CME Crosstraining with Dr. Gurpreet Dhaliwal

Howdy - This Scott Selinger and welcome to the podcast on behalf of the Northern California's chapter of the American College of Physicians Council of Early Career Physicians.  I should note that I'm thinking about calling the podcast ABCs for ECPs, ECP's being early career physicians.  It seemed a little more legit than the original working title, modeled after my favorite phrase to hear from a patient, "Can I be real with you?"  

One of my biggest concerns starting off my medical career, is staying up to date.  Through medical school and residency, it seemed like so much time was devoted to learning about new practice altering information because I was always trying to catch up with and impress my attendings with things they hadn't heard of.  At the end of residency, I think I was subscribed to at least 10 different journals and newsletters, on top of the e-newsletters and listservs, and trying to peruse through all of them is just something I felt I had to do every week.  I was always searching for that one little nugget of information that would make life better and easier for my patients and for myself.  

But now I'm out, and I'm practicing in a busy setting and having trouble to find the time to do as much reading and research.  But I still feel that need, that pressure, to stay up to date on all the breaking evidence.  Now of course we're required to have our continuing medical education and doing things to fulfill our ABIM maintenance of certification requirements, but that's not my real driving force.  I'm sure we've all seen patients either coming into the hospital or transferring to a new clinic on a bizarre outdated medication regimen.  And my fear is ultimately becoming one of those physicians.  

While there's not a fantastic amount of high quality data out there, a systematic review published in the Annals of Internal Medicine about 10 years ago, looked at 62 studies regarding various outcomes relative to physicians years of practice.  Almost 75 percent of these studies showed decreasing guideline adherence in a variety of performance and outcome measures with increasing years of experience, and that scares me a little bit.  Now I'm sure like all studies there's geographic and practice setting variance, but overall it makes sense that the more entrenched you get into the everyday world of patient care, the harder it is to be able to step back and access your own practice and the advancing practices of those around you.  

To put it more simply I feel like I'm Rocky in Rocky III.  I've come from being a little nothing to an attending physician.  I've knocked out Apollo Creed twice, med school and then again in residency and know I'm riding high and taking pictures and even doing pod casts.  But I know somewhere out there it's Clubber Lang, some new kid on the block or some new piece of data that's hungry, and slowly working its way up the chain, and if I don't do enough to stay on top of my game I'm gonna get knocked out.  So what is an early career physician to do?  Well to help get some guidance I spoke with Dr.  Gurpreet Dhaliwal, a clinician educator and associate professor in clinical medicine at UCSF who has particular interest in medical education and clinical and diagnostic performance and improvement.  

Me:  Doctor Dhaliwal thanks so much for joining me today.  So I guess to dive right in, what mistakes do you feel physicians make starting out; as far as what they try to do with staying up to date with all the recent advances, and new papers and things like that.

GD:  I'm thinking it's hard to make a mistake in terms of trying to stay up to date.  But just doing that itself is a good effort.  It's a commitment to lifelong learning.  I think one of the mistakes that might be made is that thinking the best way you're gonna do service to yourself and your patient is keeping up with all the new studies that are coming out.  A lot of the new studies are alluring and interesting, but a lot of the research doesn't change our day to day practice.  They're more news than they are information you can use.  So I wouldn't, heavily prioritize reading research articles.  

Me:  I know now there's now tons of different ways that everything is being published.  What do you feel are becoming the most common ways that people are using to stay up to date with the changing practices?  

GD:  I think one of the best ways to stay up to date is to recognize that you sort of choose three different streams of learning from the literature that come to you.  On one level are things where you just literally get them as a headline.  These may be scanning the table of contents that come by email or maybe seeing even I'll get a news alerts about, big research.  

Then there is another layer of things where you get a more in-depth but still relatively brief report on something, like a podcast or a summary of the article that, that comes from Journal Watch or ACP journal club or something along those lines, and then finally is those moments where you sit down and actually read something in-depth, and by that I mean you're starting to commit more than ...  Fifteen to twenty minutes of reading.  And when you do that I think that those episodes are few and far between.  But, that's when you have to choose whether you're going to read a research article in depth, a review article in depth or maybe read a case in depth.  But there's different ways the information is streaming to us and part of that is how much time we have to commit to each one of them.  I think a good strategy is that on a daily basis you're getting that headline steam, through your inbox, and on your phone and then within some period you just need to give yourself a little more help with facts in the literature, like reading general watch, and at least once a week you commit to more structured reading, either based on stuff that you have for your patients, or your own general reading.  

Me:  What do you feel are the most efficient things that you do in those areas as far as which services you use?  

GD:  I would describe what I do as sort of cross training.  I give myself the same messages multiple different ways so I know that the information exists, even though I haven't necessarily read it in depth, so, for instance, I will get the key table of contents for a lot of the medical journals that I subscribe to and that means I get to see at least what's out there even if I never clicked on any of those articles.  Then I'll listen to the podcasts on a weekly basis of some of the major internal medicine journals.  So I hear the data the second time there.  Sometimes it's a little more nuanced or a little different.  Usually that's all I need to be aware of that research, to have heard the message One or two, or maybe three times.  If I ever actually need that research to take care of a patient and make a decision, that's when I'll find myself actually looking at the article in more depth, and saying, does it apply or not? 

Me: And I guess as far as knowing how often to cross train how often in a given year do you think you hear something, or read something that's truly practice changing versus a lot of very small, well this is, this maybe interesting down the line. 

GD:  Yeah, I would say I bet for a, a general hospital or general internist that probably 90% of what I read or hear about is interesting, intellectually but potentially for patients in the future it may be 10  percent.  It's news that I can use or I'm gonna change what I do today.  But a lot of times, I'm saying I'll change what I'm doing today because I have heard about the same topic for a number of months or a number of years in other places.  So, there is a value of being aware of the literature or feel of moving in some direction, like there is a change coming up.  I remember the article last year now I'm hearing it again, and this third time, it seems like it's really getting enough time to achieve by practice.  So sometimes, opinions are changing but there's benefit from having been aware of the topic for the past year or two.  

Me:  So I guess finally, since we are, you know, coming to people on a podcast, right now, what, what do you think of the podcast as a way to help you keep up to date?  And what are some of your favorite ones? 

GD:  I think the podcast has been one of the best ways I keep up to date.  I, listen to the, the podcast for the big five journals, The American Journal of Medicine, NEJM, JAMA, Annals, BMJ and there are other ones that have weekly podcasts as well.  But what I really like is each one of them is different.  Some of them, like the Annals are 10 minutes and they just briefly summarize each of the articles.  Some of them are long, like NEJM, takes about 25 minutes to give you A broad overview of the whole issue.  Something like the BMJ or the Lancet they go into specific detail about one of the articles that's in the paper or the journal that week of what is the proposed detail that they really like.  And, I have to say those are oft-times subjects I wouldn't find myself reading about.  After I hear the in depth report I feel that quite a bit more informed.  So this is just a lot to learn.  And then there's just the practicality.  We're all searching for time to keep up with the literature.  I listen to those podcasts for instance when I'm exercising or when I'm in my commute, and so I'm able to use that time in a way I wouldn't otherwise, keep up.  I encourage everyone to try a couple of them.  It's part of the cross-training approach, where you just get here, and interact with the material in a different way.  So it sticks a little more in your brain. 

Me:  I really like his idea about cross training.  Although that term seems a little 90s for me.  So, instead, I might call it, mental crossfit, to give it more edge.  But what do y'all do in your day to day practice?  Does this sound like something doable to you?  Or do you still feel like you're getting overloaded with breaking news and alerts?  As always, we'd love to hear your feedback on this.  So if you have any burning questions or comments.  You can post them on our Facebook page or email them to caanocecp@gmail.com.  And if you had time, be sure to head on over to our Facebook page for the Northern California chapter of the ECP Council of Early Career Physicians so you can find out more about the events going on in the chapter.  And just to try out a new closing, thanks for joining me and tune in next time for Easy for, for more ABZs, from ECPs.  Two ECPs as well.

"Introductions" or "Why didn't they teach me how to say hello"

This is Scott Selinger and welcome to the first podcast on behalf of the Northern California’s chapter of the American College of Physicians Council of Early Career Physicians.  Given that this is our inaugural podcast, I thought it’d be a good time to talk about introductions - how you enter into that first meeting with a new patient and how you handle the name game.

Before I’ve done pretty much anything new in life, be it starting 6th grade, a new job, interviews, whatever - I’ve gotten a call from my dad where he just says: “remember first impressions.”  While this started out as rhetoric I would roll my eyes at, it’s become very important in my role as a physician, as I’m sure it has for every doctor out there.  That moment where you meet a patient for the first time is paramount in establishing trust and setting the tone of the rest of your relationship with them.

One thing that I’ve found is more important now, especially given how busy we all are in cold and flu season, is taking a moment to ready yourself before meeting that new patient.  We have so many other things are mind is on during the day - returning that page or email or message, following up on a lab, getting out on time - that it’s easy to let that ruin your first impression, your tone of voice, and your body language.  It’s crucial that your new patient knows that the only thing you’re thinking about while you’re talking to them is them.  Of course that can’t always be the case, but more and more I’ve found how helpful it can be before opening that door or pulling back that curtain, to stop, take a deep breath, put on a little smile, and focus on forging a great new doctor-patient relationship.

But then how do we introduce ourselves?  It’s probably a lot easier in the outpatient setting because by the time someone arrives in your office, they usually know who you are (and in many cases may have read a little blurb about you as well).  In the hospital, it’s a much more difficult setting - the new patient may not know why they are there (or even who they are), they may have already seen numerous other doctors and healthcare workers and have lost track of names, and they usually don’t know what every doctors’ role is (and why should they?).  

In both settings, it’s important that you clarify what your role is in their care.  It could be “I’ll be handling your day to day medical care and coordinating with our specialists, if needed” or “I’m here to talk with you a little about what’s been going on and start you on the path to getting better and then one of my colleagues will meet with you in the morning to check in and help guide your care from there” or “I’m here to be your go-to person for any aches, pains, rashes, coughs and colds that pop up and keep you as healthy as I can.”  This is important and often overlooked as the last thing you want is to be finishing up your encounter and hear something like “so when is my doctor getting here?”

Now what’s in a name?  How do you introduce yourself to your patients?  Some people introduce themself as Dr. Smith, others as Dr. Adrian Smith, and still others just say Adrian Smith and then clarify their status as a doctor and their role.  I’ve found that people are pretty divided on this and a lot of it seems to come from where they trained as the east coast (and even the south coast where I trained) has a much more formal atmosphere in general than here on the west coast and I think that plays into what style of introduction you use.  

What I was taught, and I think most people had this same training, is that your patient should be addressed as Mr. or Ms. and you introduce yourself as doctor so-and-so.  I can’t count how many training videos for patient interactions I’ve seen that start this exact way.  But is this ideal in today’s world or is this part of the outdated paternalistic model of the patient-physician relationship?  Trying to find hard data out there in favor of this approach is difficult, but there are a lot of opinion pieces and blog posts talking about how being addressed as “Doctor” and keeping the relationship more formal helps preserve the sacred contract we have with our patients.  The point is that as much as we in medicine are being pushed towards a standard consumer business model, we’re not Steve from the cell phone store - we need to present ourselves as a steady shoulder for our patients to lean on when they’re hurt or afraid or angry or scared.

On the other side, a quick look through pubmed actually showed some evidence that patients prefer a more informal introduction.  A study done on about 250 patients in a military family practice setting last year showed that patients preferred to be greeted by their first name and for the doctors to introduce themselves by their last names.  A study a few years ago in a vascular surgery clinic showed similar results.  

There was also an interesting study from the Archives of Internal Medicine back in 2007 where they asked about 450 patients their preferences and then video taped the actual encounters.  Just over 50% of patients wanted to be addressed by their first names only, and almost another 25% wanted to hear their first and last names.  Interestingly, on video about ⅓ of physicians called patients by their last names and over half didn’t call their patient by any name at all and boy in those cases you really just have to hope you’re talking to the right person or that could get awkward pretty quickly.  Finally, the survey showed that just over half of all the patients wanted to hear their doctors first and last name, about ⅓ only needed their last name, and the videos showed that in this case, you can always get what you want as those percentages matched up pretty nicely.

As with most things in medicine though, there is no class 1A evidence here, there is no right answer, there is only the art of medicine.  There are broad guidelines with caveats that you should refer to your local susceptibilities and specialists to tailor things to your individual populations and really this does come down to the personalized, individual-focused medicine we’ve heard so much about in the news lately.  I personally walk into the room, call the patient by their full names (which helps to make sure I’m in the right room), tell them my full name and then sit down and start chatting because that’s what I’m comfortable with and what works with my patients.  I don’t care if they call me doctor since generally the vast majority of my patients are older than me and I feel a little awkward asking my elders to show me a sign of respect (which by and large they do anyway because that’s just how they were brought up).  Oddly, for the first time in my life I have a lot of people referring to me by my middle name, which sometimes appears to be my first name due to the layout on my webpage.  That I’m not ok with because while Scott Selinger is a dedicated physician, dog enthusiast, and Dallas Cowboys fan, I haven’t quite figured out who Jeff Selinger is, if not my evil alter-ego. 

But what do y’all do in your day to day practice?  Have you found this to be something you still haven’t figure out or did you long ago get into your introduction groove to the point where it’s now just automatic?  As always, we’d love to hear your feedback on this, so if you have any burning questions or comments, you can post them on our facebook page or email them to canocecp@gmail.com.  And if you have time, be sure to head on over to our facebook page for the Northern California Chapter of the ACP Council of Early Career Physicians so you can find out more about the events going on in the chapter.


REFERENCES

 http://www.ncbi.nlm.nih.gov/pubmed/24083924

 http://www.ncbi.nlm.nih.gov/pubmed/19577761

 http://archinte.jamanetwork.com/article.aspx?articleid=412602

What is this podcast all about?

I'm Scott Selinger, American College of physicians member, native Texan, but current Californian and fairly early career physician.  Having just finished my chief residency in internal medicine in mid- 2013 and practicing as a primary care physician since then I'm getting the ball rolling on this podcast on behalf of the Northern California ACPs Council of Early Career Physicians for a few reasons.  

First and foremost, we felt that it can be a sounding board for musings specific to all the early career physicians out there by which we mean anybody in their first sixteen years of practice after medical school.  

Secondly, we wanted it to be a way for the Northern California ACP members and early career physicians to communicate a little about what's going on in their practice.  Given the nature of medicine today and the other commitments we all have, we have a tendency to isolate and practice on our own little island unless we make efforts otherwise.  Our hope is that this podcast can succinctly address some of these issues that we've seen in our own practice and we'd love to hear about what's going on in yours, so we can direct future podcasts in that direction.  

Finally, we like to use this as a part of a growing multimedia effort to get the early career physicians of Northern California a little more united and universally aware of some of the things going on with our local group and help colleagues network a little more easily.  

Now While I truly do enjoy the sound of my own voice and thereby assume everybody else does as well, we're going to try to keep these on the short side - something you can listen to on the drive to work at the gym, walking the dog or whatever you have time to fit it in.  We also hope to be able to include interviews with some of our leading ACP fellows, Governors, Masters and other leaders about their take on some of these issues.  

We look forward to broadcasting for you, with you and about you and stay tuned for the first installment.  If you have any burning questions or comments you can e-mail them to canocecp@gmail.com or head on over to our Facebook page for the Northern California chapter of the ACP Council of early career physicians, seek and find out more about the events going on.