Feedback? No, Feedforward.

Today I read an interesting paper in Medical Education titled Feedback, the various tasks of the doctor, and the feedforward alternative.

The authors comprehensively review the unintentional damage that feedback may cause to both motivation and performance. In a nice review of the literature and in a meta-analysis, the evidence suggests that traditional feedback can have complex, and at times negative results, thereby impairing performance. At play here is a self-regulatory theory with two distinct foci: prevention-a state of mind characterized by vigilance and concern with punishment, and, promotion -a state of mind characterized by eagerness and concern with rewards.

In essence, the evaluator must understand the self-regulatory focus of the learner so as to best understand the impact of feedback.  The authors argue that positive feedback motivates more than negative feedback under a promotion focus and that this effect reverses under a prevention focus.  

Are you still with me?

Next, they propose the Feedforward interview technique. If done properly, this indeed is an exploratory, self reflective, interview between student and teacher. The authors cite limited data in support of the new technique.

The components are:

• Introduction: set a positive tone
• Story: the learner must recall a life or work story that led to personal fulfillment
• Peak: the learner must recall the peak moment and psychological reaction
• The conditions: the learner must explore what allowed for the story/peak experience
• The feedforward question: To what extent/degree does the current work and educational experience bring the learner closer/take away from the condition of happiness and fulfillment?

The feedforward approach may be too Ivory Tower, even for the Ivory Tower. Here is why this may not play out in reality:

• Many medical schools educate 150+ students per year in clinical clerkships. Most struggle to simply get physicians to complete a written student evaluation.
• Feedforward student interviews would be time consuming. Without a structural change that actually provides protected time for teaching and formal feedback sessions, this will fall by the wayside.
• Extensive training of both evaluator and learner will be required to implement the feedforward interview.
• The feedforward evaluator must understand the self-regulatory focus (promotion vs prevention) of the learner whereas in the traditional model, feedback is dependent upon the observational skills of the mentor. I suspect that the former is less natural than the latter for most physician educators.

Feedforward interviewing may simply be too forward thinking in the current structure of medical education.

My apologies for today’s unduly long commentary.

Modern Day Nursing: Beyond Caps, Uniforms and Traditional Roles

During my first month of internship, a co-intern and medical school classmate gave me some sound advice on a weekend when I was assigned to the cardiac ICU: “ingratiate yourself to the nurses, they know cardiac patient care much better than you, and they can make your life much easier in the unit.”  Point well taken.

My perception was that young physicians (young perpetually defined as my age or younger) were respectful of nurses and viewed them as important patient care partners. Gone were the days of nurses as mere patient care subordinates in matching uniforms with caps, carrying out doctors' orders and emptying bed pans.

In a recent column titled Doctor and Patient: Nurses’ Role in the Future of Healthcare, surgeon-columnist Dr. Pauline Chen debunks this notion, highlighting how the medical profession, administrators and third-party payers, either intentionally or not, have relegated nurses to the sidelines of the healthcare policy debate. Nursing is heading in a direction of higher standards in education and patient care with greater visibility as patient advocates. This can only be for the betterment of patients, particularly if embraced by physicians and hospital leaders. One hopes that nurses will play a greater collaborative role in all levels of medical care and follow up, resulting in a true team based approach to patient management. A team based, hospital unit model for safe patient care, with active decision making by nursing, is well described and championed by Dr. Peter Pronovost in his book Smart Hospitals, Safe Patients. This is a must read for all physicians, nurses and patients.

On a different note, I was interviewed, for the same column, different article, about glove use at the bedside and how healthcare providers are literally and figuratively losing touch with patients. 

More on that later.

Book Bound

In this week’s Travel section of the NY Times, there was a featured article on the Mission District of San Francisco, an area replete with independent bookstores, cafes and theaters, a veritable Mecca for bibliophiles of all stripes and colors. At the article’s end, I was ready to pack my bags for a literary destination vacation. One of my favorite activities in Richmond is strolling through Cary Town and the Fan district with my wife and dog, popping into used bookstores such as Chop Suey Books and Black Swan Books.

This article reminded me about a very cool read that I picked up in Argentina last August.  The book, titled Nadie acabará con los libros (No one will finish off books) is a true book lover’s book on books. Written as a series of interviews and discussions between Italian literary great, Umberto Eco and French screenwriter and book collector, Jean-Claude Carriere, the manuscript covers literary history, printing, and bookbinding, with beautifully interposed commentary on culture in general. This is a real gem from two men who revere books for their words and for their visual and tactile beauty. The authors argue that despite the Internet, blogs, and other digital media such as electronic books, there will be a continued need and preference (by some) for words in print.

When the power is out, the Internet is down, the Kindle has lost its charge or when I need to simply endure a nuclear winter, at least I will still have a book or two to keep me occupied! I hope that conventional books do not become such a rarity, confined mostly to niche followers, like vinyl records, which, despite the recent resurgence, are largely for the turntables of music lovers.

Richmond City FC Copa Navidad 2010: No losers, Just Winners

Medicine is my profession and football (soccer) is my passion.  As I am near my expiration date as a competitive footballer, it is with great pleasure and pride that I was still able to mix both today.

Richmond City FC successfully completed its 6^th annual Copa Navidad charity fund raiser event. The Richmond City FC Blues faced the Maroons today for bragging rights.  Despite the match ending in a hard fought draw, the real winner was this year’s charity designee: Richmond’s Fan Free Clinic , which provides medical care and access to Richmond's poor and uninsured. 

Richmond City FC is proud to raise money this Holiday season to support the Clinic and its mission.

Thank you, Fan Free Clinic, for all that you do.

The Richmond City FC Blues

The Richmond City FC Maroons

Richmond City FC in the 2010 Copa Navidad

With Richard Corbett, Development Director of the Fan Free Clinic

Rock Stars in Medicine and Science

This month there is a glossy spread in GQ Magazine featuring the Rock Stars of Science. More information can be found on the organization's slick website. The Rock Stars of Science organization recognizes scientific achievement and popularizes medical research. Heavily featured are distinguished physicians and researchers in the fields of cancer, biology, genetics, Alzheimer’s disease, cardiovascular diseases and pharmaceutical research. While I am not sure how much of an impact this will have in generating interest, advocacy and research, it certainly cannot hurt, especially when researchers are featured along music greats such as Debbie Harry, Bret Michaels, Timbaland, Keri Hilson, Jay Sean, B.o.B and Heart.

Underrepresented in the Rock Stars of Science are physicians, researchers and advocates in the fields of health services research, public health, preventive medicine and infection prevention.  Gaining prominence in these areas is hampered, in part, by the funding shortage to support clinical and health services research. In a recent position paper, the Society of Healthcare Epidemiology highlights the dire shortage of research funding in infection prevention.  Further, research and advocacy in preventive medicine, healthcare access, health outcomes research or even hospital epidemiology does not typically lead to blockbuster discoveries.  Thus, it seems unlikely that health services researchers, healthcare policy advocates or epidemiologists will make the cut for the next Rock Star of Science photo shoot.

For a different perspective in medical rock stardom, I refer the reader to a manuscript in Academic Medicine, aptly titled, Rock Stars in Academic Medicine. The authors surveyed the Deans of 126 US medical schools discovering that the prevalence of rock stars was 1%-6% of full-time faculty. These high-performing faculty members at academic medical centers contribute to institutional prestige by success in basic or translational research, or by superb clinical programs and philanthropy.  Although medical schools are usually willing to provide extra resources to gain and retain these faculty stars, the return on investment is quite simply greater institutional prominence.

For one of VCU’s Rock Stars, I refer you to Dr. Michael Edmond’s blog.

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The New Fashion Bug

Breaking news from the fashion industry: The Juicy Couture store in New York City was closed owing to a bed bug infestation!

Bed bugs (Cimex lectularius) are historically associated with squalor and poor hygiene. Obviously, having cooties in the couture does not jibe well with a fashion house selling high end merchandise. This is traumatic for both retailers and shoppers.

Anyone in tune with the news is well aware of the re-emergence of bed bugs across hotels in the USA. Bed bugs bite and feed off of human blood. This usually produces some form of skin reaction and irritation/itching.  As bed bugs are blood feeders, there are concerns about the transmission of infectious diseases. Theoretically, bed bugs could transmit hepatitis B, C, HIV, Lyme disease and other blood borne pathogens. To date, however, there is not a single proven case of an infectious disease passed on to humans by bed bugs. A nice review of this nefarious insect was recently published.

The real trauma is one of physical (itching) and psychological discomfort along with lost revenues in the case of retailers and hoteliers. This definitely gives new meaning to the term Fashion Bug.

Antiretrovirals Before Sex

There is a recent publication in the NEJM titled: Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men. A very scholarly and well constructed blog-commentary was just written on this by my colleague, medical blogger extraordinaire and very good friend, Dr. Michael Edmond.

In brief, the investigators assigned 2499 HIV negative men or transgender women who have sex with men to receive a combination of two oral antiretroviral drugs or placebo once daily. All subjects received HIV testing, risk-reduction counseling, condoms, and management of sexually transmitted infections. After a maximum of 2.8 years in follow up, a 44% relative reduction in the incidence of HIV was detected in those taking the antiretrovirals. The absolute risk reduction was only 2.4%.

I am by no means conservative and generally welcome new perspectives and ideas to challenging medical problems, however, I simply cannot get excited about this study.

My reasoning is as follows:

• The findings may be efficacious in a controlled study but will likely not be effective in the real world. Why?
• Adherence to medications is always a problem, without oversight from study personnel, adherence in the real world will be less than ideal, compromising the protective effect off the antiretrovirals
• Antiretrovirals have side effects, further compromising efficacy.
• In the event that there is poor adherence, prolonged, erratic use of antiretrovirals will lead to drug resistance, compromising the efficacy of treatment when one does have HIV/AIDS
• This strategy is costly. Antiretrovirals cost $10,000 + per annum. Will third party payers allocate valuable resources for ‘preventive’ antiretroviral services when other preventive measures such as mammography, colonoscopy, cholesterol screening and smoking cessation programs, all of which are already underutilized, are likely to have a greater population based health effect?
• This strategy will only work for people who have insurance and access to healthcare. The USA still fails to provide universal healthcare to its citizens. Thus, broad based implementation of this strategy does not seem likely.

Perhaps we should aggressively promote safe sex, condom use, and universal testing for HIV in all medical settings.

Call me old fashioned.