Wednesday, October 24, 2012

Why Residents Are Vital To Successful High-Value Education Projects

Christopher Moriates, MD is a Clinical Instructor in the Division of Hospital Medicine at the University of California San Francisco (UCSF). He is currently Co-Chair of the UCSF DHM High Value Care committee. During residency training he co-created a cost awareness curriculum for residents at UCSF. 

I learned a lot of medicine during residency, but perhaps I actually learned even more about how to just get things done in a hospital. If you wanted a right-upper-quadrant ultrasound done for our patient, I was your man. I had a complicated series of unwritten algorithmic flow diagrams in my head that included handwriting an order, making sure that it was faxed to the right number, calling the appropriate person to get a technician if it was afterhours, and knowing who to call for the preliminary results.  These were all dependent on the day of the week, time of day, and whether we were at UCSF, San Francisco General Hospital, or the V.A. Sound ridiculous? Yes, it was.

Trust me, though, these broken systems are not unique to our medical center. Consider, the following analogies from the brand new Institute of Medicine report:
  • “If banking were like health care, automated teller machine (ATM) transactions would take not seconds but perhaps days or longer as a result of unavailable or misplaced records.
  • If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination.
  • If airline travel were like health care, each pilot would be free to design his or her own preflight safety check, or not to perform one at all.”
Yes, ridiculous, indeed.

I have been out of residency now for exactly 87 days, and everything has changed. A new computer system has been implemented at our hospital and a whole new crop of interns - like Magellan chartering the Atlantic to the Pacific for the first time - are boldly routing out their own new process maps for countless different scenarios.
As an attending, my new formula (thankfully) looks like this:

“Need ultrasound done -> Ask intern.”

I am already woefully out-of-touch.

My point is, if you want to know about all of the waste in the system, the crazy things that we do that don’t make any sense, the countless middlemen and non-value-added steps, and the overtreatment and excess testing that lead to harm for patients, then you need to ask a resident on the “frontlines.”  And, you know what? Not only do they intimately know about these areas of nonsense, but it drives them the most insane!

This is because this pervasive waste in medicine is disrespectful not only to the patients that we inflict it on, but also to our medical professionals whose time is squandered maneuvering through meaningless steps.
At a recent national meeting, the question was raised by a medical educator, “But how do we try to implement “Choosing Wisely” or “Lean” initiatives when we have trainees at our medical center?”

The question should not suggest how do we achieve these goals despite trainees, but rather how do we do this with trainees. No, take it even a step further. How do we get our trainees to show us how to best incorporate a “Choosing Wisely” philosophy?

Let’s consider this illustration. As a third year medicine resident, I was the primary “champion” for our new Cost Awareness curriculum at UCSF. Frankly, my colleagues were rooting for me to succeed. Now, the questions posed at the conferences by residents after we “opened up Pandora’s box” of cost consciousness were not necessarily easy – I don't think that many punches were pulled by some who were uncomfortable talking about hospital charges for the first time, or reviewing cases that showed our excesses. But the majority buy-in and enthusiastic support of the residents for a project by one of their own was likely a powerful strength to our successful launch.

My fellow residents stopped me in the wards to tell me “how proud” I would be of them for… talking their intern through not getting that unnecessary chest CT scan, or stopping the repeat blood cultures within 72 hours for their patient with fever, or… on it went. This curriculum and movement was something that we were doing together, not something being done to us.

So, what can departments and residency programs do to help facilitate residents’ involvement in these sorts of projects?

1. We can provide the scaffolding necessary for success. The first time I wrote up a formal educational needs assessment, or gave a noon conference, or spoke at a scientific meeting, I needed faculty mentors to help guide me through the process. With this sort of backbone support I was able to climb so much higher than I would have on my own. To help catalyze this process, programs can actively identify and match residents with appropriate mentors who are experienced in Quality Improvement and/or Value projects.

2. We can do what Dr. Talmadge King, Chair of Medicine at UCSF, did recently and explicitly state that “Choosing Wisely” is a priority of our department. This means a commitment to put some of our support, time and resources behind these types of projects and educational initiatives.

3. We can specifically carve out time for residents to pursue, achieve and present these projects during their residency. I mind you, not in spite of their patient care training, but in line with it. Many programs already do this for traditional research projects. We need to create an environment where these new types of projects are valued as academic contributions to our institutions.

4. We can help obtain and share data about costs, charges and variation at our own medical centers. For many this information is impenetrably, and unreasonably, hidden and opaque. We need help from the top to get access to this data.

 5. And if all else fails, we can do what we always do in medicine to convince people that this is a worthy cause. We can quote Sir William Osler: “Medical care must be provided with the utmost efficiency. To do less is a disservice to those we treat, and an injustice to those we might have treated (1893).”


  1. As a 3rd year resident in pediatrics, I completely agree with this. There are so many idiosyncracies to learn to be able to implement the plan of care, it's almost akin to a hazing! I think all residency programs require their residents to do a QI project, but for many I think it's just another hoop to jump through, not feeling like what we do "is a worthy cause." Having attending champions would make things more surmountable, although it'd be important for them to realize that our ideas on how to improve the system for *residents* (and only *indirectly* benefiting patients) are still valid/important.

    As an aside, I do take a certain perverse pleasure in knowing the phone numbers to the lab, micro, the blood bank, the X-ray tech, and the pharmacy off the top of my head, or knowing that the magic word to order a transfusion in the CPOE is "RBC," or that a portable 2-view CXR is near impossible to obtain... all the while lamenting the fact that I have to correct my attending's orders because he/she ordered it the wrong way in the system!

    Initiatives like Choosing Wisely & LEAN are so important to bring medicine into the 20th century, but residency doesn't really train you to take on the "big issues" like decreasing unnecessary lab tests or eliminating middlemen; in pediatrics at least, it's more "decrease juice intake" or "plot BP percentiles at well child physicals." These are important topics for sure, but I'm not sure I feel ready to tackle these problems!


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  3. I mind you, not in spite of their patient care training, but in line with it. Many programs already do this for traditional research projects. Compass Claims is a huge name which is providing insurance services in all sectors.

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