Students (from MS1 to MS4)

Applying for a residency starts with choosing your specialty.  The application for residency includes personal statements, curriculum vitae, letters of recommendation, transcripts and all the other components required by ERAS.  This application is then used by the NRMP to match medical students to their residencies.  It’s a fairly complex process on a relatively short timeline.

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The prezi below was put together to walk medical students through the process – from picking a specialty to matching in the specialty and program which is the best fit for you.

 

I’d love feedback from anyone if I’ve missed something or could explain this in a better way – please comment below!

Best of luck to the students who are starting this process to match next spring – and thanks to all the faculty, administrator and deans who help them along the way!

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Top Ten Tips on Starting Medical School

Starting medical school is one of the most exciting moments in a physicians career… but it can be a little daunting!  This talk is one I gave recently to the college students in the Baylor College of Medicine Summer Surgery Program.  In addition to talking about how medical school is different from college, I also included my top 10 tips for successfully making this important transition.

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Why is there a battle going on about MOC … and why should you care?

Everyone hates exams.  Most of us hate regulations.  But, exams and regulations in medicine came about because of abuses in the past that led to the public distrusting doctors.  It’s a fascinating, and somewhat terrifying history that starts with changing “medical schools” from for profit (and horrible!) businesses into what we know today.  As general doctors started doing ophthalmology, surgery, or obstetrics full time, it was became clear that defining what constituted a specialty, and demonstrating that practitioners were competent was important.

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What does it mean to be “board certified”?

Being “board certified” means that one of the 24 specialty boards in the United States attests that you have met all the requirements and have passed rigorous exams to show that you are qualified to practice in that specialty.

Does the board certification last forever?

Short answer, no. Family Medicine was the first specialty (in 1970) to realize that initial certification was not enough.  As the public continued to ask for evidence that physicians remained up to date, Surgery (1976), Emergency Medicine (1980) and Ob/Gyn (1986) added a recertification examination.  As of 1990, the remaining boards became “time-limited” which means board certification expires after 6-10 years, unless physicians take and pass the recertification examination. So, many internists who are now in their 60s and 70s didn’t have to do anything other than pass the initial examinations.  (This is referred to as being “grandfathered”).

 

Who makes up “the board” for the specialties?

The members of most boards are volunteer physicians in the specialty.  In surgery, which I know the best, the board members are called “directors”.  There are 41 directors of the American Board of Surgery who represent a variety of organizations and specialties in surgery.  These volunteer surgeons spend 20+ days a year away from their practices with no pay (although their expenses are paid) to give the oral examinations in surgery, and to design and validate the written examinations. They also have a variety of committees and projects which focused on one critical question: “What do we need to do to make sure we maintain the public trust in surgeons?”

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How do the specialty boards decide if specialists are up to date?

Since 1990, boards have to be “maintained”.  If you don’t maintain your board, you lose it.  Hence the term, Maintenance of Certification (MOC).  So what do you have to do for “MOC”?  In addition to having a license, most boards have requirements to document hospital privileges and provide letters of reference.  Here’s a summary of the other requirements for four of the largest boards:

 

Continuing Medical Education (CME) Recertification examination Practice Assessment Cost
Internal Medicine Must do some CME every 2 years.

Must get 100 MOC points every 5 yrs. (roughly 20-25 hrs/yr)

Recertification examination every 10 years (counts as 20 hrs MOC points) Nothing required.

Can earn MOC points by QI or by teaching.

$1940 ($194/yr) for General Medicine.

$2560 ($256/yr) for specialties.

Ob/Gyn Read at least 30 of the 45 articles provided by the board annually  and answer four questions/article (=25hrs CME credit) Exam every 6 years but may be exempt if excellence demonstrated by answers to articles. (pilot program) Completion of ABOG practice improvement modules

QI projects

Presentations/publications

$265/year.

Additional fee of $175 if exam is required.

Pediatrics 100 MOC points/5yrs. At least 40 in CME, 40 in practice assessment

“Question of the week” delivered by email.  20 questions = 10 MOC pts.

Recertification examination every 10 years (counts as 60 hrs of CME) Institutional or practice QI projects $1300/5yrs ($260/yr)
Surgery 90 hrs in 3 yrs. (30 hrs/yr) of CME (lectures or online)

60 hrs (20/yr) have to be Level 1(test questions involved)

Recertification examination every 10 years (counts as 60 hrs of CME) Participation in an outcome or quality improvement program $1600 ($160/yr)

 

What happens if doctors decide to not do MOC?

Being board certified is voluntary and so is maintaining a board.  But, if doctors choose not to do MOC, they will lose their board certification.

Here’s some of the possible implications if a doctor loses board certification:

  1. Hospital bylaws almost universally require staff members to be board certified. These bylaws will have to be rewritten for doctors who have lost their boards in order for them to work in these institutions.
  2. The ACGME requires that faculty that teach residents are board certified.
  3. The American College of Surgeons requires that all doctors are board certified who work in ACS accredited Trauma Centers or Children’s Surgery Centers. .
  4. The American Academy of Pediatrics requires that all doctors in the NICU are board certified in order for the NICU to be verified prior to accreditation.

My bottom line on MOC

Since the new MOC requirements went into place I have increased both the quantity and quality of the materials I use to stay up to date, which I strongly feel has made me a better surgeon.  I still don’t like taking exams, but every time I do (I have three boards, so I take a lot of them!) I learn so much that I find the experience invaluable. (Yes, that’s after the exam, not before or during… that hasn’t changed since medical school.)

MOC isn’t perfect, but it’s evolving, and the reason it exists is a good one.  Passing laws state by state to make MOC “optional” has the risk of hurting the public’s trust in physicians – and the risk of creating quite a bit of chaos for hospitals, training programs, and others. For what?  Saving $200 a year?  Not having to take the test every 10 years? Not having to log the CME that is required by almost all state medical boards?

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“Here’s what’s at stake: we physicians are granted an extraordinary amount of autonomy by the public and the government. We ask people to disrobe in our presence; we prescribe medications that can kill; we perform procedures that would be labeled as assault if done by the non-credentialed. If we prove ourselves incapable of self-governance, we are violating this trust, and society will – and should – step into the breach with standards and regulations that will be more onerous, more politically driven, and less informed by science. That is the road we may be headed down. It is why this fight matters.” Robert Wachter, MD

 

 

 

 

 

 

 

Rethinking Institutional Metrics of Success

Recently, I was talking to a superstar surgeon who had travelled to Africa for two weeks to operate and teach. Lives were saved, a gift was given, but when he returned he was told that the two weeks he had spent in Africa resulted in not meeting his RVU target for the month…which he now had to “make up.”

Are you kidding? I can’t think of any physician that would think this is ok….

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I have held leadership roles and I am not naïve. “No margin, no mission” is a universal truth. Financial accountability and stability are necessary for us to heal patients, teach and change the future through research.   But, if we only measure and report productivity it will be the only metric that is perceived to matter…. and that’s not ok.

Financial and productivity metrics are critically important in any business. Healthcare is a very complicated business. But for physicians, medicine is a profession, not a business. This distinction explains why the standard business metrics of productivity don’t sit well with most physicians.

A stethoscope is on a balance sheet. Health care costs

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I’m becoming more and more convinced that we need to rethink how we define “success” for the physicians (professionals) who work in a business (healthcare). If we don’t, I’m afraid we will lose our way…. and potentially a generation of physicians.   So, as a starting point…. what if we thought about the following as potential new metrics of institutional “success”?

RVUs of the group, not the individual

It is human nature that what is counted is assumed to “count” the most. In addition to my friend who was almost despondent over having to “pay back” a mission trip that was part of his original contract, I have watched bright and hard-working physicians choose to stay to do one more little case or see two more consults instead of going home to their children because of this RVU pressure. By the way, these events were when a partner was on call and in the hospital, available and willing to take on this work.

Physicians are a competitive lot. If you give them a target to meet, they will do everything necessary to meet it. But the RVUs for an individual physician vary over time and with circumstances. Because medicine is a profession and not a “job”, there are very few physicians who are “slackers”.   Reporting the RVUs for individual physicians has the risk of hurting the morale of the physicians that are working hard, and rarely motivates people that don’t want to work hard. Besides, do we really want to send a report that monthly RVUs didn’t meet target to a physician who took time off to care for their own hospitalized child? (Yes, it happens.)

Let’s commit to a new institutional paradigm. Set RVU goals for the group. Trust the chiefs and chairs to be responsible for monitoring productivity. Let them take into account the normal ebbs and flows of work as a physican. Trust them to call in the few physicians who are consistently below expectations.

Turnover of physicians in the group

In an academic practice, it’s a good sign if strong, mid-level faculty members are recruited away to other institutions. In all groups there will be physicians who leave for family reasons or because a spouse has been recruited. But keeping track of physicians who leave for other reasons may be a metric that can reveal a bigger problem. Given the extraordinary cost of replacing physicians, isn’t this a metric that should be followed?

Burnout

Burnout is reported in 50% of physicians and costs institutions money. I strongly believe that every physician should have an assessment for burnout as part of their annual evaluation. Physicians that score high on the burnout scale need help – for their sake and the sake of the institution. The cost to the institution in decreased patient satisfaction and increased liability should be enough, but burnout is a life limiting or even life threatening condition. Let’s protect our most precious resource in medicine by paying attention to this epidemic. Why not reward divisions and/or groups that consistently demonstrate low levels of burnout? Why not use what they have learned to coach other groups who need help?

Support staff to physician ratio

I am quite certain that most people have no idea the amount of clerical work that physicians do today. For institutions, it’s a waste of extraordinarily profitable physician time and a major contributor to physician distress. No one knows what the ideal ratio of support staff to physicians should be, which support staff are more important, or what the differences should be between specialties.   So lets measure it, report this metric and compare between groups in our own hospitals and between institutions.  Let’s also make sure we understand how the ratio of support staff to physicians impacts burnout and physician turnover.

Teaching, research and innovation

Professionals work to make a difference but sometimes are not recognized for their successes. Even grown ups love a gold star.  Let’s make a big deal about teaching local physicians, publishing new research, receiving “Doc of the month” awards and building new programs. Celebrate successes – of all kinds – publically and sincerely.

Gifts of time

Likewise, let’s call out and celebrate the physicians who serve on boards of charitable organizations, who travel to treat patients and teach in underdeveloped areas, who sponsor student groups or who otherwise donate their time and expertise to make the world a better place.

Pay equity

I understand that salaries are “complex” in medicine, but it’s time to realize that they can be extremely unfair. When new physicians are hired at a higher salary than extremely successful physicians who have been there for 20 years, something is very wrong. When women and minorities consistently make less, something is very wrong.

There is no way that budgets can suddenly be changed to make pay equity a reality, but its time for all of us to make a commitment that pay equity will happen. Decide how long it will take … 5 years? 10 years? Once you have decided, let your physicians know you will commit to this change. To be transparent, report an annual metric of the percentage of physicians that meet the goal of pay equity. Make these changes. It’s the right thing to do.

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