Leaders in Medical Education

Dr. Alexander Djuricich, Associate Dean for Continuing Medical Education at Indiana University

Thasin Jaigirdar
Sep 24, 2014

Dr. Alexander Djuricich is Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis. His areas of interest include quality improvement and patient safety, competency assessment, how doctors think and learn, physician involvement in social media, and medical education for residents and faculty. He also blogs about medical education and can also be found on twitter @MedPedsDoctor.

What drew you to become interested in medicine and pediatrics and internal particularly?
The variety of patients, and seeing different things every day, is what drew me to combined internal medicine-pediatrics (or “Med-Peds” for short).  I originally enjoyed pediatrics, and was planning on a career in it, but my medical school had 5 months of required internal medicine rotations scattered in the 3rd and 4th years.  When I spent 2 months on the required sub-internship rotation at the beginning of my 4th year, I knew that I could not give up caring for adults, and thus decided to add internal medicine to my future; thus, I decided on “Med-Peds” early on in my 4th year (which is relatively late).  It has been exciting to be at an institution that is so supportive of Med-Peds, not only in training residents to be Med-Peds physicians, but also in hiring them for a variety of positions from primary care to hospitalist to certain niches of subspecialists. I love having a voice in two separate departments, and meeting new people all of the time.

What do you believe are the toughest challenges aspiring doctors face today?
Staying true to why one goes into medicine (for humanistic reasons) while still understanding the business aspects necessary to survive, is one of the biggest challenges that we face.  Our medical students last year created a conference called the FIRM conference: Finding Inspiration and Resilience in Medicine.  This is one way to take a step back and reflect on what really matters in medicine, and recall that physicians and other health care providers themselves are people, just like the patients that we care for.  We also have families, and have to think of caring for ourselves as much as we care for our patients.  Medicine has to address the burnout issue.  The data are staggering: doctors are more likely to have alcohol abuse problems, are more likely to think about and act on suicidal thoughts, and are more likely to have anxiety and depressive conditions.  The more we can support our own, tackle this head on, the better we will be for it.

A second one is trying to know everything.  Learning in medicine nowadays is like drinking from a fire hose.  You’ll get some in, but much more will spill all over the place.  The successful aspiring doctor will be ok with that, while the struggling one will focus too much on cleaning up the spill!

I see that one of your areas of interest includes physician involvement in social media. How do you foresee social media impacting medicine going forward?
We are all so busy.  Think about the impact of speaking with multiple patients one-on-one, saying the same thing over and over, versus communicating with many one time, via social media platforms.  It has the potential to provide advocacy messages for the things that matter (e.g., “flu shots are now available in our clinic; please call XXX-XXXX to arrange getting your flu vaccine”).  The challenge is that learning the new skill of “how to do social media” on top of everything else sometimes turns off physicians (particularly older ones).

I see social media playing an impact with respect to finding alternative ways to reach our patients. We need to reach our patients through any means that they are willing to listen.  Since so many people are now communicating via this route, we in medicine need to integrate how we communicate with how our patients wish to receive that communication.  If that medium is a social media platform, then so be it.  What we have to be careful of is not to violate HIPAA.  As it stands in 2014, it is not ok to tell my patient in a Facebook post to double the dose of her blood pressure medicine.

Let’s take an example of a doctor caring for patients with allergic conditions.  If a common reason for those allergies is exposure to dust mites, then think about the impact of that doctor creating a two-minute video on YouTube, placed on the doctor’s practice website, that explains to patients how to avoid exposure to dust mites.  The message needs to be simple, straightforward, and to the point.  That would not be hard to create, yet would be a great resource that brings patients in, teaches them, and can save time in the office when the patients are actually in the office.  A physician who models this perfectly is Dr. Wendy Sue Swanson, from Seattle, who creates many such videos for her practice; check out her many posts at “SeattleMamaDoc 101” (for the record, I have not yet met Dr. Swanson in real life).

In addition, social media provides another forum for how we can communicate with each other.  One of my favorite ways to hear from others (including medical students and trainees) is the Twitter “#meded” chat on Thursday nights, 9 pm EST.  It is an hour well spent learning from others about a variety of medical education topics.

In summary, I see four ways that physicians and other health care providers can meaningfully use social media.  The first, to treat patients, is not currently recommended in 2014 in current social media formats.  The second is to teach others (that is, to disseminate information).  The third is to learn from others (that is, to receive information from others).  The fourth is to advocate, both for our patients and for our profession.

Can you talk on behalf of life-long learning in medicine and its importance?
Our medical school has been competency-based for well over 10 years now, and one of the competencies we want students to achieve is lifelong learning.  Within this framework, I’ve been giving a session to beginning 3rd year medical students for several years now about the importance of lifelong learning.   One of my favorite slides is literally showing a page out of the Merck Manual from 1966, which describes the treatment for acute myocardial infarction (MI), or “heart attack”.  In this textbook from 1966, the treatment for acute MI at that time was to admit people to the hospital, give them strict bed rest, tell them to avoid having a bowel movement (so as not to “stress” or “strain” the heart), and give them phenobarbital (a “downer”).  My, how things have changed!

What I think is important for learners nowadays to understand is that what we learn now will absolutely change in the future.  It is not important to necessarily know everything, but rather how to obtain that information.  I still have my copy of Harrison’s Textbook of Medicine from my intern year in 1994.  The section on congestive heart failure, one of the most common conditions seen in US hospitals nowadays, says that beta blockers are CONTRAINDICATED in heart failure (for those interested in why that was the belief, beta blockers are negative inotropes, which was felt to make the heart squeeze not as well, which could then lead to worsening symptoms of heart failure).  Now, they are standard of care.  I have used this example to teach residents about lifelong learning for several years now, but I now also spend time overseeing continuing medical education at my institution.  The impact on practicing physicians is critical, and physicians must really know how to access information today just as much as knowing what the information is.

The ramifications of this are really interesting, because the ways that one documents staying current in medicine nowadays is known as “Maintenance of Certification”, completed through the individual boards of the American Board of Medical Specialties.  Currently, it is still required that physicians “take a test” (it formerly was a written test, but now is done on a computer).  Many physicians now are questioning this, asking why doctors need to memorize facts if in the “real world”, they look things up.  I don’t have a right answer to this, but it is certainly a tough question, and one worth pondering as medicine continues to evolve.

What are some changes you would like to see in the healthcare system today?
I have lots of thoughts about changes to the healthcare system.  Here are just a few of them.

  1. Please don’t devalue primary care.   I am still trying to figure out why so many medical students write something to the effect of: “I want to help people in primary care settings” when applying for medical school.  Yet, when it comes time to make decisions about a career choice, they shun the option of a career in primary care.  Are we “beating it out of them?”  Are they getting mentors who are subspecialists saying “Why would you do primary care?  What a waste?”   I don’t know the right answer, but I am concerned.  A phenomenal piece on the problems of overspecialization was just written in Time magazine on August 19, 2014, by Dr. Sandeep Jauhar, entitled: “One Patient, Too Many Doctors: The Terrible Expense of Overspecialization”.  It is absolutely worth a read.  Having a higher ratio of primary care docs to specialty docs has been proven to reduce costs, without reducing quality.  I hope that we can get future physicians to see this, and respond by choosing meaningful careers in primary care.

  2. Along the same lines, can someone at a high level please stop the insanity of useless paperwork that is driving doctors nuts?  I signed a form 4 separate times to give approval for renewal for a patient of mine with cognitive impairment and incontinence to receive adult diapers.  This patient has needed these for years.  Justifying the “medical reason” for this on a paper, with a detailed explanation of why—someone in a position of authority needs to stop this.

  3. I would like to see more of an emphasis on clinical reasoning (what I call “thinking like a doctor”) in medical education, and less on band-aids that have been put in place to account for other regulations and mandates.  I have studied handoffs in teaching hospitals for several years now.  We spend more time preparing for and doing handoffs than we do listening to the patients and describing our thought processes (what some call “differential diagnosis”) about what the patient’s condition is.  While I believe very much in the importance of a good handoff, it is worthless if the information in it is flawed from a hurried intern who is just trying to meet duty hours and “not violate duty hours which may get them in trouble”.  One of my Med-Peds colleagues did a time study of interns in the hospital.  They spent a grand total of 12% of their time on direct patient care.  You can guess what other areas were more than that—computer time!

  4. Trying to find the happy medium between doing what is right for the individual patient, yet looking at population health as an area to improve the health of the communities in which we live.  Medicine traditionally has focused on “it’s all about the individual patient”.  However, in case you haven’t noticed, we have a crisis of epidemic proportions with respect to the cost of healthcare in this country.  We have to address how much we spend, and think about things that will have an impact on populations.  I applaud the Choosing Wisely campaign for tackling this issue.  One other area to think about is public health.  The funding for public health is not where it needs to be, despite knowing that investment in prevention and public health saves money in the long run.  Medical TV shows glamorize acute care heroes coming in and saving the patient just in time, whereas public health and preventive strategies just aren’t “sexy”.  But they are surely important, and their impact is long-lasting.