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

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