December 12, 2014

Rationalist Back to the Future: "It's About Time."

Anxiety welled up deep within me, not knowing the sort of world we lived in.

It's tough when the world as you know it explodes in a flash of sparking light and flaming tire trails.  

Now... (whatever THAT word meant)... *Now*, I didn't know whether or not the very fabric of the universe would unravel with an accidental bootstep unto the wrong butterfly.  I had read about that in a Ray Bradbury novel.  It disturbed me greatly that such an event could actually come to pass.

Did my personal curiosity and gnawing hunger outweigh the existential threat I posed to ALL OF EXISTENCE?  Surely not.  Yet I couldn't live in an undeveloped neighborhood that wouldn't be built in the next five to ten years.  I didn't want to starve to death because I was too afraid to walk into Lou's Cafe and order a Pepsi Free.  I needed safe harbor.  And if I was going to find a quiet haven where I could make the least impact on history, it would be here.

I checked the address again: 1640 Riverside Drive, Hill Valley.
I didn't bother to check the time on my watch.  Time was irrelevant, irrevocably broken.  Oops.

---

I took my hands out of the pockets of my vest and flexed them several times.  They were stiff and bone-white.  Ever since I realized it was November 5th, in the year 1955, my hands were clenched tightly to minimize contact with the outside world.  Now, I wiped them nervously on my jeans and walked up the dark driveway.

Hesitating briefly, I rapped the door and stepped back, not knowing who or what to expect. The door flew open with such frenetic gusto that I knew even before laying eyes on him, that it was the Doc himself.  

"Listen, Doc..."
"Don't... say... a word!" His eyes darted around his front lawn and he dramatically yanked me into his living room.  Normal Doctors of Experimental Tinkering and Science wore starched white lab coats.  Doc Brown on the other hand -- he wore a silvery nightgown.  His frizzled white hair was barely contained within a device that could best be described as an inverted colander with colorful lights dancing along a geodesic framework of electrical wires extruding from various contact points.

"I don't want to know your name, I don't want to know anything about you!"  I knew better than to interrupt the Doc when he was in one of his moods.  The wild look in his eyes sparkled with the manic light of someone who hadn't slept in a week.  The best you could do was hang on and play along.

He licked a suction cup and without my consent, he slapped it against my forehead.

"I'm going to read your thoughts," he announced with bravura, as he fussed with some dials on an electrical monstrosity that sparked and smoked in equal measure.  This device was apparently supposed to be an electroencephalogram.

"Let's see now, you've come here from a great distance?" He grasped at his metallic helmet for cognitive support.
"Even if you're only trying to pull more information out of me through cold reading, grasping at the high-probability straws, you're correct."
"Quiet! Don't tell me anything."  His brow furrowed in a mockery of concentration.  "You want me to buy a subscription for the Saturday Evening Post?"
"You were on such a roll! Just stay evasively general and reinforce chance guesses."
"Not a word, not a word, quiet now!"  Irritation curled his lips and his fingers as he waved me off.  "Uh... umm... Donations!  You want me to make a donation to the Coast Guard Youth Auxillary!"

"Your persistence in highly specific statements are not serving you well." I pinched the bridge of my nose.  "Moreover, let's talk about your mind reading device.  Have you ever heard of Dr Hans Berger?  In 1924, he recorded brain waves in an attempt to discover the powers of telepathy.  He ALREADY INVENTED THIS DEVICE.  Now, neurologists use EEGs to detect sleep wave patterns and epileptic foci.  But they have NEVER been able to detect surface thoughts.  Especially not by using a small rubber suction cup and an electrical device more likely to trigger a seizure in your brain than it will read mine!"

It shocked me.  Was this really the brilliant mind that taught me the rules of rationality and the methods of scientific inquiry?  Would this really be the scientist who would break the fourth dimension with backyard materials, Christmas lights, a DeLorean and a nugget of Plutonium?  I was appalled, to say the least.

I decided to end this farce of science.  "Doc... I'm from the Future..." I announced, as I yanked off the suction cup.

"I'm from the Future ... Scientists Youth Auxillary!" I amended, seeing his face starting to turn crestfallen.  I was not lying per se.  After all, I was his lab assistant in the year 1985.  Or yesterday, by my biological clock.
"Your device TOTALLY works and it TOTALLY won't give you a seizure."  His goofy grin didn't waver against the face of sarcasm.
"And I have a brief survey for my school project that I have been asking all of the Doctors of Experimental Tinkering and Science."
"It's about time!" he said triumphantly.  "I knew you would come."

"You're right... it IS about time," I said slowly.  I guided him towards his garage with blueprint plans in hand.  "But not quite in the way you're thinking about.  You won't get the recognition you deserve -- not for another 30 years or so, I'm guessing..."

---

Together, we could discover whether or not I was a creature displaced from my time-stream in an alternate universe off-set by thirty years.  Perhaps I was a fifth dimensional being with powers to see time in a non-linear fashion now that the illusion of causal time-event occurrences had been cast away from my reality.  Perhaps the changes I made here in 1955 would be reflected further down my time-stream in 1985 in ways I would become aware of through some sort of memory-altering sequence.  Perhaps time existed only as a mathematical unit and I had only "rewound the clock" backward to a point in a static time-cone that projected both forwards and backwards in a timeless physics model of reality.

There was one thing I was certain of.  Doc Brown's inspired hand was guided by rational mind at odds with his own irrational behavior.  I often wondered why he picked me to be his apprentice -- if it weren't for his guidance, I'm pretty sure I would have been like all of the other high schoolers who enjoyed skateboards and cars.  He would occasionally have me read very specific books, like the "Sound of Thunder" by Ray Bradbury or neurology texts on EEGs that... that were hints, telling me he knew who I would become!

Doc Brown was not the brilliant mind that had been grooming me to become a future scientist.  I was grooming myself.  It was future-me, in the past, directing him behind the curtain.  A ruse, a long-con, preparing me for this very moment of realization.  It would be a very long road until I could safely test my theories on time and avoid paradox.

I had twenty five years to break the news to the Doc that I was an accidental time-traveller.

I had thirty years to save the Doc's life.

In the meantime, I would avoid destroying the universe.

December 05, 2014

Semi-Public Announcement: seeking pre-alpha comments on "Medics and Magics"

I posted on G+ under "Fantasy Writing/World Building" and cross-posted on reddit/rational tonight.
http://www.reddit.com/r/rational/comments/2ofzm9/of_medics_and_magics_story_synopsis_for_a_new/

This represents my semi-public announcement for my hobbyist foray into fantasy writing in the style of free web fiction ala "Worm" or "Harry Potter and the Methods of Rationality."

The idea for my alt-blog has been a personal dream to unite all of my loves (science, medicine, and fantasy) into a coherent package that reflects my identity.  That is NOT to say that my characters will be an "author self-insert" or a "podium" to share my personal views on the world.  My main drive is to build a fun cool fantasy world that stimulates my imagination and pushes me to explore our world further in a rational, empirical fashion.

I recently discovered that Diane Duane has continued to publish books for her Young Wizards series that I read in elementary school with the first book: "So You Want to be a Wizard."  Duane comments that the more fantasy writers mix truth in with a lie, the stronger it gets.

http://en.m.wikipedia.org/wiki/Young_Wizards
https://www.goodreads.com/author/quotes/11761.Diane_Duane

'Tis my goal to strengthen Iatropia to a fun new level for fantasy fiction.  I'm trying to set myself up for success, so please check out the link above and comment!

December 02, 2014

My Paradigmatic Assumptions

As a family physician with an undergraduate degree in cellular/molecular biology and a relationship-centric graduate and post-graduate training, I possess a blend of different paradigmatic assumptions.  On the one hand, positing initial conditions with cause-effect relationships seen in the physical sciences, I believe in the ability of Science to justify and explain phenomena that we experience. I take it on faith that we all experience slivers of a True Reality through our perceptions.   (This is called Positivism by my own admission of prior ontological and epistemological  programming as a scientist.)  On the other hand, I also believe that a simplistic, reductionist approach pursuing an "objective, external truth" removes a key humanist component in appreciating a "shared social 'reality'" and a "shared social good," a category in which non-physical phenomena dwell.

I do believe there are demonstrable benefits in medicine and science for pursuing an external, objective "one Truth, one Disease" reality when a physician meets a patient and diagnoses them, with say, hypertension.  However, I also acknowledge that our collective beliefs shape our "shared social 'reality'" and our approach to disease.  Each person possesses a unique blend of background human in-born traits like race/sex/personality.  In contrast, sociocultural and epigenetic factors like ethnicity/gender/socioeconomic status. are constructed over time atop these background traits and become structural fixtures as well.  (This is called Constructivism in which truth only gains meaning [and is only known] through social construction.)

Two patients with the same disease may act in very different ways, since they have different constructs.  Similarly, two physicians may act very differently, depending on whether or not they treat the disease... or they treat the patient... the community... or even society itself.

I plan to propose a robust and evocative model that addresses the philosophical differences between the Positivist and the Constructivist, as well as the potential conflicts between patients and physicians.  Firstly, [my thesis] draws upon the positivist principles of natural order-assembly present in physics in phase-change states, and biology in the synthesis of organic molecules like proteins or DNA.  Secondly, it accounts for constructivist scaffolding structure of inborn traits, epigenetic components, sociocultural factors, and educational influence as the basis for idea generation.  Concepts like a disease-diagnosis form, catalyzed by principles of pathophysiology, cognitive "toolkit" heuristics, or past experiences.  The core of the diagnosis is primed by an organized, medicalized mental case presentation pattern-matching to prior illness scripts (or instance scripts.)  In looping back and engaging patients in education and shared-decision-making, aligning a patient's self-perception of disease empowers them to change themselves in cases where a disease is in part a social construct -- moving from a disease-oriented model to a patient-oriented health model.

For example, a physician may react to a patient with hypertension as a machine with an elevated number that can be titrated downward with successive dosing of medications to relax the internal blood pressure.  In contrast, another physician may view hypertension itself as a result of structural violence resulting from generations of low socioeconomic status, poor education, low literacy, living in a food desert without access to healthy low-salt options, lacking safe places to exercise and all things considered, a lower priority given to costly medications relative to other financial imperatives.  Yet another physician may try to advocate for policy on improving access to care and reversing the obesity epidemic.

Alternately, the relationship of the doctor-patient on the subject of an "invisible, risk-factor" disease like hypertension or early stages of type II diabetes is strictly paternalistic.  The physician requests a bond of trust that the number they report (be it blood pressure or blood sugar) is elevated to an unhealthy or possibly even dangerous degree and the patient has to decide whether or not this is credible data.  Do some patients see a physician in the same light as a mechanic who may try to convince a naive car owner to pay for additional parts and labor for something that they don't understand?

December 01, 2014

Strategic Plan for Medical Education: A New Constructivist Model of Cognition

A New Model of Cognition

My main driver for getting a Masters degree in Medical Education was to have the opportunity to do high-level research in the field of clinical reasoning and medical decision-making.  Even as a fourth-year medical student tutoring first-year students through their Problem-Based Learning seminars, I was very keen on the process of developing a differential diagnosis and becoming an expert diagnostician.  I recently discovered an old email showing that I looked through the literature with a librarian for this exact question:
Hello, I am a fourth year medical student interested in conducting a research project on the cognitive process of generating a differential diagnosis (ddx) geared to second year medical students…  the project I want to do involves teaching second year med students how to be systematic in making a ddx and avoid the pitfalls, with a pre-unit and post-unit survey to measure their progress and confidence in differentials.  Some of the questions I might ask are:·         How many ddxs do you routinely make in PBL sessions on the first page of your [case]?
·         How often do you feel that you have the right, specific diagnosis in your HCPs before the conclusion of the case?
·         How confident are you that you have a broad number of ddxs in your [case]?
·         How would you rank your ability to generate a ddx compared to your peers?
·         Pick the best definition for the following terms: heuristic, bayesian analysis, attribution error, pre-test and post-test probability
I have done some general searches on Pubmed looking for articles on medical education and differential diagnosis, but I have not found any literature that has done any similar projects in the past.  It would be helpful to know if there are any surveys that have similar assessment measures.

I recently discovered a new constructivist theory that explains the cognitive process of clinical reasoning that I am calling “[redacted, pending publication]”.  In a nutshell, the current dominant dual-process model involves weighing judgments as Type I automatic thinking vs Type II deliberate thinking, in which we toggle between the unconscious heuristics/biases brain and our rational, conscious brain.  I think this is incorrect.  I feel that we form ALL ideas as spontaneous, self-assembling “crystals.”  The formation of diagnostic crystals is catalyzed during the brewing process by nucleation on heuristics/rules/prior experience under the right cognitive conditions.   (see Appendix 1 for details)

My vision is that in the next 10 years, I will change the way doctors think about clinical reasoning.  I plan to accomplish this in the next 6 months by doing research to justify my “[thesis]” theory through a demonstrative literature review for my Dundee thesis project.  I plan on showing how my new theory meets the criteria of quality (trustworthiness, transferability, dependability and conformability) as well as authentic criteria of fairness (ontological, educative, catalytic and tactical) as outlined by Guba and Lincoln (1989).  Then, I plan on working as a clinician/researcher and in the next 5 years, I will publish articles on this subject in several major journals (aiming for Academic Medicine, Medical Education and Psychological Review where most of my literature review has derived).   In the next 10 years, I write a book on “[redacted]” as a new theory on the psychology of judgment.

These are “big, hairy audacious goals (BHAGs).”  I will share my vision by telling stakeholders that "We will change the way doctors think about clinical reasoning, using procedural methods to ---[to be revealed]."  According to Collins and Porras,
“A true BHAG is clear and compelling, serves as a unifying focal point of effort, and acts as a catalyst for team spirit... A BHAG engages people—it reaches out and grabs them. It is tangible, energizing, highly focused. People get it right away; it takes little or no explanation.”  (Collins and Porras 1996)
The idea of changing the way all doctors think is compelling.  Even though the theoretical concept will need to be explained, I feel that everyone intuitively“gets” the concept that our brains bubble and brew and sometimes, while we are in the shower or out on a walk – BAM!  An idea comes up seemingly from nowhere.  "[The thesis]" model elucidates this process and invites people to maximize their chances of creating “Eureka!” moments.

My institution has a Department for Clinical Decision-Making (CDM) that is well-known for its leaders in the field of CDM.  (Tufts, n.d.)  We have a course for first-year medical students called “Introduction to Clinical Reasoning” that I will be building on by preparing fourth-year medical students for residency in an elective called “Family Medicine Exploration Elective” in which I plan on exploring the concepts of flow and intuition for expertise development.  In order to gain alignment with the CDM department, I plan on utilizing Kotter’s model (1996) for Change Management, to determine how to best accomplish our shared goals.  I will share a hybrid model that adds in Heath and Heath’s “Switch” concepts (2010) that use a visual analogy that making change is hard, like a human rider trying to force an elephant to walk down a path.  (Appendix 3.)




The first step in the hybrid Kotter-Heath-Heath model is to Motivate the Elephant.  This means that I need to “Find the Feeling and Create a Sense of Urgency.”  I plan on instigating a change with a shift from the analytical Bayesian approach that the Department for CDM is used to and publishing my radical new theory which is an intuitive “adaptive toolbox” approach that Gigerenzer (2002) utilizes.  (Appendix 2.)  Convincing the majority of people that change is needed (Kotter recommends convincing at least 75% of managers that the status quo is more dangerous than the unknown) will hopefully prompt a forthright discussion, leading to the next step.

Next, I will Shape the Path.  This means that I need to “Rally the Herd and Form a Powerful Guiding Coalition.”  My fellowship advisor can facilitate a meeting with various members of the CDM department to discuss the implications of my research.  I need members with enough power to lead a change effort.  Kotter specifically encourages the team to work outside the normal hierarchy:
“This can be awkward, but it is clearly necessary. If the existing hierarchy were working well, there would be no need for a major transformation. But since the current system is not working, reform generally demands activity outside of formal boundaries, expectations, and protocol.” (Kotter 2007)

Together with a group of change agents, we will Direct the Rider.  In other words, “Find a Destination and Create a Vision.”  My preliminary vision statement to share with stakeholders is: "We will change the way doctors think about clinical reasoning and help them [in ways outlined in future works]."  I would like to focus on medical education by changing our curriculum for PBL and clerkships to include these scaffolding concepts.  I already have a hand in creating a new fourth-year FM elective that will integrate these principles for outpatient primary care.

Providing rational explanations is not enough to push the broader community to change.  Next, we will Motivate the Elephant by “Pointing to the Destination and Communicating the Vision.”  If we are going to push all physicians to change how they think about generating a differential, we have to tap into their feelings.  All physicians strive to become expert diagnosticians and are afraid of missing the diagnosis.  Achieving “expertise” is nebulous, but Ericsson (2004) provides us with a clear goal.  Deliberate practice and the acquisition and maintenance of expert performance require 10,000 hours over 10 years of practice.  It is my belief that we can get the attention of various parties within the institution with the following message:
  •  Medical students: “You CAN dedicate 160 hours of 10,000 hours towards becoming an expert in Primary Care reasoning in a month-long elective.”
  • Family Medicine Residents:  “You CAN accumulate around 2,000-3,000 of the 10,000 requisite hours towards becoming an expert in clinical reasoning”
  • Family Medicine Faculty: “You will only be supervising residents for ~300 hours of primary care clinical reasoning in a year.”  How do you plan on making the best use of this time?
With enough medical students, residents and faculty sufficiently motivated, we need to Shape the Path and “Tweak the Environment and Remove Obstacles.”  This involves revamping the first-year medical student “Introduction to Clinical Reasoning” curriculum so it is developmentally appropriate.  I would propose moving material like illness scripts, better suited for the onset of clinical exposure in the third-year.  Additionally, memorizing numerical likelihood ratios for determining post-test probabilities is not practical for real clinical practice.  Research by Czerlinksi, Gigerenzer and Goldstein (1999) has shown that utilizing the Tallying heuristic (Appendix 2) can achieve a higher predictive accuracy than multiple linear regression analyses when applied intelligently.  After the concepts of numeracy are established, we can change these burdensome LR to more teachable concepts like the Tallying method.  A smartphone “app” can be created to make the cognitive checklists we will design freely available for everyone to use (and hopefully if someone else does this grunt work for me... they will also make it free to the public!).  Many of these ideas are nontraditional and risky, which is encouraged (Kotter 2007.)

Finally, we will establish a set of Milestones for the Rider and the Elephant to achieve.  Typically, this is done by “Following the Bright Spots and Scripting Critical Moves” for the Rider to perform, as well as “Shrinking the Change and Recognizing/Rewarding Contributors” so the Elephant isn’t frightened and feels motivated to contribute.  However, my ideas are completely novel (my initial literature search in 2009 and updated search in 2014 provided no leads), so I will have to forge a path ahead.  I hope we will be able to set up curriculum for all years of medical school and my family medicine residency to include relevant clinical reasoning topics.  Personally, I have already achieved some milestones for myself in terms of spreading this information: designing medical student elective curriculum, presenting a Grand rounds on this subject in 2012, and give a regional conference on this topic in 2014.  My future milestones will include presenting a national conference on my thesis material in the next 3-5 years as well as publishing in major journals in medical education and psychology.    I hope to give a TED Talk on the subject of [redacted] as an analogy for judgment in general and spice it up with some memorable clinical examples.  Eventually, I will strive to write a book.

Kotter has a few more steps on “Systematizing Wins” and “Institutionalizing New Approaches” that will not matter to me specifically, unless I become a department chair or some other leader in medical education.  The vision statement and milestones I’ve set up for myself are ambitious and I would be happy even if I can make a local change within my residency.

In summary, one of my goals in life is to become a master clinician and systematize an approach for clinical expertise.  I feel that my theory on [redacted] is novel and opens up a lot of avenues for future research, medical education and continuing professional development.  The hybrid Kotter-Heath-Heath model I outlined above will help me align my personal goals with my institution.  It also helped me develop a key strategic plan that I can enact to become a leader in the field of Clinical Decision-Making and change the way doctors think.



Appendix 1.  [redacted theory.]


Appendix 2: Gigerenzer’s Adaptive Toolbox.




Combined Model for Change Management  (Heath 2010 and Kotter 2007)
1.       Motivate the Elephant: Find the Feeling and Establish a Sense of Urgency
a.       Knowing something isn’t enough to cause change.
b.      Make people feel something.
2.       Shape the Path: Rally the Herd and Form a Powerful Guiding Coalition
a.       Behavior is contagious.  Help it spread.
b.      Assemble a group with shared commitment and enough power to lead the change effort
c.       Encourage them to work as a team outside the normal hierarchy
3.       Direct the Rider: Find a Destination and Create a Vision
a.       Change is easier when you know why its’ worth it.
b.      Create a vision to direct the change effort
c.       Develop strategies for realizing that vision

4.       Direct the Rider: Point to the Destination and Communicate the Vision
a.       Change is easier when you know where you’re going.
b.      Use every vehicle possible to communicate the new vision and strategies for achieving it
c.       Teach new behaviors by the example of the guiding coalition.
5.       Shape the Path: Tweak the Environment and Remove Obstacles
a.       Remove or alter systems or structures undermining the vision
b.      Encourage risk taking and nontraditional ideas, activities, and actions
6.       Milestones:
a)      Direct the Rider: Follow the Bright Spots & Identify Potential Wins
b)      Direct the Rider: Script the Critical Moves & Engineer Wins
c)       Motivate the Elephant: Shrink the Change & Recognize/Reward Contributors
 
7.       Systemize the Wins
a)      Motivate the Elephant: Develop/promote/hire visionary employees
b)      Motivate the Elephant: Tweak the Changes
a.       Reinvigorate the change process with new projects & change agents
c)       Shape the Path: Tweak the Environment and Build Habits
a.       Use increased credibility from early wins to change systems, structures, and policies undermining the vision
8.       Institutionalize new approaches
a)      Direct the Rider:
a.       Articulate connections between new behaviors & corporate success
b)      Shape the Path:
a.       Create leadership development & succession plans consistent with the new approach
Heath, C. and Heath, D. (2010) Switch: How to Change Things When Change is Hard.  Broadway Books: New York.
Kotter, J. (2007) Leading Change: Why Transformation Efforts Fail. Harvard Business Review. Jan 2007.  Reprint R0701J.




References

Croskerry, P. (2003)  The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them.  Academic Medicine. 78(80) pp775-780.

Collins and Porras (1996) Building Your Company’s Vision. Harvard Business Review. Sept 1996. Available from: https://hbr.org/1996/09/building-your-companys-vision

Czerlinksi, Gigerenzer and Goldstein (1999)  How Good are Simple Heuristics?  In G. Gigerenzer, P.M. Todd, & the ABC Reseach Group, Simple heuristics that make us smart (pp. 97-118). New York, NY: Oxford University Press.

Kruglanski and Gigerenzer. (2011) Intuitive and Deliberate Judgments are Based on Common Principles.  Psychol Rev. 118(1) pp97-109.

Gigerenzer, G. and Selten, R. (2002) Bounded Rationality: The Adaptive Toolbox. Cambridge, MA: MIT Press.

Heath, C. and Heath, D. (2010) Switch: How to Change Things When Change is Hard.  New York, NY: Broadway Books.

Kotter, J.  (1996) Leading Change.  Cambridge, MA: Harvard Business School Press.

Kotter, J. (2007) Leading Change - Why Transformation Efforts Fail. Harvard Business Review. Jan 2007. Reprint R0701J. Available from: https://hbr.org/2007/01/leading-change-why-transformation-efforts-fail/ar/1

Tufts Medical Center: Department of Clinical Decision Making.  Available from: https://www.tuftsmedicalcenter.org/patient-care-services/Departments-and-Services/Clinical-Decision-Making/Overview.aspx


November 16, 2014

Two Techniques to Make Swallowing Pills Easier

Quick Tip for your Patients:

Two Techniques to Make Swallowing Pills Easier:
"Pop Bottle" ~60% effective
"Lean Forward" ~90% effective!

Pill-Swallowing Annals of FM

(Cross-posted on the CHA Family Medicine Residency blog)

November 10, 2014

Number Needed to Treat in Severe Sepsis and Septic Shock to Save a Life = 4.

Teaching Pearl: In severe sepsis and septic shock, only 7 out of 10 survive.  the NNT for antibiotics (in general is 4.)  There is good evidence to consider broadening coverage if: there are risk factors of surgery or prior antibiotic use.
The prevalence-adjusted pathogen-specific number needed to treat (PNNT) with appropriate antimicrobial therapy to prevent one patient death was lowest for MDR bacteria (multidrug-resistant bacteria) (PNNT = 20) followed by Candida species (PNNT = 34), methicillin-resistant Staphylococcus aureus (PNNT = 38), Pseudomonas aeruginosa (PNNT = 38), Escherichia coli (PNNT = 40), and methicillin-susceptible S. aureus (PNNT = 47).
Conclusions: Our results support the importance of appropriate antimicrobial treatment as a determinant of outcome in patients with severe sepsis and septic shock. Our analyses suggest that improved targeting of empiric antimicrobials for multidrug-resistant bacteria, Candida species, methicillin-resistant S. aureus, and P. aeruginosa would have the greatest impact in reducing mortality from inappropriate antimicrobial treatment in patients with severe sepsis and septic shock.

They note a few other risk factors identifies by multivariate logistic regression analysis as: resistance to cefepime, resistance to meropenem, and presence of multidrug resistance, but these are less useful clinically since they can only be determined post-hoc.

November 09, 2014

Leadership - moving from models to reality

Leadership models illuminate areas for personal growth and development using various lenses to focus on different blind-spots.   My personal journey in leadership has progressed with fits and starts, finally gaining momentum as I moved into residency as I developed a personal vision of how I could and would lead.  I’ve discovered new skills, styles and situations to be a more thoughtful and deliberative leader.  Through anecdotes from residency, I will share my current progress.  Firstly, I will show my Situational Leadership in the clinic.  Secondly, I will show how my Leadership style has keenly sharpened under fire in a national organization.   Finally, I will discuss how Authentic Leadership has affected me.

Tackling New Leadership Situations in a Family Medicine Clinic and Residency
Our clinic has small teams for coordinating care with patient outreach.  We have weekly meetings to review our tasks like calling patients to come in for routine appointments, developing cancer screening scripts/protocols and other routine tasks.  As an intern, I discovered that leading a medical team on rounds in the wards does not work the same way as a multidisciplinary setting with a secretary, medical assistant and nurse.  For example, when I started working with “Jay,” a front-desk staff member, I needed to titrate my leadership downward to suit his level of development.   Following Hersey and Blanchard’s (1969) Situational Leadership II (SLII) model of supportive and directive behaviors, I started with a hands-off approach.  (Appendix 1)
Initially I used supportive “participating” behavior: High-relational, low-task behavior.  I gave “Jay” control of day-to-day decisions while I was available to facilitate problem solving.  I sent messages along with some tips on how to manage the work through the day.
However, the work was not completed at the end of the week, so I switched to a coaching “selling” style: high-relational and high-task behavior. I asked another front desk secretary to sit down and coach his outreach to give him tips on how to complete the tasks in a timely fashion.  
After a month went by, I sat down and used a directive “telling” style: low-relational, high-task behavior.  I gave him direct tasks and directly supervised him carefully.  Only under this level of scrutiny did I discover that his inbox was cluttered with multiple versions of my messages I kept sending to him that he was afraid to touch or act upon them without direct approval.

My initial problem was not matching “Jay” with his appropriate development level.   Directive and supportive behavior needs to match with the development level of the follower on a competence/commitment continuum.  I had initially assumed that “Jay” was a D3 employee with moderate/high competence, when in fact he was a D1-2 employee with low competence.   However, he does not have the associated "high commitment" level.  In order to work with him effectively, I need to help motivate him.

When I recognized the utility of the SLII model , I investigated Hersey and Natemeyer’s Power Perception Profile (1979) to assess what my preferences were for a utilization of various power bases and identify which type of maturity or development level best suited my preferences.  There is a spectrum of power bases necessary to influence people's behavior at specific levels of maturity: from coercive-connection to reward-legitimate to referent-information and finally, expert.  (Appendix 2)  My highest scoring preferences were in the highest level domains of Expert and Information.  According to Hersey and Natemeyer, this correlates with a high maturity follower and I work best with M3-M4 followers.  “Jay” is an M1 follower so a better method of approaching his situation would be to form strong connections with influential/important people in the front desk and provide small observable rewards for those who do well.  A criticism I have with this model is that it implies that low maturity followers respond best to “sticks rather than carrots” and it encourages a coercive power base over a reward power base in some situations.  While this may hold true in some fields like the military, I do not think that harsh discipline has positive effects in the healthcare field except to drive people away and hurt relationships.  Finding this leadership model lacking in some respects, I sought out other ways I could work better with a team.


Developing a New Leadership Style in the Committee of Interns and Residents
In residency, I signed up as a union representative and quickly rose through the ranks from regional delegate to hospital chapter president to state executive board member for the national organization.   During my fellowship, I have worked as an elected resident board member on the Committee of Interns and Residents (CIR), a U.S. national union organization for resident-physicians.  Connecting with other future leaders, having discussions about our collective residency mission/vision/values and developing national programming around these issues has been exciting and stimulating for me.  However, it took me two years to become the authentic leader we needed.

Initially I had a laissez-faire leadership style with a hands-off attitude.  During our monthly phone calls, I would mute myself and tune out while doing other work.  I was disengaged in the tasks and had only superficial relations with the other board members and senior CIR staff.  I was inexperienced and untrained in leadership.  I did not engage in an ongoing dialogue between the resident delegates.  I showed poor governance; I neglected to help develop policies for success and I did not monitor for policy compliance/adherence.  I engaged in what Blake and Mouton would term “Impoverished Management (1,1)” with “little contact with followers and could be described as indifferent, noncommittal, resigned, and apathetic.”   (Blake and Mouton 1985, Appendix 3)

However, at the end of my first year, we had an internal leadership crisis – the staff executive director was up for a 5-year term contract renewal and we found out that about half of the senior staff was dissatisfied with his management.  There were an unprecedented number of union negotiations ongoing in addition to new chapters being recruited while record amounts of chapter losses also took place.  As a result CIR suffered low staff morale, divisive internal conflicts, and a high attrition of key staff members through both resignations and firings.  I found myself face-to-face with the sinking realization that I was a poor leader in a situation where strong governance in a period of stress and change was critical. A series of emergency meetings by the board was called.  A key quote made by the ex-president has stuck with me.
We have been absentee landlords, holding the power and influence but letting our local staffers run the organization.”

In the past year, I changed from an “Impoverished (1,1)” toward a “Teamwork (9,9)” leadership style with high concern for results and people.  (Blake and Mouton 1985, Appendix 3)  In order to do so, I considered the personal frames of Expert and Informational power, my areas of strength.   I applied these personal frames toward knowledge development and relationship-building to better engage in concerns on results and people.  I became an expert on the subject of leadership through the Dundee course and used this competence to solidify a strong corporate mission, vision, values statement and five year strategic plan.  Energizing fellow resident board members, I developed strong relationships despite a growing division between two sides of the board and we were able to agree on core parts of a leadership development plan for our executive director.

 Here is a key passage from an email exchange during the discussion process that illuminates how I drew connections between steps of our strategic plan development, using George’s Authentic Leadership principles of “True North” (2007) and Collins’ and Porris’ “Big Hairy Audacious Goals” (1996)

"A compass, I learned when I was surveying, it'll... it'll point you True North from where you're standing, but it's got no advice about the swamps and deserts and chasms that you'll encounter along the way. If in pursuit of your destination, you plunge ahead, heedless of obstacles, and achieve nothing more than to sink in a swamp... What's the use of knowing True North?" – Abraham Lincoln
Imagine that CIR is taking a physical journey towards a destination.
We are the leaders of this group through the wilderness of residency.  We are the ones with vision and direction.  We are providing guidance.
Where do we want to go in the next 3-5 years?
We can walk towards a hospital and rally a group of dissatisfied residents, we can walk to a town hall and support legislation, we can go to a conference or class room and learn about something we aren't getting in our residency, etc.  … Some paths may lead us down dead-ends or take us on a long, expensive tangent.  Others may be shortcuts that attract new members or engage our current members to participate more in the journey.
Why are we walking down some paths and not others?
I feel that this is because deep down; we know what we want at the end of residency.  We know why we went into medicine.  And we are looking for ways to help our patients, to help our fellow residents and to pave the path and make it safer and higher-quality.  These are the core values.
We are aiming towards the “Big, Hairy and Audacious" True North.
Each step should take us a little closer.  Each activity we have should reflect a value … that provides the driving motivation to keep us walking.
                                                (abridged email, full exchange in attached leadership portfolio)
As George’s interviews with great leaders showed, Authentic Leadership is about something more than traits alone: “[the] team was startled to see that you do not have to be born with specific characteristics or traits of a leader.  Leadership emerges from your life story.”(George 2007)  This reflective exercise shows a few examples from my life story in residency and fellowship.

The components of Authentic Leadership model are self-awareness, internalized moral perspective “true north,” balanced processing and relational transparency.  (Appendix 4)  Reflecting on this model raised my awareness that developing Authentic Leadership meant two things for me. 
1) My relationship with “Jay” has struggled due to my “false front” and lack of transparency with my feelings.  I have been passive-aggressive in my leader-member interactions and I will strive to be more open without coming across as abrasive or aggressive.
2) Initially in CIR, I contributed to a culture of disengagement.  In a period of critical change, I recognized how I was complicit and at fault.  I helped shift the CIR executive board from a management organizing/staffing discussions toward a leadership paradigm with vision-boarding and coalition-building.

Moving forward in future leadership positions, I will be open and aware of my own personal failings.  I will center myself around my internal moral compass.  I will become even-keeled and measured in my emotions, thoughts, and actions.  I will develop deeper bonds with my team to find out what drives us all so we can pump each other up when we are down.  I will be an Authentic Leader.



Appendix 1: Situational Leadership



Appendix 2: Power Perception Profile
1.       Coercive power is derived from having the capacity to penalize or punish others. (French and Raven 1962)
2.       Connection power is based on connections with influential or important people… in which compliance occurs because they try to gain favor or avoid disfavor of the powerful connection.   (Hersey, Blanchard and Natemeyer 1979)
3.       Reward power is derived from having the capacity to provide rewards to others. (French and Raven 1962)
4.       Legitimate power is associated with having status or formal job authority. (French and Raven 1962)
5.       Referent power is based on followers’ identification and liking for the leader. (French and Raven 1962)
6.       Information power is based on the ability of an agent of influence to bring about change through the resource of information.   (Raven and Kruglanski  1975).
7.       Expert power is based on followers’ perceptions of the leader’s competence. (French and Raven 1962)





Appendix 3: Leadership Style Grid


Appendix 4: Authentic Leadership


Bibliography
Blake, R. R., & Mouton, J. S. (1985) The managerial grid III. Houston, TX: Gulf Publishing Company.

Collins, J. and Porras, J. (1996) Building Your Company’s Vision. Harvard Business Review.

George, B. (2007) Discovering Your Authentic Leadership. Harvard Business Review.   Reprint R0702H.

Hersey, P. and Natemeyer, W.E. (1979) Power Perception Profile -- Perception of Self. Center for Leadership Studies. University Associates, Inc.

Hersey, P., Blanchard, K. and Natemeyer, W.E. (1979)  Situational Leadership, Perception, and the Impact of Power.  Group Organization Management.  4(4) p418-428

McCaffery, P. (2010) The Higher Education Manager's Handbook. Second Ed. New York: Routledge.

Raven, B. &  Kruglanski, W. (1975) Conflict and power. In P. G. Swingle (Ed.), The structure of conflict. New York: Academic Press