The Tenets of Professionalism

I have often heard the legal profession described as the “second oldest profession” and with the “oldest profession” being an inappropriate topic area for this blog, apparently that would put the medical profession as the “third oldest” profession.  Whether or not either the medical or legal profession can lay claim to precedence to an “older” title is probably irrelevant but the key is both professions have been around for thousands of years; while much has changed, their basis hasn’t.  For the medical profession, this basis is probably best summed up by the famous quote from Dr. Mayo, “The best interest of the patient is the only interest to be considered”.

It may be fairly obvious but by choosing to be trained in one of the medical disciplines, you have “joined” a profession!  Based on the discipline, professionals may voice different oaths, but in the end, we all have committed to several basic behaviors:  confidentiality of the information we have received from those we will serve, clear and effective communication with both the patient and others that will be assisting us in serving the patient, being respectful of those we serve and modeling respect for ourselves and the profession that we represent by our words and actions, and finally actually being available when called upon to take care of our patients or clients.  In the complex world of today’s medicine, in order to meet the “best interests” of the patient, being professional also means that the concept of team needs to be promoted as well.

One of the other major concepts of a profession is that professionals are self-regulating.  This is sometimes thought as merely a personal obligation, but in many instances this can also be peer-to-peer or group obligations.  Essentially, all of us require the skills to provide and receive feedback, especially from our peers, so that the feedback is constructive. 

For the last several years, I have been involved in the Patient Advocacy Reporting System (PARS) created by Vanderbilt University.  The program was developed from research that showed that there was a direct correlation between patient complaints and medical malpractice suits.  The program has been enormously successful because it uses peer messengers to make physicians aware of patient complaints that have been received about them.  Vanderbilt’s research has shown that when physicians receive peer feedback, they are more likely than not (70%+) to act upon the information and bring their focus back to patients and consequently the amount of patient complaints decline (as does the risk of lawsuits).

The success of the PARS program is directly related to professionalism.  The recognition by our peers that the profession is worth self-regulation and that they can play a part by providing feedback about issues that are important to both patients and physicians.  The recognition by the physicians receiving the message and feedback reflects that our peers have a common basis to discuss the feedback with them and that they should take the time to listen to their peers about how to improve their own professionalism.

Being part of a profession is an honored path that we should all recognize and take responsibility for by making the profession better than when we first joined.

--David Danielson, JD, CPA, is Senior Vice President of Clinical Risk Management at Sanford Health, is an Assistant Professor of Internal Medicine at the USD Sanford School of Medicine and is a member of the National Patient Safety Foundation's Board of Governors

Reflections on 100,000 strong for our patients

Recently, I have come to agree with Dr. Berwick, viewing the IHI Open School as not just a movement, but a revolution started by students who are motivated to change the culture of care in the systems where we work.  We are finding that in order to make the changes we need to achieve higher quality care at a lower cost, we must transform entire systems of care.  100,000 students and residents signed-on to the IHI Open School is an incredible number and is certainly a huge milestone!  These students are entering their respective health professions as natural leaders in quality and safety.  In many ways, they have now become the experts in their systems.  But our patients need us more than ever.  We need more students to sign-on.  The systems are not changing quickly enough and we require a small army to teach others how to develop safer, more effective, patient-centered care that is timely, efficient, and equitable.  This means teaching the science of quality, safety, teamwork, and communication.  We must do this together.  And it must be multi-disciplinary.  Health care delivery is increasingly complex.  Patients are confused, vulnerable, and are being harmed more than we would like to admit. 

The IHI Open School is the absolute best way for us to come together, connecting with students of all disciplines in our local chapters, advocating for IHI Open School courses to be integrated into the curriculum at our schools, teaching other health care providers about these important topics, and engaging in dialogue with students and faculty around the world through the IHI Open School chapter network.  I originally thought of the IHI Open School as a motivator, an entity designed to encourage students to complete courses on their own time and develop the skills they need.  However, after four years of existence, it is now becoming an integrator.  The concepts we learn through IHI Open School are the threads that connect all health disciplines.  Every student in every health discipline should have these skills.  Application of these skills has solved many complex problems and will continue to solve problems and improve patient care on a larger scale.

So let’s bring 100,000 more students to the IHI Open School. 100 years ago, Dr. William James Mayo stated in his commencement address at Rush Medical College in Chicago, “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, a union of forces is necessary.”  Indeed, our union of forces is the IHI Open School. 

 

--Ryan Miller is a 3^rd year medical student at the Sanford School of Medicine and Chapter President for the South Dakota IHI Chapter

Doctor is Spelled T.E.A.M.

I am a first year medical student who has come to this point in my life via a different path compared to most other medical students. As a college and high school basketball coach for eight years, I learned to study performance as if it were a science. The most interesting part of athletic coaching to me was not who could develop the most complex or innovative strategy, but who could get their individual players to execute their roles within the team strategy as close to perfection as possible. I am coming into medical school from a background of studying players to learn how to help them perform to their highest capability.

Understanding how to assist individuals to reach their capacity translates to medicine, and to every other field. The problem that I find interesting is not how to find new information, but how to use the existing information better. As a coach, my job was to find new ways to help each athlete get to a place where he does his job flawlessly. As a student, my day is now currently filled with gathering information. There is so much to learn, I feel as though I may never quite grasp things with as much detail as I would like. But, I know eventually I will be as prepared as I need to be - just as those before me have been. So, in thinking about becoming a doctor someday, I now think about how I will ever be able to keep things straight and not make any mistakes. Because I know if I do make a mistake, the consequences will be much more severe than a low test score. That brings me back to the same question that I faced in coaching. How can I get the most out of what I have? How do I consider all the data and tendencies that we will learn, and not leave anything out? So far, I think we have learned about maybe twenty drugs - and I struggle to keep them separate. How will I be able to do the same, when that number is in the hundreds or more?

The answer, I think, is to realize that a complete knowledge of medicine is too complex for me. I am going to need help from other people. In order to be able to rely on others in the future, I need to start working on doing so now. The time to cultivate professional, trusting relationships is not when disaster strikes and I can't quite remember the correct sequence of remedies I need to apply. It is the days and months before that time. Thus when it all comes crashing down, I know I will be able to trust those around me to help achieve the best outcome.

This idea is the ultimate lesson in being part of a team. That is what makes athletics so valuable, and is hopefully the lesson that we will start to learn as we begin our medical careers. Learning how, not just to work with other people, but to rely on them and allow them to rely on you. Of course the knowledge is important. Of course it is my responsibility to know it all myself as well as I possibly can. This is not an excuse to be lazy and rely on others to get you by. This is just understanding that more can be achieved when people work together. Being a great teammate is a skill that needs to be cultivated. It takes some humility to ask for help or to ask for other ideas. The time to start working on those skills is before you actually need to use them.

 --Scott Stevens is a first year medical student at the Sanford School of Medicine

A Season of Renewal

It’s the season of renewal at the University of South Dakota Sanford School of Medicine.   Our former senior medical students have moved on to residencies to complete their transformation from student to colleague.  Men and women who were college students a few short months ago are now medical students.   They bring with them their enthusiasm, aspirations and hope for the future.  

Our new students will find a medical school that is undergoing its own process of renewal and transformation.   In 2012, USD SSOM was rated in the top ten schools in the nation in rural medicine and in family medicine and was named one of the top ten most popular medical schools in the country by US News and World Report.    Our graduates have enviably high rates of passing national boards and high median board scores, and the school recently passed accreditation with flying colors.  Despite this great foundation, changes are afoot because we recognize that the curriculum of the past will not adequately train physicians of the future.   .   

Soon, students will notice fewer lectures and more interactive small group sessions.  Basic science courses will be coordinated with each other to provide a more vivid and memorable picture of the function of the human body.   Clinical work will be more clinic-centered, because the outpatient setting is where most diagnoses are made and where 75% of visits in the U.S. occur.  More time will be set aside for electives and this will occur earlier in the curriculum to allow students to gain more experience in an area of interest before they have to choose a specialty.   Our new Frontier and Rural Medicine (F.A.R.M.) program will allow a select group of students to spend significant time in a rural community of less than 10,000 people.

This is a lot of change and we are not alone.   Virtually every medical school in the country is overhauling its curriculum right now.   In part this is in response to the recent Carnegie report that pointed out that the structure of medical education had not changed in more than a century.   Medical education has simply not kept up with educational theory.   Long-term memory is created when learning is interactive, uses multiple modalities, is repetitive, and is directly related to patient care.  Clearly, it is time for us to change.  But how do we know that we are creating a better system?   The answer is that USD SSOM is uniquely positioned because the Carnegie report cited the Avera Sacred Heart Yankton campus of USD SSOM as a national model for educational reform.   This means that the school has experience in delivering the modern clinical curriculum and has the outcome data to show that students who go through this curriculum are highly successful as measured in many ways including performance and test scores.   Only a small handful of schools in the country have this experience.   Another major asset in this process is the high quality of the teaching faculty in the school.   It is difficult to ask basic scientists and clinicians to change the way they teach, yet they are not only willing to do so but they are also highly engaged in creating the new model.   The best systems (and the best people) are those that are flexible and responsive to changing needs.   The communities and health systems are strong supporters of medical education, and we will continue to rely on these important partners.   Our final important asset is the students themselves, who provide critical input and advice to us at every stage of the process.  

The new curriculum must be responsive to the medical needs of South Dakota and the nation.   It is always important for physicians to provide excellent care in a face to face environment.   However, there is an increasing need for physicians to step back and consider the health of populations.   The modern physician should insist that the quality of care be measured and improved, leading the effort rather than resisting it.  Medical school needs to provide the tools for young physicians to do this.   Many diseases now are related to behaviors and social factors that are not going to be influenced by medications or tests.   Modern physicians need the tools to motivate behavioral change.  Physicians also need to be competent to practice in an increasingly multi-cultural world.   Finally, and perhaps most importantly, physicians need to adhere to the highest standards of professionalism.   These are tall orders, but they can be accomplished.

One of the things I like best about academic medicine is the variety and change that is inherent in it. We have the privilege of working closely with some of the best minds and some of the nicest people in the country.   Building on this foundation, we share our new students’ sense of optimism and look forward to the future.

--Mary Nettleman, MD, MS, MACP is Vice President for Health Affairs and Dean of the University of South Dakota Sanford School of Medicine

June 28, 2012--A Day in History

June 28, 2012…..will this become a landmark date within the history of our country?  Perhaps not, but as I pause to collect a few thoughts for Unum Vox, it is hard to take one’s eyes off of CNN, or the explosion within the blogosphere, over today’s Supreme Court ruling relative to the PPACA (Patient Protection and Affordable Care Act).  Without a doubt this is a critical moment in our country’s lurching, ponderous journey towards universally accessible, affordable, safe and reliable health care.  Rest assured, the political debate will only escalate, pundits will continue to pontificate, but a stake has now been placed firmly in the ground, and any effort to diminish, augment, or change our approach to health care reform will have to travel through this historic piece of health care legislation, or at least be measured by/compared to it.

Regardless of an individual’s political or philosophical persuasion, the PPACA pushes this country in several positive ways.  In fact, many laudable accomplishments can already be attributed to it.  The misfortune of severe illness no longer renders an individual uninsurable.  “Pre-existing illness” will disappear from the insurance industry’s lexicon.  Young adults will continue to be able to access the benefits of family coverage rates until age 26.  Through exchanges, employer based plans, and expanded Medicaid coverage we should be able to approach fully accessible health care for 95% of all citizens, and simultaneously remove a long standing embarrassment for this country amidst the roll call of nations within the developed world (even many countries considered to be “third world”).

Admittedly, this piece of legislation was/is far from perfect.  Much of the “tough medicine” true reform requires was side-stepped by our political leaders.  Sustainability is only possible within the context of affordability, and most will agree that the measures taken within the PPACA fall far short of dealing with the difficult decisions needed to take control of the inexorable climb of health care costs.  Until we hard-wire care that is fully cost conscious, and high value, this effort will collapse under its own weight.

However, I take great solace and daily inspiration from two critical observations by Dr. Donald Berwick, past director of CMS, and founder of IHI.  First, he likened the journey towards high quality, safe and reliable health care to a car trip, and he stated that the health care community (i.e. not Congress) drives that car.  Secondly, he opined the following:  “the key to improvement is coverage, and the key to coverage is improvement.”  In other words, we will never produce high value, high quality care for our country until everyone has access to that care.  Likewise, unless we produce care that is of the highest quality, universal coverage will be unsustainable.

As for me, I choose to be greatly encouraged today.  The keys are in OUR hands. 

--Tom Braithwaite, M.D., FACP is Chief Quality Officer at Sanford Health in Sioux Falls

The Art and Science of Nursing

      My desire to be a nurse came about eight years ago when I was hospitalized on a pediatric floor for three weeks. I was the crazy kid who wanted to go back to the hospital when I came home because I missed “my nurses.” I remember the nurses who comforted me and listened when I was scared, and the nurse who told me “honey, crying isn’t going to help anything.”  After my experience as a patient, I knew I wanted to be a nurse who made a difference. I strive to be a genuine nurse of integrity and compassion, a life-long learner dedicated to collaboration and teamwork so that I can provide the best quality care possible.

      Jesus has called me to love the people around me—“Love one another. As I have loved you, so you must love one another (John 13:34).” He has also blessed me with a love for science and a longing to understand how the body functions so complexly. Being a nurse is one of the most tangible ways I can think of to love others using the characteristics and talents God has given me. Nursing is both an art and a science. To be a nurse is to care for the whole person—physically, emotionally, and spiritually. A nurse cannot adequately care for a patient unless he or she considers all aspects of care; being a nurse is not merely the ability to start an IV, remove sutures, or administer a medication.

      I firmly believe I can be the “smartest” nurse, but if I do not have compassion and know how to care for the whole person, my patients will suffer. Knowledge is important. Keeping up with research and being able to explain the complexity of a patient’s health status to the family is essential to nursing care. However, nursing is also about comforting the family of a dying patient, celebrating the little milestones of a stroke victim, and holding the hand of a crying child.

      I remember my first day of nursing clinicals, just two years ago. I was terrified to give a bed bath. Looking back I think, “Wow! Look how far we’ve come.” I remember my first patient; her name and diagnosis but little else. When I first started nursing school, I was so focused on disease and trying to make things perfect. Now I look back to more recent experiences, and I remember something different.

      I remember an older gentleman who was scared out of his mind for a complex surgical procedure he would be undergoing the next day. I remember seeing fear in his eyes, and seeing that fear eased when I simply asked if he wanted to go for a walk. With a smile on his face he said, “If I get to go on a date with you, then ABSOLUTELY!” I remember his wife, and how all three of us joked around about me “stealing” her husband to go on “walking dates.” We talked about his fears, and he told me about his faith in God and how it was the only thing that was going to sustain him. Yes, I learned a lot about his disease process, but I remember more than his diagnosis. I remember his family and his stories and his faith, and I remember praying for him every time I entered his room.

      Ultimately, nurses see patients at the best and worst moments of their lives, yet accept them the way they are. Nurses acknowledge the uniqueness of each patient by individualizing care, and through this they integrate knowledge and research with compassion and love. A nurse of integrity is a lifelong learner, someone who recognizes he or she is not all knowing, and one who is willing to ask questions of others in the clinical environment. A nurse realizes that he or she is just one part of a patient’s plan of care, and strives to interact with the entire healthcare team in order to provide patients with the best quality care.

      After graduation I will be starting a new career as a pediatric intensive care nurse. Nervous? Yes. Excited? Absolutely. I know I am starting out in one of the most challenging places in nursing. I am going to have days when I feel like I do not know anything. I am going to be placed in situations where I do not have the perfect words to say. But this is what I do know: GOD IS GOOD. He has given me this opportunity to love children and their families, and to grow as a leader. Ultimately, nursing combines the science of the human body and research with the art of communication, compassion and love, and I am blessed to be part of it.

           - Caitlin Leimbach is a recent graduate of South Dakota State University, and currently working as a nurse in the Sanford Pediatric Intensive Care Unit in Sioux Falls. Caitlin is also a graduate section leader for our SD IHI Open School chapter.

Teamwork: For Better or for Worse

As a first year medical student looking into the future, I often wonder what it will be like not to fly solo, as we must to earn a grade in medical school, but to solve problems as a part of a health care team. This idea has been touched on, but not fully explored as of yet in my medical career, though it can be said to be an essential aspect of health care. I have personal experience with both the positive and negative sides of teamwork. When I was in the third year of my chemical engineering major, one of the required classes was a chemical engineering lab, Unit Operations (it was like a chemistry lab, except we used industrial sized equipment). The class was designed so that students were employees of a company and were sent “Memos” asking for reports or designs on different topics; the memos did not provide any instructions on how to complete the task. Students were divided into groups, and members of the group were assigned different jobs which changed for each lab: Planner, Experimenter, Analyst, and Consultant. The group had to complete a minimum 50 page paper every other week, as well as present every week on their progress to their “Supervisor”. Each member received their own score, but it was impossible to complete any one section if the other members hadn’t completed their own work. Unit Operations created a situation where you are only required to complete your job, but you are penalized if a member of your group doesn’t do their job. At the time I began this class, I was excited because we used real industrial-sized equipment, but I quickly learned the frustrations inherent in mutually dependent teamwork. I struggled in the first semester of Unit Operations because my group members did not pull their own weight, leaving me to pick up the slack if I did not want to be pulled down. Actually, in the end, one of my group members failed the class. However much work it was at the time, I truly learned how essential communication and follow-through are for successful teamwork. Now, the failed teamwork in that case led to a member’s failing the class (and poor grades for the rest of the team), but on a health care team, such failure could end up having a negative impact on a patient.

 I first encountered the importance of health care teams when my father became sick my freshman year of undergrad. He went to the ER with severe abdominal pains anticipating that it would be another blockage resulting from scarring from his past abdominal surgeries. However, the general surgeon and ER physicians he saw upon arrival discovered that he had acute necrotizing pancreatitis. As they couldn’t figure out why my father had pancreatitis (turns out the pancreatitis was a side effect or a reaction to his blood pressure medicine), and he was rapidly deteriorating, multiple other health care providers were called to provide assistance. These physicians included: internal medicine, GI, pulmonary/Critical Care, interventional radiologist, and ID. All of these physicians were needed to maintain his health until a decision could be made for a recovery plan. After three days with no progress, it was decided that he could not be successfully cared for in Sioux Falls, so he was airlifted to the Mayo Clinic where he was under the care of a whole other set of the same type of physicians caring for him in Sioux Falls with the addition of a thoracic surgeon, a general radiologist, a biliary surgeon, and a transplant doctor. It took another three days in the Mayo ICU surrounded by dozens of doctors, fellows, residents and nurses before someone finally realized the most likely cause of his pancreatitis. The blood pressure medicine was pinpointed and discontinued, and my father was able to leave the ICU two days later, though it took another couple of months before he was able to return to a normal life style. Throughout this ordeal, my father was frequently not aware of what was going on to him and about him; he did tell me two things he managed to notice, 1) that many times there were potential miscommunications between different doctors and between doctors and staff (nurse, respiratory therapists etc.) which luckily my mother was able to catch and 2) from the many doctors who assisted on his case, it was a GI doctor, who had clearly been in excellent communication with the other doctors, who first recognized the pancreatitis as a potential side effect of the medication and took control of my father’s care once he had stabilized.

My father’s case clearly demonstrates the need for inter-disciplinary collaboration, the need for improvement in the communication between physicians and other supportive health care providers, as well as the importance of family support. The IHI Open School was created to ensure that health care teams, like those that took care of my dad, can succeed beyond their current level. If the students of today truly learn to collaborate, then situations like my dad’s may not occur; instead of 6 days to figure out what was causing his condition, it could have been discovered in the first couple of days. Acute necrotizing pancreatitis is not something that is easily survived and it was only with the successful collaboration of multiple health care teams that my father is alive today.

- Laura Danielson is a first year medical student at the Sanford USD School of Medicine and is the editor of Unum Vox. 

Introduction to “Unum Vox” & The Importance of Health Care Team

Ryan Miller, second year med student
IHI Open School, SD Chapter President

In 1910, William James Mayo spoke of what we now call “patient-centeredness” at the commencement address of Rush Medical College.  He stated, "It (has become) necessary to develop medicine as a cooperative science; the clinician, the specialist, and the laboratory workers uniting for the good of the patient.”  He further stated, “Individualism in medicine can no longer exist."  As you can see, teamwork in medicine is not a new concept yet 20^th century medical education and healthcare delivery has greatly struggled not because we haven’t seen new and improved ways to treat the patient’s disease but because we have been doing this largely in “silos”. So here we are in the 21^st century with its growing complexity, having to revisit these fundamental concepts and place them as priorities. 

The Institute for Healthcare Improvement (IHI) South Dakota chapter’s mission is “To bring together multiple healthcare disciplines and teaching institutions for learning and collaboration on patient safety and quality improvement. We seek to do this through the common platform of the IHI Open School and by building teamwork among us as South Dakota learners. All of this is for the patient’s best interest, which is healthcare’s reason for being. We therefore seek to foster patient-centered environments through learning approaches that address the complexity inherent in healthcare delivery systems, into which the patient enters. To these ends we seek to help equip students from all disciplines and at any stage of learning, with the tools necessary to become leaders in patient safety and quality improvement.”

Students recognize the need to work as a cohesive team. When members of our IHI Open School chapter were asked what they think most needs to be improved in healthcare settings today, the themes of teamwork, communication, and patient-centeredness were far and away the most mentioned. One of our Physician Assistant students said, “Ensuring that the patient and family are WELL informed and understand the situation. COMMUNICATION between disciplines. No one is ever on the same page. E.g. order CT with contrast on patient with renal disease… causes lots of delays to determine if risk outweighs benefit.”  An occupational therapy student said, “Professionalism both with interactions between workers, patients, and co-workers; true empathy or care for the patient at all times.” Maureen Bisognano, President and CEO of the Institute for Healthcare Improvement, has spoken widely about the impact of these types of stories on the care we provide patients.

Recognizing the power of story and perspective, we would like to introduce the inaugural blog of the IHI Open School, South Dakota Chapter!  The blog, “Unum Vox,” (Latin for “One Voice”), serves as a new way to share our experiences, learn from each other, and most importantly, speak with one voice for the patient.  “Unum Vox” will feature the writings of South Dakota health care students, professionals and faculty on topics related to the South Dakota chapter’s theme “Together One Voice For The Patient.” Potential areas include patient safety, performance improvement, leadership, professionalism, communication, teamwork, systems thinking, human factors, reliable design and just culture. It is hoped that these subjects will be explored through stories of real patients and their caregivers, allowing all who read it to continually improve their own ability to seek out the patient’s best interest. This blog will be updated monthly and every South Dakota health care professional student, who is also a member of IHI, has the opportunity to contribute. We are delighted that Laura Danielson has both taken on the leadership for editorial review of Unum Vox…and has written the first Unum Vox blog with a compelling account of events in her personal journey as a learner and as a family member.

Blog posts may be a maximum of 1,000 words and must relate to the chapter’s theme “Together One Voice For The Patient”. Ideas can be drawn from clinical, classroom, personal experiences, opinion, responses to articles and more. Upon submission, several editors will evaluate blogs and the chosen blog author will be notified. Individuals who are chosen will be identified on the website. To submit a blog post, email Laura at Laura.Danielson@usd.edu.  We encourage you to write for this blog!  With the diverse experiences that members of our chapter have had, we can truly learn from each other to improve care, and speak as “one voice.” 

Ryan Miller is the founder and chapter president of the South Dakota Chapter of IHI Open School and is a second year medical student at the Sanford USD School of Medicine.