We Need to Talk: Advancing Open Inquiry

ABSTRACT

In this article, the authors explore the current state of divisiveness in U.S. society and its impact on medical schools. Higher education institutions are increasingly faced with challenges in supporting freedom of speech while respecting marginalized groups who may feel attacked by certain kinds of speech. "Cancel culture" has resulted in misunderstandings, job loss, and a growing fear of expressing ideas that may offend someone. These dynamics are particularly relevant in medicine, where issues of racial justice, reproductive health, gender identity, and end-of-life care, occurring in the context of personal and religious differences, affect patient care.Despite these challenges, there must be ways to talk and listen respectfully to each other and bridge sociopolitical divides. Open inquiry and discussion are essential to medical education and patient care. There needs to be a common language and a setting where open engagement is encouraged and supported. This requires expertise and practice. The authors describe several models that offer constructive approaches toward this goal. Organizations including Braver Angels, Constructive Dialogue Institute, Essential Partners, and Greater Good Science Center are working to advance open inquiry and discussion, as are psychology leaders whose methods encourage empathy and learning from one another before engaging in a charged, polarized discussion topic. These and others are using methods that can benefit medical education in supporting diversity of ideas and deliberative discussions to equip students with skills to overcome divisiveness in their training and clinical practice.Promoting civil discourse is critical to society's well-being, and respectful engagement and open inquiry are essential to medical education and patient care. Despite the challenges posed by current societal divides, there are ways to talk with each other respectfully and constructively. The authors assert that this requires ongoing effort and practice, which are crucial for the health care enterprise to flourish.

Create a COVID-19 commission

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Emerging topics in dementia care and services

BACKGROUND

The National Institute on Aging (NIA), in conjunction with the Department of Health and Human Services as part of the National Alzheimer's Project Act (NAPA), convened a 2020 Dementia Care, Caregiving, and Services Research Summit Virtual Meeting Series. This review article summarizes three areas of emerging science that are likely to grow in importance given advances in measurement, technologies, and diagnostic tests that were presented at the Summit.

RESULTS

Dr. Cassel discussed novel ethical considerations that have resulted from scientific advances that have enabled early diagnosis of pre-clinical dementia. Dr. Monin then summarized issues regarding emotional experiences in persons with dementia and their caregivers and care partners, including the protective impact of positive emotion and heterogeneity of differences in emotion by dementia type and individual characteristics that affect emotional processes with disease progression. Finally, Dr. Jared Benge provided an overview of the role of technologies in buffering the impact of cognitive change on real-world functioning and their utility in safety and monitoring of function and treatment adherence, facilitating communication and transportation, and increasing access to specialists in underserved or remote areas.

CONCLUSIONS

National policy initiatives, supported by strong advocacy and increased federal investments, have accelerated the pace of scientific inquiry and innovation related to dementia care and services but have raised some new concerns regarding ethics, disparities, and attending to individual needs, capabilities, and preferences.

Making Doctors Effective Managers and Leaders: A Matter of Health and Well-Being

The COVID-19 crisis has forced physicians to make daily decisions that require knowledge and skills they did not acquire as part of their biomedical training. Physicians are being called upon to be both managers-able to set processes and structures-and leaders-capable of creating vision and inspiring action. Although these skills may have been previously considered as just nice to have, they are now as central to being a physician as physiology and biochemistry. While traditionally only selected physicians have received management training, either through executive or joint degree programs, the authors argue that the pandemic has highlighted the importance of all physicians learning management and leadership skills. Training should emphasize skills related to interpersonal management, systems management, and communication and planning; be seamlessly integrated into the medical curriculum alongside existing content; and be delivered by existing faculty with leadership experience. While leadership programs, such as the Pediatric Leadership for the Underserved program at the University of California, San Francisco, and the Clinical Process Improvement Leadership Program at Mass General Brigham, may include project work, instruction by clinical leaders, and content delivered over time, examples of leadership training that seamlessly blend biomedical and management training are lacking. The authors present the Leader and Leadership Education and Development curriculum used at the Uniformed Services University of the Health Sciences, which is woven through 4 years of medical school, as an example of leadership training that approximates many of the principles espoused here. The COVID-19 pandemic has stretched the logistical capabilities of health care systems and the entire United States, revealing that management and leadership skills-often viewed as soft skills-are a matter of life and death. Training all physicians in these skills will improve patient care, the well-being of the health care workforce, and health across the United States.

Social license for the use of big data in the COVID-19 era

Strategies to enable the reopening of businesses and schools in countries emerging from social-distancing measures revolve around knowledge of who has COVID-19 or is displaying recognized symptoms, the people with whom they have had physical contact, and which groups are most likely to experience adverse outcomes. Efforts to clarify these issues are drawing on the collection and use of large datasets about peoples' movements and their health. In this Comment, we outline the importance of earning social license for public approval of big data initiatives, and specify principles of data law and data governance practices that can promote social license. We provide illustrative examples from the United States, Canada, and the United Kingdom.

Addressing Student Burnout: What Medical Schools Can Learn From Business Schools

Although they enter school with enthusiasm for a career in medicine, medical students in the United States subsequently report high levels of burnout and disillusionment. As medical school leaders consider how to address this problem, they can look to business schools as one source of inspiration. In this Invited Commentary, the authors argue-based on their collective experience in both medical and business education-that medical schools can draw three lessons from business schools that can help reinvigorate students. First, medical schools should offer more opportunities and dedicated time for creative work. Engaging with diverse challenges promotes intellectual curiosity and can help students maintain perspective. Second, schools should provide more explicit training in resiliency and the management of stressful situations. Many business programs include formal training in how to cope with conflict and how to make high-stakes decisions, whereas medical students are typically expected to learn those skills on the job. Finally, medical schools should provide better guidance on practical career considerations like income, lifestyle, and financial skills. Whether in medicine or business, students benefit from open discussions about their personal and professional goals. Medical schools must ensure that students have an outlet for those conversations.

The Role of Physicians and Certification Boards to Improve Quality

Amid growing focus on individual physician performance, it is timely to examine what evidence exists that physicians can be facilitators and leaders for health care quality improvement in their local health care environments. Despite the importance of governmental policy and national initiatives, change in health care quality must occur in the context of local communities. Therefore, individual physician involvement, working with other local health care leaders and providers, will be crucial to future quality improvement. The objectives of this article are as follows: (1) outline why physicians must be involved in quality improvement, (2) delineate the barriers and facilitators to physician involvement, and (3) discuss how medical certification boards can facilitate greater physician involvement in quality improvement.

Trading Off Longer Life for Worsening Health

This article demonstrates and explains why future declines in mortality will have a diminishing effect on the metric of life expectancy but a large impact on the size of future elderly cohorts. Additionally, the article addresses a hypothesis in which it is argued that morbidity and disability will decline and become compressed into a shorter duration of time before death. Although studies have demonstrated that declining mortality can lead to worsening health, what is missing from the literature is a formal mechanistic hypothesis that describes why this phenomenon takes place. Two primary mechanisms are identified. One is based on arguments in which medical technology is identified to improve the survival of those with disabling conditions; the other is that declining mortality from fatal diseases leads to a shift in the distribution of causes of disability from fatal to nonfatal diseases of aging. Procedures for testing this hypothesis are discussed.

Aging: adding complexity, requiring skills

The role of systems in addressing the needs of elderly and chronically ill populations remains a far from universal way of thinking, much less practice, in health care. Re-engineering the current fragmented system to align providers, patients and payment models to facilitate proactive management of conditions associated with advanced age and/or one or more chronic diseases - rather than responding to costly consequences of a health care system optimized for acute care conditions - will be a major challenge for all stakeholders. There are, however, promising success stories that are taking place in the United States today that may provide a model for improvement. The authors define the issues faced by the health care providers and payers that arise when providing care for the elderly and those with chronic conditions - issues that threaten to overwhelm the financial and human health care resources that exist to serve these populations. They define innovative ways of thinking about systems of care, and provide examples of unique systems that have applied theory into practice. These successful leaders may offer lessons in proactively managing complex health conditions, overcoming communication barriers and using technology to complement the necessary human touch that is essential to health care delivery.

Shared medical regulation in a time of increasing calls for accountability and transparency: comparison of recertification in the United States, Canada, and the United Kingdom

In the United States, Canada, and the United Kingdom, the medical profession is accountable to the public for the delivery and quality of care provided to patients. Traditionally, this accountability has been achieved through the development and maintenance of professional standards established by the profession itself-self-regulation. Medical self-regulation is being re-examined by regulators, government, and the profession in response to a range of drivers including payers seeking ways to hold physicians accountable for cost-effective care; patients seeking more information about their physician's qualifications; and the emergence of a number of high-profile cases of unacceptable medical practice. This article outlines the current state of medical regulation in the United States, Canada, and the United Kingdom and highlights the increasing external pressure on the self-regulatory framework that is leading to a shift toward shared regulation between the profession and other stakeholders.

Crossroads in quality

Expanding insurance coverage is a critical step in health reform, but we argue that to be successful, reforms must also address the underlying problems of quality and cost. We identify five fundamental building blocks for a high-performance health system and urge action to create a national center for effectiveness research, develop models of accountable health care entities capable of providing integrated and coordinated care, develop payment models to reward high-value care, develop a national strategy for performance measurement, and pursue a multistakeholder approach to improving population health.