September 3, 2009

Ten things we want to do at the Medicine 2.0 Congress in Toronto! #med2

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September is here this week which means we are counting down the days til Medicine 2.0 in Toronto! I have been going through the schedule and have already received facebook, Linkedin and twitter invites to connect from people attending the conference, so I thought I would write about what I am looking forward to most about the conference and why…. here goes….

1. Meeting Jen McCabe Gorman and Berci Mesko - these two visionaries have spurred my thinking and interest in health and medicine 2.0 for well over a year now and I have been avidly following their progress. They have taught me much and inspired me more, so I am excited to hear more about what they are upto (webicina and contagionhealth) and meet them in person!

2. Learning more about Organized Wisdom- this endeavor is hands down, one of my favorite technological attempts to reach across the relational divide between health seekers and health providers. I especially love their engagement of our usual communicative routines to facilitate a health community online.

3. Hearing E-Patient Dave speak – Dave is giving the keynote on the first day and I have made travel arrangements to cross the entire country in time to hear him speak (this is a conference first for me!). I have been reading his blog for over a year as well, and he, like Berci and Jen, has taught me much!

4. Participating in the Un-conferences – as a communication scholar, I tire easily of the usual conferencing format. It’s capacity to disengage and disconnect people from ideas and each other is unsurpassed. Hence my strong support for the unconference…. as slightly intimidating as it is, there’s just something infectious about spontaneity (and not in a public health kind of way….or maybe it should be!).

5. Attending the presentation “Success in Virtual Clinics for Hispanics: Lessons Learned from Forumclinic Users” – I am especially interested to hear about their virtual community efforts and practices, and hopefully meet the folks who worked so hard to put these efforts together. Community is hard enough off line, and even with participatory technologies with us, we still can’t always guarantee the people factor.

6. Hearing Pat Rich from the Canadian Medical Association tell us about “Asklepios and Mydoctor.ca”. I have written about Asklepios before so I am excited about hearing about their progress and how the social network has been received by practising physicians.

7. Participating in and listening to our co-presenters in the panel Web 2.0 approaches for clinical practice, clinical research, quality monitoring on Friday September 18. The thing I like about this panel is that is sounds very grounded in clinical practice and experiences, which as an ethnographer intrigue me. I really look forward to our conversations!

8. Dividing myself in half so I can attend the panel happening at the same time as the one I am participating on – Building virtual communities and social networking applications for patients and consumers. These communities sound extraordinary and so I am not sure how I am going to clone myself in time to hear the presentations. I will seek out the presenters though to hear more, hopefully at one of the social events or gathering times.

9. Attending the NextHealth presentation later that day – I have been trying to find out more about this effort ever since I saw a video online of one of Jen McCabe Gorman’s presentations on same…. should be exciting!

10. Finally – attending the last session on “Ethics 2.0: Implications for Connected Health (Panel with interactive audience response system)”. I love these kinds of discussions and I appreciate any attempts to think about what our technologies are doing to us, not just what they enable us to do with them. Connected health really challenges some of our modernist ideas around the individual, privacy, ethics etc. I also want to hear more about the work of the eHealth Strategy Office at the University of British Columbia. So there you have it! I will, of course, cloning efforts successful, be attending more than I have written up here; but these are the ones I will make sure not to miss…. if you haven’t seen the schedule for the conference, click here. This is the conference I am looking forward to most this year!

With thanks to myrrien, chrisheuer and maggi_94 for their wonderful images!!

To your good health!

Kirsten Broadfoot

@kblucy & @sterena

 

August 31, 2009

Medicine 2.0 Congress: A Commitment to a Community of Learning #med2

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“New technologies have extended the reach of our interactions beyond the geographical limitations of traditional communities, but the increase in flow of information does not obviate the need for community. In fact, it expands the possibilities for community and calls for new kinds of communities based on shared practice.” – Etienne Wenger

Some days I yearn for that day 10 years ago when I opened my first AOL email account and heard that sensitive, yet robotic voice say, “you’ve got mail!” I would dial in once a day, be connected after 5 minutes and than sign off when I had finished, hearing again that same voice say, “goodbye.” It was simple and easy and the beginning of a commitment to a community of learning.

Times have changed however, as we all know. Yet social media like social networks, Facebook, twitter, and wikis haven’t exactly been welcomed with open arms by everyone. In fact, the emergence of such movements has produced a bit of resistance, fear, frustration, criticism and maybe too, a yearning for something different. Why? For one thing, it asks users to take a risk – a leap of faith into an environment that demands participation, collaboration and openness within and between others. This move can be uncomfortable, but also a move that can promote a more in-depth understanding of various organizational forms by encouraging the exploration of alternative, and more collaborative, communicative practices about health, medicine and clinical practice.

Because we are excited about such possibilities, we are headed to Toronto for the Medicine 2.0 Congress in a few weeks where we will be presenting a project titled, “Clinical Care in the ‘Spaces in Between’: Web 2.0 and the Communicative Reformation of Clinical Practice.” You are welcome to read the abstract here.

The conference is unique in its bringing together of participants from 18 countries including academics, software and Web 2.0 developers, biomedical researchers, consultants, business leaders, health professionals, consumers and payors. Together, we will look beyond the health 2.0 hype to identify the evidence of what works and what doesn’t in communicating effective care within and between communities. These discussions, interestingly are facilitated by the conference’s philosophy of openness, which is very conducive to discussions, networking and collaboration. The conference will begin with several noteworthy keynote speakers and then will cover topics ranging from virtual communities, personal health records, health information, clinical practice, medical education, medical learning and much more.

For those of you attending, we are looking forward to meeting you and generating some stimulating discussions together! And for those of you who aren’t attending, we’d love to hear from you as well about the conference, our abstract or your own commitments to a shared practice within these communities. After all, new conversations like new technologies can extend the reach of our interactions beyond the limitations of traditional communities thereby underscoring our shared concern and passion for improving clinical practice.

My AOL and “you’ve got mail” days have expanded and despite my own resistance, I have found much delight in the uniqueness of new technologies and new forms of organizing for, if nothing else, their commitment to a community of learning.

Hope to see you in Toronto!

Thanks to Dru Bloomfield and slowburn for the images.

Carey Candrian

 

August 24, 2009

Health care reform: What’s nursing got to do with it?

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I was recently talking with a nurse that works in an emergency department who is a year away from receiving their doctorate in nursing and becoming a nurse practitioner. Specifically, they were talking about the struggles of working with administration at their medical school and how after 5 years of being a student, the university did not know the nurse’s name as most classes are offered online. Furthermore, during our discussion, the escalating cost of nursing school was underscored. The nurse wondered why the medical school was attempting to make getting their doctorate – in order to help others – so incredibly difficult. Similarly, in a terrific blog, NurseTeeny explores the culture of nursing school, including some of her own experiences and expectations of the journey.

Pooja Aggarwal, a fourth-year medical student at the Johns Hopkins School of Medicine highlights the danger of such actions, writing in the Baltimore Sun that with an increasing life expectancy, by 2020 we will likely lack 200,000 physicians. Why then are only 2 percent of medical students choosing family medicine? Well, according to the Journal of the American Medical Association, 40 percent of students generated loans greater than $130,000 by graduation. Thus, the study concludes, “many find a career in primary care out of the question when procedural fields with higher reimbursement rates give the option to earn more than twice the income and work fewer hours.” Great – but that doesn’t help answer the problem of who exactly will take care of those thousands of patients when they get coverage?

A similar concern is shared by KevinMD in terms of the shrinking numbers of med students choosing primary care. He states, “unlike primary care, nursing schools turn away qualified applicants due to the lack of teachers and facilities, something that increased cash from the federal government could help to fix. Such a ready and willing workforce could help fill the gap that many Americans find themselves in when looking for a primary health care provider.” After all, nurse practitioners already perform many primary care duties, among others unique to their profession.

So now I’m wondering why we aren’t hearing more from nurses about what true reform looks like. As KevinMD goes on to state, “nursing’s ‘patient-centered’ model also allows for a personal primary care experience, and nurse practitioners have been proven to lower time on ventilators, complications, and length of stay. And on average, nurse practitioners earn $81,000 a year, almost half of the $160,000 than typical primary care docs (not including the cost of training).”

Hmm. So we have a shortage of primary care providers due to increasing costs and difficulties associated with medical schools making that form of care as a career less attractive. We also have a potential population capable of at least easing or mediating that shortage. Now, this post is by no means proposing a solution; rather providing an opportunity to pause for a moment and open a space for a possibility — to re-think the voice of nurses, the role of medical education, the opportunities for patient care and the need to continue talking often, yet carefully about true reform.

As my conversation continued with the nurse pursing their doctorate, they discussed more of the challenges of working within a system that regulates and scrutinizes their every move all the while working in a profession that is looked at as a stew-down, rather than a cohesive or collaborative unit. As they put it, nurses and doctors provide different forms of care that ultimately benefit the patient when working together. When we finished our conversation, the nurse said they had a taken a 60% pay cut in order to become a nurse. Why? Because for them, the work they do is important and being a nurse makes them proud. Ultimately, their hope is that they will have a role in health care to make sure we do a better job at it for everybody.

Why did you become a nurse?

What role do you think nurses should play in health care reform?

Are reform plans placing enough emphasis on training physicians to serve in preventative roles?

Thanks to Billie/PartsnPieces and jef safi for the images!

Carey Candrian

Btw, we will be attending Medicine 2.0 Congress – We’d love to meet if you’re coming as well. Contact Us: http://sterena.com/contact-us/

 

August 19, 2009

Communicating professionalism through social media

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The word professional carries tremendous weight. It is a term that is used often, yet deeply misunderstood, taken for granted and rarely interrogated. It is also a term that carries incredible momentum for the cultural constructions it advances in terms of how we create, evaluate and communicate professionalism. Furthermore, the lines between professional and personal relationships in medicine are being challenged. Specifically these days, social networking sites are blurring the lines around what it means to be a professional.

As Joanne Shaw discussed in her article, A Reformation of Our Times in the BMJ last spring, the changing relationship between doctor and patient can be understood through the analogy of equating medical science with religion, where the “bible” is medical information, the technology is the internet, and the priests are the medical profession. She writes, “the internet has brought the canon of medical knowledge – previously accessible only in expensive textbooks, subscription journals, and libraries – into the hands and homes of ordinary people.”

Further, as many doctors already subscribe to these new principles, she highlights that many patients will continue to want a more traditional relationship with their doctors. Others yet will push for something different. For example, Dr. Sachin H. Jain, who in his second week of medical internship, received a “friend request” on Facebook from a woman whose baby he helped deliver. In his recent article about this challenge, Practicing Medicine in the Age of Facebook, in the New England Journal of Medicine he writes, “The anxiety I felt about crossing boundaries is an old problem in clinical medicine, but it has taken a different shape as it has migrated to this new medium.”

As seen in these discussions, health care providers are now required to navigate through an organizational field that is complex, multifaceted, and heavily contested as they tap dance between doctor as professional, doctor as manager, doctor as healer, doctor as friend and doctor as human being. These authors suggest that issues raised by social media are in many ways similar to issues that physicians and medical institutions have dealt with for generations. As Dr. Sachin H. Jain states, “Physicians, after all, are members of real-life communities and might be observed in public behaving in ways that are discordant with their professional personas. During medical training, the importance of maintaining professional distance — however much one desires to have a close, meaningful relationship with one’s patients — is taught by educators and reinforced by the use of beepers and paging services meant to shield physicians from their patients.”

These reformations and challenges are reminders that our theories and understandings of and about health care should consider not only the formal interactions with patients and providers, but should also attend to a physician’s personal growth and development, which is undoubtedly impacted by her of his career and training, and how that impacts their professional and personal relationships. With such a task, comes a commitment to understanding professionals and communicating professional identity and care in a way that enhances the quality of life – both professionally and personally – for all involved.

How is social media offering alternative paradigms for quality care, work life and education where you are?

Thanks to rajtantajtanmovement for the blurred images…

Carey Candrian

 

August 10, 2009

Rethinking what counts as normal and the challenges of health care

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“Theories of the real…control the vocabularies of healing…if one could construct a map to negotiate a way through rival beliefs on health and healing, its baseline would be ontology, what counts as real. From this line a path would lead to the status of individuals in competing realities, then to different understandings of therapy that follow from competing descriptions of the human person. Finally, the moral and political languages of liberty, privacy, competence, and authority would appear. The first position, though, is reality. It fixes directions for the traveler journeying through the languages of health and healing, and provides the baseline references to justify beliefs about health acts and possibilities. –Frohock (1992, pp. 47-48)

What constitutes health is a question recently posed by H. Gilbert Welch, M.D., a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. One technique he discusses is simply narrowing the definition of what is health. Think to yourself for example, how many people you know who have high cholesterol, low blood pressure, low vitamin D, low iron, diabetes, osteoporosis and so on. These abnormalities are important however; and often are a difference that makes a difference in health care.

But, as Dr. Welch points out, this strategy has generated a host of other problems. As he states: “Doctors who are overwhelmed by the number of ailments their patients allegedly have (and who are often distracted from the most important ones); doctors in training who are increasingly confused about who is really sick and who is not; lawyers who increasingly have a field day with the charge of ‘failure to diagnose’; patients who get too much treatment or lose health insurance because they been given a new diagnosis; and a frazzled, fearful public adrift in a culture of disease. Oh, and did I mention that it has been a disaster for health-care costs?”

Thinking through definitions of what is normal can be explained communicatively. In so doing, we begin to ask what counts as normal and why this concern should matter. What counts as normal calls our attention to “abnormalities” and “health” not as natural categories but as products of social construction maintained through interaction as Berger & Luckmann (1966) explain in greater depth. In short, our interactions are filled with contests for meaning. But definitions like what is normal, or what it means to be healthy or ill, are used by individuals and groups to construct their own preferred versions of reality in place of alternatives that may be uncomfortable for them.  Clearly, we have come to a lot of agreement about these things which allows us to communicate more easily with each other, but often less creatively and productively.

Understood communicatively, the point is not to resolve what constitutes health but rather to reclaim productive tensions as a critical aspect of all life – including health. Even more, thinking about what is normal, brings some relief – as well as a reminder – that these are perspectives rather than attributes of individuals and groups. Therefore, it is impossible to understand what it means to be normal without examining the assumptions that lie below our understandings of health and illness. These assumptions, like the dominant focus on the disease cancer and not dying from cancer, in general terms become “common sense”. But do these commonsensical assumptions leave room for understandings not based only in standardization but also on what individuals experience and express? For example, one of the best cancer hospitals in the world proclaimed in public advertising and on every one of their computers, “The Best Cancer Care…Anywhere.” How would we rethink cancer if it read, “The Best Care of Patients with Cancer…Anywhere?”

Rethinking what is normal in light of the healthcare reform messages flooding every headline is no simple task. If health is understood as the absence of abnormality as Dr. Welch alludes to, the only way to know you are healthy is to become a customer. But a customer of what? Or a customer for whom? And a customer to what extent? Further, he elaborates that health is a state of mind that when viewed as the absence of abnormality, conflicts with the desire and hope for a healthier society. In other words, our definitions of health fix meanings through the languages of health and healing, justify beliefs about health, move people to act in certain ways, and hold spaces of possibilities.

How do your own definitions of what is normal influence the care you seek/receive?

How do our understandings of health and illness impact the work environments of the medical providers doing this work?

What challenges face you and your practice of bringing comfort and care to your patients with increased expectations and restrictions as well as an inherently narrow albeit contestable definition of normal?

Looking forward to your thoughts!

With thanks to zen and dmason for their images…

Carey Candrian

 

June 8, 2009

Philosophies of clinical care walking to a different drum

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“The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.” – Atul Gawande

I visited a local hospice a few weeks ago. The nurse practitioner I was talking with told me a patient came in a year ago with monitors still attached to their chest from the hospital. When hospice admitted the patient they were removing the monitors as the patient interrupted, “wait, how are you going to monitor me without them?” The nurse paused being struck by the question and said, “we monitor you here with our eyes.”

Similarly, I was visiting a palliative care team in action who were 45 minutes into a conversation with a patient who was not well when a nurse came in to draw blood. The physician turned toward the nurse and said “that test is not necessary right now.”

Both examples shed light on a shared premise: the needs of the patient come first. The Mayo Clinic also shares the same premise as Atul Gawande discusses in his recent New Yorker article. Denis Cortese, the C.E.O. of the Mayo Clinic states, “When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing.” As a result, this premise has improved patient care quality and costs are lower than just about anywhere else in the United States. Their medical communities are not following anyone else’s recipe but they’re organizing through a strong sense of accountability and identification that takes seriously collective responsibility for improving patient care. How are they doing it and why aren’t others rethinking their practices you might ask?

The concept of accountability from a colonist perspective, is concerned with the repercussions for not having followed the rules set forth by a dominant group. Communication scholar Amira De la Garza, PhD however, encourages us to let go of this meaning and look at the word again. Account-ability. The ability to account. To tell a story. So when we are accountable, we are able to tell a story. But in order to know a story, it has to become part of us. It’s not easy. But the hospice nurse’s ability to monitor the patient through their natural instruments – their breathe, the color/temperature of their skin, their words said and not said, the functionality of their body, their weight and their nutrition intake allows them to be harmoniously account-able to themselves and the patient. They rely on others, other rely on them for knowledge about patient care. In a sense, these become their core set of beliefs and values that they become identified to and take on as their own.

Such identifications are important because they help us in making sense of our experiences, organizing our thoughts, reaching decisions, anchoring the self and granting individuals personal meaning. Most importantly, identification is rhetorical; it allows people to persuade and to be persuaded. Identification is not a thing or a product but rather a process. People most often ask ‘what is’ identification rather than ‘what happens’ when people identify with groups, organizations, collectives and to a lesser extent, beliefs, values and goals. The ‘what happens’ question is the one Atul Gawande asks of both the Mayo Clinic and McAllen Clinic. Answering this question allows us to see two very different ways of organizing care. It is not a question of which is better but an opportunity to hold open for a moment, an important possibility for clinical life and care.

The Mayo clinic, like my hospice and palliative care experiences, is walking to a different drum. Their guiding beliefs and values have created a language and philosophy of care that is extraordinary different from the synchronicity and coherence of dominant medical beliefs, values and norms. In so doing, they are producing a different meaning of care through their understanding of what it means to be account-able and what happens to health care costs, patient care, and physician relations when individuals identify with this set of beliefs and values.

So, we have a choice: are we going to reward the innovators who are trying to build a new generation of care or provide more pen caps at less cost?

What does a philosophy of care built on the needs of the patients look like to you?

What would this clinical practice do for you?

What would it not do for you?

Thanks to kqedquest and OR4N6E for their images. . .

We look forward to your comments!

Carey Candrian

Learn about our services here.

 

May 26, 2009

The life of language, the art of participatory medicine

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As market transformations continue to take hold within the health care industry, new patterns of organizing to meet the increasing complexity of service delivery are needed. As a result, great pressure is being placed on researchers, practitioners and patients to develop new ways of talking, listening and working within the clinical environment.

Last week, Verlyn Klinkenborg’s NY Times article about the lost art of reading aloud circulated the web. The article has lessons for everyday talk as well as for understanding new ways of organizing within the medicine 2.0 and “e” movements. Specifically, the words in the article shed light on a pattern health reform should take note of – the life of language.

The article states a significant number of Americans these days read by listening, or listening aloud as she calls it. From this perspective, there is something interesting and even lonely that is part of a larger pattern. As she states, “instead of making music at home, we listen to recordings of professional musicians. When people talk about the books they’ve heard, they’re often talking about the quality of the readers, who are usually professional. The way we listen to books has been de-socialized, stripped of context, which has the solitary virtue of being extremely convenient.”

But listening aloud is not the same as reading aloud. Although both are important ways to learn something about the rhythms of language, “one of the most basic tests of comprehension is to ask someone to read aloud from a book.” Further, “reading aloud recaptures the physicality of words. To read with your lungs and diaphragm, with your tongue and lips, is very different than reading with our eyes alone.” In short, the language becomes a part of your body. Because, words are the “breath and mind, perhaps even the soul, of the person who is reading” and I would add, the person who is healing or being healed in the clinic.

Among the social media movements, practitioners and patients are being encouraged to respond to a lot of things in an attempt to become participatory or go “e.”

And clearly, “e” is providing a new way of organizing and therefore a response to many market demands. First, as e-patient Dave underscores, is the harmonious way Web 2.0 lets us discover, and help each other discover, new partnerships and resources. Second, The Hastings Center entered the blog-world (albeit late!) because of the need to start a public conversation about curbing health care costs and be a voice in health care reform “e” communities. Third, scienceroll discussed a recent e-course – how to create and manage a quality medical blog – that was the first e-course to be publicly accessible including tips about step-by-step tutorials into the realm of medical blogging and micrblogging. My point: “e” movements are indeed having an enormous effect on the way people communicate, the way people connect, the way people learn, the way people think of others and themselves and the way people care for each other and want to be taken care of.

This new way of organizing is being produced through a very active, playful and important language – the art of participation.

What then is the relationship between the art of participation and the art of speaking out loud?

As the patterns of “e” movements continue to be developed, altered, and maintained we might indeed have a new form and culture of medicine. Participation, however, needs to be worked out in these “e” movements. Specifically, what role is participation playing in reforming health care? Who can participate? Whose values are guiding our understanding about what it means to participate? What does participation sound like or look like? And what would a language of participation achieve in clinical practices?

These are questions for a very ambiguous and complex word that means different things to different people; yet a word and a discourse that is remarkably important for health care.

That said, the argument could be made that participating in social media forums or “e” communities, listening to podcasts, blogging, microblogging, commenting, twittering and so is a sign of a new prosperity in the 21 century and a new connection to medicine. But as our article reminds us, participating like reading is “incomplete, impoverish, unless we are also taking the time to read aloud” (talk out loud). There is something peculiar about talking out loud together, even empowering as we each navigate our ways through our own experiences of pain, suffering and hope.

I encourage you to take this practice seriously in your own communities and practices so that these forums for talking, listening and participating begin to translate into the clinic to allow patients and practitioners to move from being the consumers of health care information to the co- producers of resources such as advice for situations of uncertainty, uniqueness and conflict…

What kinds of words and actions do you think would constitute a vocabulary of participation??

Thanks to Keegan Jones and dalydose for their images…

Carey Candrian

Learn about our services here.

 

May 18, 2009

Improvising clinical practices and transforming talk

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“Improvisation involves reworking precomposed material and designs in relation to unanticipated ideas conceived, shaped, and transformed under the special condition of performance, thereby adding unique features to every creation” (Berliner, 1994, p. 241).

Continuing with the theme of medical education, Sarah Greene from e-patients discusses the book, Pedagogy of the Oppressed by Paulo Freire as a way to improvise talk in medical training and clinical practices.

Although the book is about teachers and students, she supplements these words with doctors and patients. The book underscores that “real revolution can occur when the playing field is leveled between doctor (teacher) and patient (student), whereby critical thinking is infused in education and where ‘doctors become patients’ and ‘patients become doctors.’ Communication amongst students (i.e., social networking) is equally important in this equation.”

She highlights two sound bites in particular:

–Participatory medicine cannot tolerate an absurd dichotomy in which patients are merely following their doctors’ decisions—a dichotomy reflecting the prescriptions of the dominant elite. Revolution is a unity, and doctors cannot treat patients as their possessions.

–The dialog which is radically necessary for the participatory medicine revolution corresponds to another radical need: that of women and men as beings who cannot be truly human apart from communication, for they are essentially communicative creatures. To impede communication is to reduce humans to the status of things.

Her hope, as well as others, is to have the theme of participation, dialogue, critical thinking and communication become infused in medical education materials. And her concluding call: Let’s communicate! But how can we begin to transform or improvise talk?

Karl Weick, a leading organizational scholar, developed improvisation as a mindset where he uses the vehicle of jazz improvisation as the source for orientating ideas. Specifically, understanding communication as improvisation can be understood as “transforming the melody (discourse) into patterns bearing little or no resemblance to the original model of using models altogether alternative to the melody as basis for inventing new phrases.” Improvisation involves the embellishment of something and in this case the embellishment of dominant (scientific) clinical practices.

Understanding communication as improvisation is like understanding communication as a song. The song can be played exactly as scored or with improvisation, but “one would not expect an improvisational theorist to play only one song over and over anymore than one would expect a jazz musician to play only one song throughout a lifetime” (Weick, 1998, p. 550). In a society where fluidity and discontinuity are central, improvisation must play a role in clinical practices.

If improvising is the goal, what would improvising look like for both patients and providers?

Although uncomfortable of “how-to-do communication” lists, I think it’s important to highlight a way this transformation can unfold. That said, I borrow four interaction skills from Stan Deetz, PhD, a professor of communication. These skills, although basic, are believed to carry much significance in terms of revising the way we talk, think, and act in medical training, the clinic and social media forums.

The first interaction skill is immediacy. This is a sense of being present, paying attention, and listening through the inclusion of emotions. It is not simply waiting for your turn to respond but requesting understanding by being responsive. Immediacy is patient and careful.

The second skill is concreteness. This form of talk includes expressions that avoid abstractions by providing details because abstractions create problems. For example, rather than saying, “patients are irresponsible,” try saying, “I was disappointed last week when my patient did not follow-up after their appointment.”

Ownership is the third skill that explicitly involves assigning and expressing appropriate responsibility for feelings and actions. This form of talk stays away from unowned statements such as “you make me so frustrated” because these statements immediately remove the responsibility from you and places it on someone else. This someone else can be a set of rules, generic shoulds and oughts, or actual people.

Finally, the fourth interaction skill is acknowledgment. This way of talking involves making explicit your understanding of the other person’s message prior to responding. In so doing, each participant is affirmed and valued and meanings are clarified. Acknowledgment usually requires some degree of paraphrasing of the other’s statement or nonverbal messages, but goes beyond this to include questions like, what is the patient really saying? What are the most important thoughts, feelings, or perceptions that the patient is expressing?

These skills may sound like a no brainer. Nonetheless, I encourage you to take one or all four of the skills and start incorporating them into your  own clinical encounters. This will be an attempt to begin to improvise or transform talk and therefore, begin to re-think medical training and clinical practices as we’ve come to know them and as we’ve come to imagine them.

With thanks to kevindooley and Daniel Greene for their desert images…

Carey Candrian

Learn about our services here.

 

May 12, 2009

What does it mean to be a professional: Re-thinking medical education

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The NY Times recently wrote an article stating if American higher education is to thrive in the 21st century, colleges, university and curricula need to be completely restructured. The article outlines several steps of restructuring in order to make higher learning and professional development more adaptive, collaborative and imaginative. Although this article is directly related to higher education, there is much overlap with the recent articles encouraging a restructuring of the ways we train doctors and nurses, or medical professionals.

Last week, KevinMD asked whether the best and brightest really should become doctors during a time when working with others is becoming essential to patient care. In his post he also questions the role of exams and test scores in producing the kind of knowledge that is in demand as reform gets underway.

Relatedly, Maggie Mahar wrote extensively about the need to reinvent the way we train doctors and nurses by beginning to change the way we choose students for admission to medical school in the first place and therefore, deciding what such training should look like. In her article, she outlines several basic premises that need to be incorporated into medical training.

First, she discusses the need for being able to talk about death by encouraging students to spend time with a palliative care team because in many medical schools, death, and talking about death is not part of the curriculum. Second, she encourages collaborating, rather than competing — not just with the patient but collaborating with each other, through mutual respect.

Third, she states teachers must emphasize that medicine is always changing and avoid the communication plague, “this is the way we do it.” Because as of this moment, communication is closed and such activity skews the development of mutual understanding as well as the ability to bring contestation to some of the practices that are believed to be carved in stone. These practices endlessly leave out other treatments, voices and perspectives from entering the discussion(s) that guides knowledge construction and patient care.

Fourth, Maggie Mahar discusses the need to change the way medical schools assess applicants. She quotes Dr. Robert C. Bowman who points out, “We must require those who are academically prepared to be maturationally  prepared. We need to raise the bar in people skills as high as we have in academic skills and not cave in and admit physicians who cannot meet the tests in both categories.”

These steps, among others, need to be taken as we transition to a more patient centered, collaborative medicine. This, however, is not a simple task. The article about ending the university as we know produced tremendous resistance among the academic community because for many of them, they don’t see any “problem” with the ways things are and therefore, can’t understand why a restructuring is needed. At the same time, it is clear that neglecting to incorporate such educational practices will leave students and patients ill-prepared for a society filled with fluidity and difference.

For medical education that is confronting an ever aging population, insurance companies, an influx of social media agendas and a more informed patient, medical training is becoming a complex communicative practice that must continue to re-write the very things we value (and compensate) in producing a functioning professional for collaborative medicine.

That said, I leave you with the following questions:

    What do you want medical education to achieve? How do you perceive the role of medical education in producing a functioning professional?

    And how might you begin to engage the outlined premises of collaborative medicine in conversations surrounding medical education?

Looking forward to your thoughts…

Thanks to St. Murse and stevegarfield for their images!

Carey Candrian

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