Moriates, C. A Few Good Words. 2018.
No matter where you are in health care – a student, a resident, a physician, a nurse, a PA, whomever – you too can lead from where you stand and create a culture around you that contributes to high-value care delivery. Module 10 will discuss how to lead value improvement projects and programs in health care settings.
Role models play a critical part in creating culture change. In “Bringing High-Value Care to the Inpatient Teaching Service”,2 Dr. Goop Dhaliwal, a highly respected master clinician-educator from the San Francisco VA Medical Center, discussed how he came to realize that “attending physicians have a responsibility not only to talk the talk but also to walk the walk” of high-value care delivery.
“I inform the senior residents that along with the standard instruction they expect from their ward attending physician, I will also be focusing on their ability to defer common practices—sometimes even “standards of care”—that are out of sync with evidence, discordant with the stewardship of health care resources, or conflict with patients’ preferences,” Dr. Dhaliwal wrote.
This requires grappling with each of our own discomfort with uncertainty and fear of making a mistake.
I divulge my discomfort in order to engage theirs: “Like you, I’m wondering about the small chance that our patient could become septic because we did not give him an antibiotic.” But I also try to counter this unease by reminding them of risks, adding “but I’m also thinking about Mr. Smith, where we likely overdiagnosed pneumonia, and by unnecessarily prescribing antibiotics caused his Clostridium difficile infection and his protracted hospital stay.”
Dhaliwal G. Bringing High-Value Care to the Inpatient Teaching Service. JAMA Internal Medicine, 2014
You do not need to be an attending physician to be a role model. As discussed in module 7, medical students can lead through simple small acts such as incorporating considerations of value in their daily oral patient presentations (“SOAP-V”). Residents can also help change the conversation during morning report or other case conferences by illustrating how to practice appropriate restraint and step-wise work-ups when appropriate, rather than generating exhaustive differential diagnoses and “shot-gunning” every test that anybody could think of on the first pass.
“Attending physicians have a responsibility not only to talk the talk but also to walk the walk if we hope to help create a generation of physicians who come to understand that the best doctors are often defined by restraint rather than action… It has been challenging at times, but the experience has convinced me that modeling high-value care is the most effective way to teach it.”