Category Archives: Formazione

Basta attenzione solo alla struttura, lavoriamo sul cambiamento dei sistemi organizzativi e della cultura

Sir Muir Gray ci ha offerto un (apparentemente) semplice schema di interpretazione dei servizi sanitari: ognuno di essi è caratterizzato da una struttura (istituzionale, giuridica, economica, geografica, fisica), da sistemi organizzativi (idealmente impostati per realizzare le finalità dei servizi sanitari), dalla cultura (generale, professionale, organizzativa).


Dobbiamo riconoscere che in Italia, e in tutte le sue Regioni e Province autonome, l’unica modalità per introdurre un cambiamento dei servizi sanitari è quello di pensare a una riforma: cioè a un cambiamento della struttura (istituzionale, giuridica, economica, geografica, fisica). Nessuna attenzione, invece, viene dedicata alla necessità di cambiare i sistemi organizzativi e la cultura sottostante.

Il recente libro di Roberto Perotti (ex Commissario alla spending review) “Status quo” affronta il tema del “perché in Italia è così difficile cambiare le cose (e come cominciare a farlo)”.

Una frase, in particolare, mi ha colpito: “E’ proprio della mentalità giuridica attribuire importanza spropositata all’impianto istituzionale, compiacersi dell’eleganza formale e dell’equilibrismo di un compromesso, e immaginarsi che piccole variazioni a uno statuto possano portare benefici strutturali al paese. Se solo il mondo fosse così semplice…” (pag. 170).

Lavorare sui sistemi organizzativi e sui necessari cambiamenti culturali significherebbe “chinare la testa e lavorare” (R. Perotti, ibidem) sui problemi veri, sulla loro dimensione quantitativa e qualitativa, ipotizzare nuove soluzioni praticabili (socialmente e politicamente) e sostenibili (economicamente, professionalmente e culturalmente).

Certamente è più semplice fare una nuova legge, una nuova deliberazione, un nuovo atto aziendale pensando che un atto legislativo o amministrativo possano di per sé determinare il cambiamento.

Chissà se ce la faremo? Si dovrebbe cominciare smettendo di raccontarci bugie!


Renewing the dialogue between the medical and nursing professions @kevinmd @Medici_Manager

A recent post observed that the “highly charged scope-of-practice” fight between the medical and nursing professions has resulted in social media hate speech – too often, from physicians directed at other physicians. “Like bees to nectar, a post on the topic is sure to draw dozens of anonymous, hate-filled comments” write the authors.  They propose the following “principles for civil discourse” which I believe should apply more broadly to all social media commentary, not just on the physician versus nurses conflict:

“Anecdotes are fine, but avoid drawing generalizations from one story. (‘We had that dumb NP once. She didn’t know where the gallbladder is located. So NPs must all be dumb.’)

Identify the underlying emotion of a comment that irks you, and name it when you respond. (‘Doctor Strangelove, it sounds like you’re frustrated that NPs have fewer hours of training and are asking for the same salary as MDs. Here’s my take: ….’)

Name-calling is out. Polite, respectful comments are more likely to be taken seriously, and to stimulate a productive conversation. ( ‘SJ, I appreciate hearing your viewpoint. Here is WHY I disagree with you.’)

Own your comments. Instead of making broad generalizations, make it clear that you are offering your opinion. (Rather than saying, ‘NPs simply should not be practicing without some sort of physician supervision,’ say ‘I don’t think NPs should practice without any physician supervision.’)

Consider phrasing your comment in the form of a question. (‘I’m troubled by the thought of NPs working in a rural area with no access to collaborating physicians. Does anyone have experience with that?’)

Go for the win-win. (‘The demographics, economics and politics of health care reform suggest there’s enough pie for all of us in the primary care world. We are all undervalued and overworked. By uniting in cause and working with each other, both groups stand to gain in terms of creativity, relationships, and (dare we say) income.’)

Find the best alternative to a negotiated agreement (known as “BATNA” — taken from the classic tome, Getting to Yes). (‘NPs are here to stay, with increasing autonomy across more and more states. Let’s find a way to work together — whether you’re a doctor or NP, our end goals are the same.’)”

If such principles were broadly accepted by all of us involved in social media commentary, they would result in a much better informed, respectful and constructive discussion than name-calling and personal attacks. Civil discourse, though, by itself won’t be enough to end the uncivil war between the nursing and medical professions.  What’s needed is a way to get to the “win-win” point where the legitimate interests and concerns of both professions are recognized and addressed.

Recently, the Annals of Internal Medicine, ACP’s flagship peer reviewed journal, published a paper titled, “Principles Supporting Dynamic Clinical Care Teams: An American College of Physicians Position Paper” which I believe could become the basis of such a win-win outcome. (Full disclosure: I am the principal author of this paper, along with my co-author and colleague Ryan Crowley, which was written by us on behalf of ACP’s Health and Public Policy Committee and Board of Regents).

Our goal in developing the paper was to constructively address the legitimate concerns of both professions as a step toward renewed dialogue between them.  Nurses have legitimate concerns about being held back by restrictions on their licenses and physician supervision arrangements that limit their ability to provide care to patients, that is within nursings’ skills and competencies.  Physicians have legitimate concerns that their unique and more extensive years of medical training are being devalued by the calls to substitute independently practicing advanced practice nurses for primary care physicians.  Both professions assert that their views are based on what is best for patients.

Our paper asserts that professionalism is the answer to resolving such differences. “Professionalism” we wrote “requires that all clinicians — physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals — consistently act in the best interests of patients, whether providing care directly or as part of a multidisciplinary team. Therefore, multidisciplinary clinical care teams must organize the respective responsibilities of the team members guided by what is in the best interests of the patients while considering each team member’s training and competencies.”

The goal, then, must be to assign, “specific clinical and coordination responsibilities for a patient’s care within a collaborative and multidisciplinary clinical care team should be based on what is in that patient’s best interest, matching the patient with the member or members of the team most qualified and available at that time to personally deliver particular aspects of care and maintain overall responsibility to ensure that the patient’s clinical needs and preferences are met. If two team members are both competent to provide high-quality services to the patient, matters of expedience, including cost and administrative efficiency, may contribute to division of that work.”   While we affirm the importance of, “patients having access to a personal physician who is trained in the care of the ‘whole person’ and has leadership responsibilities for a team of health professionals, consistent with the Joint Principles of the Patient-Centered Medical Home” we also state that, “Dynamic teams must have the flexibility to determine the roles and responsibilities expected of them based on shared goals and needs of the patient.”

“Although physicians have extensive education, skills, and training that make them uniquely qualified to exercise advanced clinical responsibilities within teams…well-functioning teams will assign responsibilities to advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals for specific dimensions of care commensurate with their training and skills to most effectively serve the needs of the patient.”  We observe that, “especially in physician shortage areas, it may be infeasible for patients to have ‘an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care” and that, “in such cases, collaboration, consultation, and communication between the primary care clinician or clinicians who are available on site and other out-of-area team members who may have additional and distinct training and skills needed to meet the patient’s health care needs, are imperative.”

On the debate over each profession’s role in solving the primary care workforce shortage, our answer is, “a cooperative approach including physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals in collaborative team models will be needed to address physician shortages.”

And on the most divisive issue — state regulation of nursing scope of practice — we state that, “Clinicians within a clinical care team should be permitted to practice to the full extent of their training, skills, and experience and within the limitations of their professional licenses as determined by state licensure and demonstrated competencies. All clinicians should consult with or make a referral to other clinicians in disciplines with more advanced, specific, or specialized training and skills when a patient’s clinical needs would benefit from such consultation and referral.”  We assert that,  “Licensure should ensure a level of consistency (minimum standards) in the credentialing of clinicians who provide health care services” and called on state legislatures and licensing authorities, “to conduct an evidence-based review of their licensure laws” and “consider how current or proposed changes in licensure law align with the documented training, skills, and competencies of each team member within his or her own disciplines and across disciplines and how they hinder or support the development of high-functioning teams.”

Now, I know that the paper will not please everyone in the medical and nursing professions, but we hope that it can be the starting point of a renewed dialogue between the professions.  We end the paper by noting that, “ACP offers these definitions, principles, and examples to encourage positive dialogue among all of the health care professions involved in patient care—in the hope of advancing team based care models that are organized for the benefit and best interests of patients. ACP also hopes to inform policymakers to ensure that regulatory and payment polices are aligned with, rather than creating barriers to, dynamic team-based care models. ACP encourages discussion of dynamic clinical care teams that puts patients first.”

Let’s get this dialogue started — with civility, of course.

Bob Doherty is senior vice-president, governmental affairs and public policy, American College of Physicians and blogs at The ACP Advocate Blog.

We are spending billions to train the wrong kind of doctors @kevinmd @Medici_Manager @WRicciardi @pash22

Earlier this year, the physicians at my academic family medicine practice met with two senior officials from our parent health care organization to be oriented to its new initiatives and projects. Their presentation documented the organization’s ongoing investments of many millions of dollars into renovating subspecialty care suites and purchasing new radiology equipment that was likely to be highly profitable, but provide dubious benefits to patients.

Two of my colleagues asked why, given the expected influx of millions of newly insured patients into primary care starting in 2014, and an estimated shortfall of more than 50,000 primary care physicians by 2025, the organization had not identified expansion of primary care training as a financial priority. Where exactly did they expect to find family physicians to staff all of the new community offices they planned to open? An awkward silence ensued, followed by some polite hemming and hawing about how this was a complicated issue, and that supporting generalist training would likely require additional funding that was perhaps beyond the organization’s limited resources.

Additional funding required? How about $9.5 billion? That’s the approximate amount that that Medicare spends each year, with no strings attached, to subsidize the cost of training physicians in U.S. residency programs. Noting that the federal government doles out these dollars without requiring any particular outcomes from the institutions that benefit from them, some have called for Medicare to hold institutions more accountable for meeting America’s physician workforce needs.

If we have a surplus of radiologists and a shortage of general surgeons, why not tie funding to training more of the latter and fewer of the former? Given the decentralized nature of the U.S. health system, though, that has been easier said than done. In particular, it is challenging to follow the money trail and determine which institutions end up producing which types of doctors.

new study in Academic Medicine by health services researchers at George Washington University and the Robert Graham Center fills this information gap. Painstakingly assembling and cross-checking data from several sources on actively practicing physicians who completed their residency training from 2006 to 2008, they were able to identify residency-sponsoring institutions that were top producers of primary care physicians, that produced lower proportions relative to all physicians, and that produced none at all.

Notably, they conclusively disproved “The Dean’s Lie“ that counts all internal medicine residents as going into primary care (when only 1 in 5 actually plan to do so), demonstrating that at some institutions fewer than 1 in 10 internists become primary care physicians. They also identified a large funding discrepancy between the top and bottom primary care producers.

The top 20 primary care producing sites graduated 1,658 primary care graduates out of a total of 4,044 graduates (41.0%) and received $292.1 million in total Medicare GME payments. The bottom 20 graduated 684 primary care graduates out of a total of 10,937 graduates (6.3%) and received $842.4 million.

In short, where physician production is concerned, you get what you pay for. In this case, Medicare pays a disproportionate amount of its nearly $10 billion per year in subsidies to institutions that produce mostly subspecialists, even in specialties where supplies are plentiful, at the expense of training sorely needed family physicians and other generalists whose presence has been shown time and again to deliver better health outcomes.

That’s the big picture. Since all politics is local, policymakers who want to know what types of physicians their teaching hospital or health system is training can use the Graham Center’s free GME Outcomes Mapper tool to find out. And if enough of them do so, maybe we can all have a serious national conversation about moving beyond guaranteed health insurance coverage to ensuring that the care (and the workforce) that coverage is paying for will actually help us to live longer or better.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

Doctor integration leads to higher costs @Medici_Manager @leadmedit @wricciardi @pash22

Integrating physicians into hospitals has been theorized to be a cost-saving measure. A new poll of physician executives indicates that such integration may actually increase healthcare costs.

The American College of Physician Executives (ACPE) polled its 11,000 members, asking them what happens to healthcare costs when a physician group or practice is purchased by their hospital or health system.

[See also: Managing clinical, financial integration is key to hospital success]

Of the 468 members who answered the question, 149, or nearly 32 percent, said that healthcare costs go up. Only 22 respondents (4.7 percent) said costs go down. Sixteen percent (75 respondents) said costs remain mostly the same. About 35 percent (163) said the question wasn’t applicable to their institution.

The poll results should be taken as an indication of a possible trend but not as rock solid evidence that physician integration results in higher healthcare costs, cautioned Peter Angood, MD, ACPE’s CEO.

“I think part of the issue that we need to try and tease out further is so are the costs directly related to the physicians ordering more tests and generating more care, or is it that the fact is in order to cover the investment of the physician purchase – the infrastructure that is needed to support them and the other personnel – are those costs getting transferred into the other expenses in terms of charges in the costs of healthcare care,” he said.

Angood believes it is the latter issue spurring the higher healthcare costs, and that those higher costs are likely a temporary situation. As the upfront investment costs depreciate, the higher healthcare costs should drop, he said.

[See also: Doctor medical groups a hot commodity]

Costs should also drop, he said, if the theory of providing integrated care results in improved quality, safety and efficiencies. 

Doctors can learn from how nurses provide care @Medici_Manager @kevinmd

In today’s health care environment, we are all driven to see more patients in less time and do more with less support.  Obviously most of this is financially motivated — the delivery of medical care had unfortunately become more of a business than an art.  As more physician groups are now owned by hospital systems, the “bean counters” and administrators are now crafting the rules of engagement.  Physicians no longer have the luxury of time for a leisurely patient visit.  No longer do we have the time to routinely ask about the grandkids and the most recent trip that our favorite patients have taken in their retirement.  Ultimately, it is the patient who suffers.

Those who are ill and those who love them often need more than pills, blood tests, IV fluids and heart monitors — they need support and genuine caring.  These patients and families need a doctor or other health care provider  to sit on the edge of the bed and unhurriedly listen to their concerns — to simply chat for a bit.  Unfortunately, this is no longer the norm.  Luckily, we have dedicated caregivers on the front lines in our hospitals who can often fill the gap: nurses.

I was moved last week as I read a wonderful article in the New York Times by Sarah Horstmann.  In the essay, Ms. Horstmann (a practicing registered nurse) describes her special connection to a few patients and their families on the orthopedic unit in which she works.  She chronicles her struggle with remaining objective and professional in her role as nurse when she becomes emotionally invested in her patients.  She paints a picture of an engaged and caring nurse who is able to put everything on the line for her patients.  Her internal struggles with “crossing the line” in her care for the patient is one that we all as health care providers have faced at one time or another.

However, she handles her feelings and her patients with absolute grace.  We can all learn a great deal from Ms. Horstmann.  We should all strive to feel and care as deeply as she does.  Our patients and the care we will provide them will certainly benefit greatly.

In medicine, it is the nurses that often lead the way for all of us.  They spend the time required to get to know the patient — their fears, their thoughts about disease, their thoughts about their own mortality.  Nurses understand family dynamics and can help in managing difficult family situations.  Nurses make sure that above all, the patient comes first — no matter what the consequences.

The very best nurses that I have worked with over the years are advocates for those who are too scared or too debilitated to advocate for themselves.  Many times early in my career, I did not pay attention or listen to the lessons that were all around me on the hospital wards.  However, as I approach mid-career I am much more attune to these very same lessons that I may have missed earlier.  There is much gained when we watch and listen to others who are caring for the same patient — maybe in a different role — but caring for our common patient nonetheless.  I now realize that nurses have “shown me the way” many times and for that I am truly grateful.

Emotional investment and developing patient connections can improve care and assist patients and families with acceptance and with eventual grieving and loss.  I believe developing bonds with patients is a wonderful expression of love for another human being and is completely acceptable in medicine — as long as we are able to remain objective when critical clinical decision making is required.

In medicine we strive to provide excellent care for all patients but every now and again there are special patients that we develop emotional bonds with.  Just as in everyday life, there are certain people that you are able to connect with in a spiritual way — whether they are co-workers, colleagues, friends or significant others.  We must stop and appreciate the way in which nurses provide care — we can learn a great deal from them and ultimately provide more “connected” care for our patients.

So, next time you are in the hospital, find a nurse.  He or she will likely be haggard from running from room to room, and it is likely that they have not stopped to eat lunch.  Thank them for caring for our patients.  Thank them for showing us all how to provide better care for our patients.  Then, stop in and say hello to your patient — sit on the edge of the bed and take time to simply just chat.

Kevin R. Campbell is a cardiac electrophysiologist who blogs at his self-titled site, Dr. Kevin R. Campbell, MD.

How to Create a Culture of Self-Learning @Medici_Manager @giovanimedici

There is nothing like giving employees the drive and confidence they need to find their own way to success.
ARTICLE | THU, 01/17/2013 – 01:00

By Dan Carusi, Vice President, Global Education, Deltek

When it comes to the workforce, motivated, top performers always find a way to access the knowledge and develop the skills they need to be successful. Whether through requesting a mentor, attending continuing education classes, or joining a peer-group book club, they will go out of their way to get what and where they want. In this article, I will outline how to infuse this drive into an organization’s workforce, emphasizing the importance of corporate education by creating a culture of self-learning across the entire employee population. The key to success is a methodology we call ED3:

Envision the strategy

Design the vision

Develop the design

Deliver the product

The end goal is increased employee confidence in their knowledge and ability to successfully do their jobs.

Build Excitement and Engagement

Employees are the No. 1 resource of any organization, and the first step (after the executive team is on board) is to “employee source” and test new ideas to gather feedback. By allowing employees to have a part in the creation of the program, they will feel responsible for its success. By implementing it in one part of the organization—perhaps an on-site project team or division—and working closely with the employees, you can demonstrate initial success as it’s rolled out more broadly. Building excitement around the program can have a viral effect, and without engagement and excitement from employees, it will fail miserably.

Provide the Right Assets

Providing the right assets is at the heart of creating a culture of self-learning. The right tools delivered via the right technologies at the right place and time (and communicated properly so they are used correctly by employees) is critical to the success of the learning strategy. Today’s workforce is accustomed to digesting information in “chunks,” and this should be taken into consideration when providing learning tools. Technology allows flexibility, speed, and interaction and supports on-demand learning, all key to driving home this culture. In a self-learning program, technology should be based on the following attributes:

  • Consistent
  • Reusable
  • Transferable
  • Manageable
  • Sellable

For example, at Deltek we have a learning portal that includes “how-to-type” videos answering common questions; a forum where employees can ask questions and converge in groups to discuss them; and a place see what peers are reading this month.

Build Into Corporate Culture

In order for a self-learning program to be a success, it must be ingrained deeply into corporate culture, from the CEO down to the intern. The program needs to be strategically communicated and implemented to ensure success. With a top-down approach, success will cascade down throughout the organization. But while CEO buy-in is paramount to success, it is not the only ingredient to creating the culture. The self-learning program needs to be evangelized across the company to drive awareness and excitement, feeding and accelerating the success of it going viral. Also, it’s important that every employee understands, and is measured in relation to, his or her role. From manager to employee to the “company,” each role is important and must be clearly defined.

Create Peer-to-Peer Accountability

To instill a desire to learn across the employee population, it’s important to create peer-to-peer accountability. By creating peer groups, merchandising successes, and creating individual and team goals, employees will push themselves outside of their normal comfort zones. We think of as the “Boy Scout Approach”—scouts teaching scouts, with leaders guiding along the way. Or, in office terms, employees learning from each other with guidance from managers. This increases the transfer of knowledge and creates communities of practice, with like topics being discussed and explored by interested parties across the organization. Individual development plans that outline the goals for learning and align them with corporate goals are also important in this step.

Strategically Recognize Successes

When it comes to self-learning, we do not recommend rewarding employees financially—this is something they need to buy into from a personal and career growth perspective. If it’s truly part of the culture, employees WANT to take part—not because of reward, but because of personal gain. That said, it’s important to recognize the right behaviors and successes with some type of public acknowledgement. Since the real impact for an organization is increased retention, recruiting, and development of talent, things such as promotions, new roles and responsibilities, and positive feedback from customers should be highlighted and celebrated.

While there are many approaches to creating a successful learning and development program, there is nothing like giving employees the drive and confidence they need to find their own way to success. For the organization, a pervasive culture of self-learning drives speed, performance, and results—all of which are critical in a highly competitive landscape and ever-changing market.

The current vice president of Global Learning for Deltek, a global provider of enterprise software and information solutions for government contractors and professional services firms, Dan Carusi has more than 20 years of business experience. He is responsible for providing leadership for all aspects of Deltek University to include curriculum development, operations and delivery, global employee education, business development, and educational consulting, as well as thought leadership.


Richard Smith: Is the New England Journal of Medicine anti-science? @Richard56 @Medici_Manager @pash22

4 Jul, 13 | by BMJ Group

About once a year a furious researcher writes to me complaining that the New England Journal of Medicine won’t publish a letter that strongly criticises, even demolishes, an article the journal has published. They write to me out of frustration, not because I have any influence over the Bostonian paragon, but because I’ve dared to criticise it in print a few times.

What my correspondents can’t understand is why the journal won’t publish their letter when electronic space is infinite and free. Why can’t the journal have rapid responses like the BMJ and many other journals?

I don’t know why the New England Journal of Medicine doesn’t publish electronically all the letters it receives, but I can hypothesise. The Bostonian paragon is unashamedly elitist and committed to excellence and virtue, just like their colleagues in the city teased by Henry James in his novel The Bostonians. Presumably the editors of the journal don’t want to overload their readers with what they see as ill informed criticisms, but want to present them with the quintessence of comment, beautifully edited of course.

But surely this behaviour is anti-science.

Medical journals are either explicitly or implicitly following the theory of science proposed by Karl Popper: scientists develop a falsifiable hypothesis and then test it to destruction. They never arrive at truth, but hypotheses that have survived the destructive fire serve as our best substitute for truth.

It follows that a very important part of science is giving everybody, the hoi polio as well as the blessed, the chance to scrutinise the hypotheses, methods, data, and conclusions of studies and present their criticisms. We can be much more confident in the findings of a study that has been exposed to tens of thousands of critical eyes than we can in one that has been viewed only by the chosen few, particularly when those few are of the same mental bent as the authors of the study.

Always in this kind of discussion I’m driven back to quoting the blind poet, republican, and regicide John Milton: “Truth was never put to the worse in a free and open encounter…. It is not impossible that she [truth] may have more shapes than one…. If it comes to prohibiting, there is not ought more likely to be prohibited than truth itself, whose first appearance to our eyes bleared and dimmed with prejudice and custom is more unsightly and implausible than many errors….”

The editors of the New England Journal of Medicine must think of themselves as superior people (and they are superior to most of us, and certainly to me) capable of distinguishing truth from error, but could they be making a mistake? I urge them to follow the advice of Rudolf  Virchow, the great German doctor and intellectual, who insisted that “Everybody is free to make a fool of himself in my journal.”

Competing interest: RS admires the New England Journal of Medicine but has several times published criticisms of the journal; and he is passionately committed to open access and sees the journal as an important barrier to complete open access.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.


Medical Schools Need to Change Approach in Training Primary Care Physicians @Medici_Manager

By James Arvantes

Most medical school faculties are not well versed in the fundamental changes taking place in the nation’s health care system, which makes it difficult for them to adequately prepare medical school students and residents for practicing in the changing health care environment. That was a central theme that emerged from a primary care policy forum held here recently by the American Board of Family Medicine.
Larry Green, M.D., speaks about primary care residency programs training for the future

Larry Green, M.D., founding director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, says primary care residency programs are working to change to better meet the needs of an evolving health care system.
“If we are going to talk about innovation and change, we often have to change the faculty, because their national inclination is to teach what they have been doing their whole careers and what they were taught,” said George Thibault, M.D., president of the Josiah Macy Jr. Foundation, who spoke as part of a three-member panel. “That is different from what we want to transform the health care system into,” he added.Thibault said transformation of the health care system requires transformation of the educational process, a goal that can only be attained by having teachers in place to train students and residents about new and emerging health care payment and delivery models. “If we are going to have a reformed health care system, we need to pay attention to the workforce — not just the numbers of the workforce, but the composition of the workforce,” said Thibault.

What medical school professors teach is an accumulation of their work and educational experiences, he noted. “They can’t teach what they don’t know. We talk about new models of clinical education (moving) out of the academic center and into the community. It is integrated rather than fragmented. Those experiences were not the experiences faculty had when they were working.”Thibault also addressed interprofessional education, saying that most faculty members did not receive their training in an interprofessional setting. “They didn’t learn from other faculty and leaders in other professions.”

Moreover, most medical school faculties are unfamiliar with online learning and other technologies. “We want to and need to develop future leaders and innovators in education,” said Thibault. But, he added, changes in medical school education will succeed only if entire faculties buy into the process. “The redesign of the education system and the redesign of the delivery system are only sustainable if they become the standard way we do business,” Thibault noted.

Thibault and the two other speakers on the panel, Barbara Brandt, Ph.D., director of the National Center for Interprofessional Practice and Education, and Larry Green, M.D., professor and Epperson Zorn Chair for Innovation in Family Medicine and Primary Care at the University of Colorado, Denver, pointed out that medical education is undergoing fundamental changes in some parts of the country to better align with changes taking place in the health care system as a whole.

“There are physicians all across this country who are doing their (best) to change the training programs,” said Green, who was the founding director of the AAFP’s Robert Graham Center for Policy Studies in Family Medicine and Primary Care. In fact, he added, the three main primary care residencies — family medicine, internal medicine and pediatrics — are all engaged in efforts to redesign their residency training programs to achieve better health care.

As an example of the changes occurring within medical education, Thibault described a primary care faculty development initiative spearheaded by the American Board of Family Medicine, the American Board of Internal Medicine and the American Board of Pediatrics to develop some common goals and competencies around curriculum development.

The initiative, funded by the Josiah Macy Jr. Foundation, the Health Resources and Services Administration (HRSA) and private foundations, has identified particular skills or competencies needed for the primary care workforce of the future. These include

  • teamwork,
  • change management,
  • leadership,
  • population management and
  • clinical microsystem skills.
Brandt, meanwhile, said the push to develop competencies for interprofessional education is exemplified by the National Center for Interprofessional Practice and Education. The center is funded by HRSA and private foundations, making it a true public and private partnership. One of the main goals of the center is to transform the siloed U.S. health care system into one that engages patients, families and communities in collaborative, team-based care, said Brandt.To achieve this goal, the center will create and test new health care organizations and structures while training a workforce that operates in team-based delivery systems to improve health care quality, safety and access.

“We really do not have a lot of evidence as far as what works in training and education for this type of practice,” said Brandt. “That is going to be one of the marks of distinction of this particular national center.”

The ultimate goal, Brandt said, “is better alignment of the health care system and higher education.”


  • The ability to change the nation’s health care system will require a primary care workforce that is trained in team-based and collaborative care, said three speakers at a recent American Board of Family Medicine policy event.
  • Most medical school faculties are not trained in new and innovative health care models, making it difficult for them to properly train a primary care workforce to meet the needs of an evolving health care field.
  • The speakers cited examples of how public and private partnerships are working to train a workforce that meets the needs of the health care system and the community at large.

Medical schools signal readiness for revolution @Medici_Manager

A robust response to an AMA initiative underscores the fact that medical schools recognize the need for a necessary update of how they educate physicians.

Posted March 18, 2013.

Educator Abraham Flexner’s 1910 report evaluating American and Canadian medical schools is generally credited with transforming medical education into its current modern age. Flexner shined a light on the importance of a more rigorous education so that future physicians could be trained in — and have a sharp mind for — the rapid scientific and technological advances coming out of the Industrial Revolution.

Over the last decade, numerous studies have looked at one question: Should the Flexner model be updated so medical education can adapt to the rapid scientific and technological advances of today’s information revolution? The answer is uniformly, yes, and the call for change isn’t coming only from medical and educational observers. Recently, striking evidence has surfaced that the schools themselves are ready to make a change — one as revolutionary as anything Flexner envisioned.

That evidence is their overwhelming response to a $10 million initiative by the American Medical Association called “Accelerating Change in Medical Education.” Before a Feb. 15 deadline, 115 out of 141 U.S. medical schools sent five-page concept proposals explaining what transformative changes they would like to make in teaching future physicians. Changes might include new ways of teaching and assessing core competencies, or more of a focus on patient safety or quality improvement. The proposals reflect a changing health care delivery system transformed by technology so that the skill of finding and applying information is as important — or more so — than memorizing it. Of those proposals, 20 to 30 will be chosen to write a longer request for a proposal that is the equivalent of applying for a National Institute of Health grant. From there, eight to 10 schools will be announced at the AMA Annual Meeting in June as sharing in the $10 million to help implement their ideas.

The AMA helped bring Flexner’s report to bear, with its Continuing Medical Education division. It rated medical schools at the time and solicited the Carnegie Foundation for the Advancement of Teaching — which chose Flexner — for further efforts in improving physician education. This was at a time that many schools’ quality was poor, and there were few, if any, standards for training doctors.

The AMA again has stepped to the forefront, not only with its $10 million offer but also with other efforts to promote initiatives to improve education, publishing papers on change in medical education and organizing high-level discussions in which experts talk about what the future of medical schools should be.

But unlike 100 years ago, when substandard schools closed or fired faculty to catch up to Flexner’s standards, the relationship between medical schools and agents of change is markedly more symbiotic.

Schools already are part of the discussion about accelerating the pace of instruction to three years instead of four, as a way to train more doctors and confront the current crisis of a looming physician shortage.

They have recognized the impact that the Internet and mobile technology have had as a means for doctors to quickly and easily review treatment guidelines and look up information on diseases, pharmaceuticals and procedures. Business tracks have been added at some schools to help future physicians learn about how to manage the complex insurance and financial environment they will face. There are now programs where physicians are taught how to work not only in an individual practice setting but also as leaders and members of teams that stretch across different professions, locations and practice settings.

The AMA’s “Accelerating Change in Medical Education” program indeed will fund individual schools with particularly compelling ideas, schools that a panel of experts will choose to reflect a variety of regions and projects. But the goal is not merely to promote transformations at a few schools. By including those schools in a medical education consortium, by sharing their ideas with all medical schools, and also by sharing other worthy ideas from schools that weren’t selected, the hope is that the AMA program helps facilitate creative thinking and out-of-the-box ideas across the spectrum of medical education.

The reason the AMA emphasizes “accelerating” change is that incremental changes aren’t enough to ensure that future doctors get the training they need in a world in which rapid business, population and technological changes have made being a doctor a much more dynamic profession. These have to be systemic changes, as bold and far-reaching in our time as they were in the wake of the Flexner report.

Flexner’s triumph stemmed from an era when there were many medical schools unworthy of the name. This next revolution starts from strength, solid opportunities and a well-demonstrated willingness to embrace change.


“Accelerating change in medical education,” American Medical Association (link)

Alla ricerca dell’informazione di qualità @Medici_Manager @specializzandi @giovanimedici @wricciardi

Carlo Favaretti, Presidente della Società Italiana di Health Technology Assessment (SIHTA), Coordinatore nazionale delle reti regionali HPH, presenta La ricerca documentale. Istruzioni per l’uso.
La possibilità e la capacità di recuperare informazioni significativeper assumere decisioni si dimostra ogni giorno di più come un fattore critico di successo, a maggior ragione nei settori dove la produzione di “conoscenze” assume un ritmo tumultuoso e la distribuzione delle “notizie” utilizza canali diversificati per quantità e qualità dei contenuti. In ambito clinico e assistenziale, come pure nella gestione delle organizzazioni sanitarie, la disponibilità di informazioni affidabili e validate può generare valore aggiunto per i professionisti, i pazienti, la comunità in generale e gli altri stakeholder solo se questa disponibilità viene “catturata” da tutti coloro che, nella pratica quotidiana, devono combinare al meglio le risorse disponibili con i bisogni e le domande dei cittadini.

Questa guida, La ricerca documentale. Istruzioni per l’uso, frutto di un appassionato lavoro di sistematizzazione di iniziative formative sviluppate da diversi anni nell’Azienda Ospedaliero-Universitaria di Udine dai miei collaboratori, vuole essere uno strumento ambizioso di agile e rapida consultazione per aiutare i decisori (clinici in particolare) a mettere a fuoco un quesito informativo, a cercare/navigare nei moderni contenitori elettronici e a selezionare dal mare magnum web-based gli elementi essenziali per le decisioni di tutti i giorni.

Ovviamente le “istruzioni per l’uso” non forniscono suggerimenti per sviluppare la curiosità intellettuale del ricercatore o strumenti per affinare lo spirito critico del professionista, qualità peraltro da coltivare con passione e costanza; cercano tuttavia di mettere in luce potenzialità e limiti dei diversi contenitori, a loro volta oggetto di selezione e validazione dei contenuti da parte dei curatori delle basi-dati.

Un ulteriore pregio di questo manuale è la selezione di “contenitori” ad accesso libero, dai più popolari ai più tecnici, col suggerimento di coinvolgere gli specialisti dell’informazione della propria organizzazione (azienda sanitaria, azienda ospedaliera, università ecc.) per il recupero di ulteriori documenti o di risorse a pagamento.
Concludo con l’auspicio che la ricerca documentale possa contribuire a migliorare la nostra capacità di lettura dei problemi clinici ed organizzativi, aiutandoci a coltivare il metodo scientifico e lo spirito galileiano del “cimento”, che il bombardamento informativo mette oggi a dura prova.

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What can nurses learn from doctors? @Medici_Manager @DocComLtd

 | PHYSICIAN | MARCH 1, 2013

There’s a lot nurses can learn from doctors.

There I said it.

But I’m not talking about clinical ability or medical knowledge. I’m talking about expectations. I’m talking about basic behaviors that dictate a predictable response.

Nurses don’t feel valued. Much of this is warranted, but I argue that some of it is self-inflicted. I said this once to a colleague and she responded, “But that places the blame on the nurse.”

I disagree. Rather than placing blame on the nurse, it empowers any nurse to realize that in each of us lies an opportunity to behave in a way that allows us to receive the respect we deserve. Stop fighting for it and start expecting it. Close the gap between doctor and nurse without offending or confusing anyone.

There are ways that we nurses can be more like doctors that don’t require additional degrees, institutional approval or even money.

Doctors use medical words

Real life nurses actually already do this. It’s just that nursing education hasn’t caught on yet. Which is unfortunate because it takes new nurses so many steps back from where they should be when entering the profession. If you don’t know what nursing diagnoses are, they are an attempt to distinguish nursing language from doctor speak when describing the very same clinical scenario. For instance, when I have a patient who’s hypoxic, I say, “This patient’s hypoxic.” I do not say, “This patient has altered tissue perfusion.” That would be silly. Every time nursing students are taught to use nursing diagnoses, the profession is shooting itself in the foot again.

Doctors quote the literature

You don’t need M.D. after your name to stay abreast of cutting edge research in the medical field. There’s plenty of clinically relevant research in nursing journals (and hey, go crazy with a medical journal once in a while—you might even understand the big words). Then tell your patients what you know. I guarantee you they’ll respect it.

Doctors use the “C” words: Consult and colleague

Doctors consult with colleagues; they discuss clinical ambiguities and tough decisions. Nurses consult with each other, too. We’re just not taught to use those words. Let’s start.

Doctors don’t apologize for doing their jobs

How many times have I heard a nurse say to a physician, “Sorry to bother you”? Saying “Sorry to bother you,” when addressing a clinical matter to a doctor who is vested in the outcome is like the President apologizing to the Senate for calling a meeting to address national policy. These are our jobs. We share a unified goal called optimal patient care. Don’t start out by providing a reason to ask for forgiveness for a crime not committed. Rather than come from a place of “Sorry.” Why not come from a place of “Thanks.” As in, “Hey, thanks for getting back to me.” Try it just once—it feels good.

Doctors expect respect

Doctors expect to be respected and are surprised when they aren’t, not the other way around. That’s not a criticism, it’s a compliment. They’ve worked hard for many years and can prove it with their school loans. Nurses come into the workforce already expecting to be snubbed, brushed off, and undervalued. We’re afraid of getting yelled at, afraid of being blamed for something, afraid of being mistreated with no recourse. And we feel pleasantly surprised when that doesn’t happen. Let’s turn our expectations around.

Meaghan O’Keeffe is a nurse who blogs at and Healthy Offspring

Eight Brilliant Minds on the Future of Online Education @Medici_Manager

by Eric Hellweg

The advent of massively open online classes (MOOCs) is the single most important technological development of the millennium so far. I say this for two main reasons. First, for the enormously transformative impact MOOCs can have on literally billions of people in the world. Second, for the equally disruptive effect MOOCs will inevitably have on the global education industry.

While at Davos, I was fortunate to attend an amazing panel — my favorite of the conference — with a murderer’s row of speakers. Moderated by Thomas Friedman of The New York Times, the list of speakers: Larry Summers, former president of Harvard; Bill Gates; Peter Theil, a partner at Founder’s Fund; Rafael Reif, president of MIT; Sebastian Thrun, CEO of Udacity; Daphne Koller, CEO of Coursera, and a 12-year-old Pakistani girl who has taken a number of Stanford physics classes through Udacity. Below is a collection of some of the highlighted comments from this remarkable panel as well as a couple from audience members who were given an opportunity to comment.

Why this disruption is happening:

Peter Thiel, partner, Founders Fund
“In the United States, students don’t get their money’s worth. There’s a bubble in education as out of control as the housing bubble and the tech bubble in the 1990s. Education costs have gone up 400% since 1980. That’s the highest escalation of costs–higher than health care. There’s now a trillion dollars in student debt. And thanks to the way bankruptcy laws were restructured under George W Bush, you can’t get out of the college loan even if you become bankrupt. This is deeply broken.

“You have to ask yourself, ‘What is the nature of education as a good?’ Ideally you want it to be learning. But it also functions as insurance. Parents will pay a lot of money for insurance against cracks in our society. Education as insurance has something to be said because it connects to the economy. You know computer science, you can get a job. But education also functions as a tournament. You do well if you go to a top school but for everyone else the diploma is a dunce hat in disguise. People need to understand what they’re trying to do? Is it insurance? A tournament? Learning?”

Where we are in the evolution of this change:

Larry Summers, former President of Harvard
“It’s important to remember this really wise quote when thinking about the transition to online education: ‘Things take longer to happen than you think they will and then they happen faster than you think they could.’ If you had a discussion with dentists on tooth decay in 1947 it would have been about brushing your teeth and dental care, but the most important thing to happen with fighting tooth decay was fluoridated water and this is similar. It’s hard to know when it will happen but at some point this will be transformative. The first stage is when it does what was being done before but better. That’s what is happening now. But we’re going to where we don’t need to have two semesters, classes of same length, grading on the basis of things called exams. You can’t think of another industry where a list of top 10 providers is perfectly correlated to what it was in 1960.”

Daphne Koller, founder of Coursera
“We’re at 2.4 million students now. The biggest lesson I’ve learned on this is I underestimated the amount of impact this would have around the world. I really didn’t envision this scale and this impact this quickly.”

Raphael Reif, president of MIT
“We manage this transition very carefully. How can MIT charge $50,000 for tuition going forward? Can we justify that in the future? We see three components to MIT- first there’s the student life, then there’s the classroom instruction, but for us, the projects and labs activity is where real education occurs. But I don’t think we can charge that much for tuition in the future and it’s a big pressure point for us.”

Bill Gates, chairman of Microsoft
“When people first put courses online people thought they could charge money and no one bought them. They put them online but from a global perspective, all these high numbers of students we’re hearing about today, the effective number of people who use them is zero. It’s not widely used as a percentage of the global population. Our whole notion of ‘credential’, which means you went somewhere for a number of hours, needs to move to where you can prove you have the knowledge and the quality of these online courses need to improve. Over the next few years the quality will improve. 90% of these courses will be long forgotten and never viewed. Over the next five years this transformation will be phenomenal but only through a pretty brutal winnowing out process.”

On what an online education world means for hiring and talent for educators:

Rafael Reif
[On the question of how to hire professors in the MOOC era] “Can you hire MIT professors who know that they need to teach 150,000 people and not 150? We have spectacular researchers who are lousy teachers. That’s sad. A teacher in the future will become more like a mentor. The model of on campus education will be more about mentorship and guidance with research as an important factor.”

We can’t presume to know what format will work in the future:

Larry Summers
“It’s important to remember that we’re not so good at understanding the subtleties of environments that make them attractive to people. Look at football for example. One way to watch a game is to sit on a cold bench with no good food and bad bathrooms, the other is in your own living room, with replay, and food you like at your convenience. And then ask yourself- which would you guess people pay for? Which do people cheer for? You’d get it wrong. There are aspects of bringing people together in groups that we can’t quite understand and judge. The working out of this will depend a lot on formulas for making it attractive and collaborative. And as football example suggests, it won’t be immediately obvious what those models are.”

What’s next in this space?

Bill Gates
“Who is going to jump first into granting a degree that doesn’t have the seat time requirement that we do today that employers will see as credible? Where does the credibility come from?

Sebastian Thrun, CEO of uDacity
“I think the question is how do you make the credential have currency that an employer knows? We’ve had good success. We have 350 companies who have hired our students. Employers worry about soft skills and we can measure that and it’s on equal performance with hard skills. The credential thing is interesting- we launched a class for credit with California schools for remedial math. We priced them at 10-15 percent of what college costs. There are lots of improvements to be made, but the outcome tends to be better today with us.”

Jimmy Wales, founder, Wikipedia
“The overall quantity and quality of formal education hasn’t changed whereas the informal education has skyrocketed in the last 30 years. People used to go to library and now go to Wikipedia. We haven’t really begun to understand the impact on that.”

Muhammad Yunus, Nobel Peace Prize Winner, Founder Grameen Bank
“What does this all mean? The technology gives us tremendous power to solve this stark problem all around us. We need to design these so no child is left out of this. What need to ask, what is education after all? We need to resolve that. What are we getting our young people ready for? It’s for the purpose of our life. And we need to make sure we give people a purpose to their life. It won’t be done by current system. It will be done by people who have nothing to do with current system.”

More blog posts by Eric Hellweg
Eric Hellweg


Eric Hellweg is the Managing Director of Digital Strategy and an Editorial Director at Harvard Business Review. You can follow him on Twitter.

10 talks on predicting the future @Medici_Manager @muirgray


We’re just a week into 2013, and the year seems filled with possibility. The turn of the New Year is generally an occasion to look back and reflect on the year that’s passed — the victories and defeats, the lives lost and the experiences found. But after we look back, we inevitably turn forward. We make resolutions and predictions for the year to come, taking educated guesses as we gaze into the abyss of the unknown. Here,10 TED Talks that offer visions for the future.

Ian Goldin: Navigating our global future
“This could be our best century ever, or it could be our worst,” says Ian Goldin. In this absorbing talk from TEDGlobal 2009, Goldin argues that the accelerating impact of globalization has the potential for miraculous human achievements, but also presents immense challenges — specifically in inequality. We may see incredible advances in technology, science and the quality of life, but will only the rich have access? Offering predictions for life in 2030, Goldin reminds us that “the rest of our lives will be in the future, so we need to prepare for it now.”

Kevin Kelly: The next 5,000 days of the web
At EG 2007, Keven Kelly noted that we had 5,000 days of the World Wide Web behind us. In this talk, he looks at what’s to come next. He foresees a smarter, more personalized and more ubiquitous web in the next 10 years, with the digital cloud forming the underpinnings of our physical environment. As the web doubles in power every two years, he shares why it’s expected to exceed human power by 2040.

Kirk Citron: And now, the real news
Projecting a “Long News” perspective onto the present, Kirk Citron analyzes the headlines at TED2010, trying to predict what will still be relevant in 10, 100 and 10,000 years. It’s not Michael Jackson’s death or the miraculous landing of a US Airways plane on the Hudson River that will matter, he says, but innovations in science. Why? Because research in 2010 paved the way for genetically modified food to feed the planet, for people to drink water on the moon, and for nanobees to enter the brain and zap tumors with bee venom. In the long run, Citron points out that some news stories are just more important than others.

Rob Hopkins: Transition to a world without oil
Rob Hopkins wants to tell a different story about the future. Not one of apocalypse or salvation but of transition — specifically, transition from our dependence on oil. As the founder of the Transition movement, he advocates for petroleum-free communities stripped of modern-day luxuries, but also free from the trappings of oil. Sustainability isn’t the solution, Hopkins says at TEDGlobal 2009, because we can’t simply invent our way out of oil dependence.

Martin Rees asks: Is this our final century?
Zooming in on the “tiny sliver of earth’s history” that has involved humans, and zooming out again to the full past, present and future of the universe, astronomer Sir Martin Rees explores the future of our planet. Highlighting the immense changes that will occur, he reminds the audience at TEDGlobal 2005 that when the sun extinguishes in 6 billion years, the creatures living on this earth will be as different from us as we are from bacteria.

Nicholas Negroponte, in 1984, makes 5 prediction 

Danny Hills: Back to the future (of 1994)

This pair of talks from the TED archives highlights the challenges and successes of predicting the future. Nicholas Negroponte’s talk from TED1984 offers five eerily on-point predictions, ranging from touchscreen phones to the future of CD-ROMS. Ten years later, Danny Hills offers a timeless theory of technological evolution that mirrors our own biological trajectory.

Larry Burns on the future of cars
Computer-enhanced cars — that run on clean hydrogen and contribute to the energy grid — are just around the corner, says Larry Burns. You’ll even refuel your hydrogen-fueled car at home, he shares. At TED2005, GM vice president for research and design Larry Burns details his exciting task of reinventing the automobile.

Aubrey de Grey: A roadmap to end aging
You could live to see the next millennium, suggests researcher Aubrey de Grey. Arguing that we could live to be 1,000 years old, de Grey explains that if we simply extend our lives by 30 years right now, we can reach the “longevity escape velocity,” with the rate of life-extending discoveries outpacing our 30-year life extension. And, he says at TEDGlobal 2005, the tools to start this process exist right now.

Stewart Brand on the Long Now
“It would be helpful if humanity got into the habit of thinking of the now not just as next week or next quarter but the next 10,000 years,” notes Stewart Brand in this talk from TED2004. Disrupting our conception of time and space, Brand describes his current project to build a 10,000 year clock that would be able to withstand the wear and tear of deep time.

The case for slow medicine @Richard56 @Medici_Manager

The characteristics of health systems are complexity, uncertainty, opacity, poor measurement, variability in decision making, asymmetry of information, conflict of interest, and corruption. They are thus largely a black box and uncontrollable, said Gianfranco Domenighetti of the Università della Svizzera Italiana at a meeting in Bologna on La Sanità tra Ragione e passione (Health through reason and passion). The meeting was held to celebrate the life and work of Alessandro Liberati, the founder of the Italian Cochrane Centre, who died last year.

Only 11% of 3000 health interventions have good evidence to support them, said Domenighetti. A third of the activity in the US health system produces no benefit, said a recent study in the New England Journal of Medicine. Half of all angioplasties are unnecessary. Some €153m a day is lost through corruption in health systems in the European Union. Four fifths of new drugs are copies of old drugs. Screening is creating diseases like ductal carcinoma in situ. Most doctors (80-90%) have taken “bribes” from pharmaceutical companies, although many may not see their free pens and lunches and subsidised travel as bribes (but if they are not bribes what are they?). Between 15% and 40% of articles in medical journals are ghostwritten. Half of clinical trials are not published, and there is systematic bias towards positive results, hence suggesting that treatments, usually drugs, are more effective and safer than they actually are.

Yet against this backcloth more than four fifths of people in most countries think medicine is an “exact or almost exact science.” In a study published in the Annals of Internal Medicine nearly 90% of patients undergoing percutaneous coronary intervention (PCI) thought that it would reduce their chances of having a heart attack, when it doesn’t. Asked about various scenarios almost half of cardiologists questioned would go ahead with a PCI even when they believed there was no benefit to the patient.

It is time, said Domenighetti, to open up the black box of healthcare. Encouraging “health literacy” seems to be a way to do this, but Domenighetti thought that this was “old wine in new bottles.” We need, he said, to encourage a healthy skepticism about the medical market and to help people understand that medicine is far from being an exact science. Data should be published exposing variations in practice, corruption, and conflicts of interest. We should explain that health depends mostly on exogenous factors not the healthcare system. And people should be given practical tools to promote their autonomy—tools like access to evidence based information.

Domenghetti ended his talk by pointing people towards the Choosing Wisely campaign in the US where professional organisations are identifying interventions that offer little or no value. A similar but broader campaign of Slow Medicine is underway in Italy, and I have little doubt that slow medicine—like slow food and slow lovemaking—is the best kind of medicine for the 21st century.

We need to pull back from what Ivan Illich called the hubris of medicine.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

Competing interest: RS spoke at the meeting and had his expenses paid by the health department of Emilia-Romagna.

Part of medical education is to learn limitations @Medici_Manager @kevinmd


There is a strong relationship comparing sports to the military, business, and also to medicine.  Young athletes, in their late teens and early 20s, are mostly brawn and use their strength and speed to achieve success early in their professional careers.  As the athlete matures in their late 20s and early 30s, the physiologic processes slowly decrease and efficiency and maturity and other cerebral skills emerge.

There are 2 rainbow arcs that describe this brawn-brain interaction.  The arc of brawn rises earlier than the arc of brain-based skills, which appear later only when brawn starts on its down slope and intersects with the rising arc of experience that peak performance occurs.

The same 2 arcs probably take place in every medical doctor’s career.  Young doctors are full of energy and knowledge.  It is only after years in practice that the doctors develop maturity of their clinical skills that makes them peak performers.

When I was a newly minted urologist in 1978 I was referred a Crohn’s patient who complained of foul smelling urine and passing “bubbles” in her urine.  I worked her up and diagnosed a colovesical fistula.  I called the referring doctor and told him that I could surgically correct this with the assistance of a general surgeon.  The gastroenterologist said, “Neil, I am going to do you a favor and not allow you to operate on her.  She has terrible nutrition and has a history of multiple fistulae and would not heal and she would likely be made worse by the surgery.”  What a valuable lesson that was helpful in my early maturation as a physician.  I was able to learn that I couldn’t cure everything and that were times when keeping the scalpel on the shelf was in the best interest of the patient.

I think part of our medical education is to learn our limitations.  My best lesson I learned was to always think of our actions appearing on the front page of the paper or on 60 Minutes.  Always ask yourself, “Would I want my decision to appear in public?” or “Is this decision or action in the best interest of the patient?”  If the answer to both questions is yes, you will not be making an error where your brawn gets in the way of your brain.

Neil Baum is a urologist at Touro Infirmary and author of Marketing Your Clinical Practices: Ethically, Effectively, Economically. He can be reached at his self-titled site, Neil Baum, MDor on Facebook and Twitter.