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Change Begins at the Bottom

Change Begins at the Bottom Trainee-Authored Letters to the Editor Funding/Support: None reported. to impart net good, which could simply contribute, but how? I was far closer to mean oer ff ing compassion once clinical the bottom than the top. Other disclosures: None reported. interventions were exhausted. Ethical approval: Reported as not applicable. So I picked up the phone. I called In the face of rampant structural inequality, patients who underwent surgery and Teva D. Brender, MD it is easy to feel discouraged by the sheer asked: How many opioids were you First-year resident, Department of Medicine, University of California, San Francisco, San Francisco, weight of the disparities our patients prescribed? How many did you take? I California; email: teva.brender@ucsf.edu; ORCID: face. The medical field is increasingly discovered that patients were typically https://orcid.org/0000-0002-2831-3039. recognizing the impact that the social prescribed 40 pills aer s ft urgery but only determinants of health have on health took 6. I shared these results with our First published online October 18, 2022 outcomes and medical school curriculums department, and within a few months the Reference are increasingly incorporating these topics. size of postoperative opioid prescriptions I am now a teaching assistant for a course at my institution fell by 63%. Over 1 Ranney ML, Betz ME, Dark C. #ThisIsOurLane—Firearm Safety as that reinforces these ideas as they pertain the following year, this work spread Health Care’s Highway. N Engl J Med. to the clinical context. Courses like this throughout Michigan, and postoperative 2019;380:405–407. can be a force for net good by leading to opioid prescribing fell by 44% across incremental improvements in the way the state. Patient satisfaction remained we treat patients and practice medicine. excellent, and millions of excess pills were Eschewing Perfection in the Systemic, radical change is needed, but kept out of our communities. Quest for “Net Good” we can still help to empower a healthier To the Editor: “Glasses would help,” population one set of glasses at a time and Since that experience, I have realized that he replied. I had asked the patient what work to become a more thoughtful and no matter your position in the hierarchy, he needed. He responded accurately inclusive field one course at a time. you can change practice. In fact, those lower (a house, a less-stigmatizing criminal in the hierarchy are oen t ft he ones who Acknowledgments: The author would like to thank record, a large bank account balance), can make a real impact. Whereas those at Dr. Juneja and the Student Affairs Department at but with a list far beyond the resources the top are far removed from day-to-day Baylor College of Medicine for the opportunity to available. I encouraged him to think care delivery, those on the ground see work on social determinants of health education smaller, which led us to glasses. It efforts. opportunities for improvement firsthand. was not much, but it was achievable. Now, as a surgical resident, I continue to Funding/Support: None reported. Before medical school, I worked for see myself as a change agent. My most an organization supporting unhoused frequent advice to medical students is that Other disclosures: None reported. individuals with complex medical needs. you too can be a leader for change. Do not Ethical approval: Reported as not applicable. Once more urgent health care needs underestimate the power of your position. had been addressed, I was able to obtain More likely than not, you will see the Mary Louisa Angly glasses for him. We also worked together opportunities that become obscured when Fourth-year medical student, Baylor College of Medicine, Houston, Texas; email: angly@bcm.edu; to secure him a job interview. you are all the way at the top. ORCID: https://orcid.org/0000-0001-9534-2342. Acknowledgments: The author thanks his mentors As a medical student, I no longer do a First published online October 18, 2022 for their continued guidance and support. lot of case management work, but the experience changed my outlook and Funding/Support: None reported. taught me the power of the “net good.” Other disclosures: None reported. In my previous role, it could be easy to become discouraged by the sheer To the Editor: In health care, we Ethical approval: Reported as not applicable. discrepancy between what was needed oen t ft ry to change practice from the top Ryan Howard, MD, MS and what was available. Despite this down. Far-reaching regulatory policies Surgery resident, Michigan Medicine, University of dichotomy, it was always possible to impose rules and quality metrics that Michigan, Ann Arbor, Michigan; email: rhow@med. be a force for net good and have an push clinicians to improve performance. umich.edu; Twitter: @rhowMD; ORCID: https://orcid. org/0000-0001-9877-9603. incrementally positive effect on the Unfortunately, these efforts rarely individuals with whom we worked. improve quality and can even cause First published online October 25, 2022 unintended harm. As future physicians, a quest for this net References good is important to keep in mind, as As a trainee, I witnessed the power of a 1 Rosenbaum L. Reassessing quality a “cure” or some perfect intervention is radically different approach: bottom-up assessment–The flawed system for fixing a flawed system. N Engl J Med. frequently an unattainable goal for many change. In 2016, my institution began 2022;386:1663–1667. of our patients. Regardless, we can always focusing on combating the opioid 2 Howard R, Waljee J, Brummett C, Englesbe work to help patients more effectively epidemic. In true top-down fashion, M, Lee J. Reduction in opioid prescribing manage chronic conditions, or at the bare leadership mobilized, millions of dollars through evidence-based prescribing guidelines. JAMA Surg. 2018;153:285–287. minimum, provide them with empathy. were invested, and entire research centers 3 Vu JV, Howard RA, Gunaseelan V, Brummett This felt abundantly clear on a palliative were established. I was a fourth-year CM, Waljee JF, Englesbe MJ. Statewide care rotation, as many of the patients had medical student interested in surgery implementation of postoperative opioid reached the bounds of what medicine and had witnessed how oen o ft pioids prescribing guidelines. N Engl J Med. could oer ff . Even then, it was possible were prescribed aer s ft urgery. I wanted to 2019;381:680–682. Academic Medicine, Vol. 98, No. 5 / May 2023 541 Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Academic Medicine Wolters Kluwer Health

Change Begins at the Bottom

Academic Medicine , Volume 98 (5) – May 25, 2023

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Publisher
Wolters Kluwer Health
Copyright
Copyright © 2022 by the Association of American Medical Colleges
ISSN
1040-2446
eISSN
1938-808X
DOI
10.1097/acm.0000000000005058
Publisher site
See Article on Publisher Site

Abstract

Trainee-Authored Letters to the Editor Funding/Support: None reported. to impart net good, which could simply contribute, but how? I was far closer to mean oer ff ing compassion once clinical the bottom than the top. Other disclosures: None reported. interventions were exhausted. Ethical approval: Reported as not applicable. So I picked up the phone. I called In the face of rampant structural inequality, patients who underwent surgery and Teva D. Brender, MD it is easy to feel discouraged by the sheer asked: How many opioids were you First-year resident, Department of Medicine, University of California, San Francisco, San Francisco, weight of the disparities our patients prescribed? How many did you take? I California; email: teva.brender@ucsf.edu; ORCID: face. The medical field is increasingly discovered that patients were typically https://orcid.org/0000-0002-2831-3039. recognizing the impact that the social prescribed 40 pills aer s ft urgery but only determinants of health have on health took 6. I shared these results with our First published online October 18, 2022 outcomes and medical school curriculums department, and within a few months the Reference are increasingly incorporating these topics. size of postoperative opioid prescriptions I am now a teaching assistant for a course at my institution fell by 63%. Over 1 Ranney ML, Betz ME, Dark C. #ThisIsOurLane—Firearm Safety as that reinforces these ideas as they pertain the following year, this work spread Health Care’s Highway. N Engl J Med. to the clinical context. Courses like this throughout Michigan, and postoperative 2019;380:405–407. can be a force for net good by leading to opioid prescribing fell by 44% across incremental improvements in the way the state. Patient satisfaction remained we treat patients and practice medicine. excellent, and millions of excess pills were Eschewing Perfection in the Systemic, radical change is needed, but kept out of our communities. Quest for “Net Good” we can still help to empower a healthier To the Editor: “Glasses would help,” population one set of glasses at a time and Since that experience, I have realized that he replied. I had asked the patient what work to become a more thoughtful and no matter your position in the hierarchy, he needed. He responded accurately inclusive field one course at a time. you can change practice. In fact, those lower (a house, a less-stigmatizing criminal in the hierarchy are oen t ft he ones who Acknowledgments: The author would like to thank record, a large bank account balance), can make a real impact. Whereas those at Dr. Juneja and the Student Affairs Department at but with a list far beyond the resources the top are far removed from day-to-day Baylor College of Medicine for the opportunity to available. I encouraged him to think care delivery, those on the ground see work on social determinants of health education smaller, which led us to glasses. It efforts. opportunities for improvement firsthand. was not much, but it was achievable. Now, as a surgical resident, I continue to Funding/Support: None reported. Before medical school, I worked for see myself as a change agent. My most an organization supporting unhoused frequent advice to medical students is that Other disclosures: None reported. individuals with complex medical needs. you too can be a leader for change. Do not Ethical approval: Reported as not applicable. Once more urgent health care needs underestimate the power of your position. had been addressed, I was able to obtain More likely than not, you will see the Mary Louisa Angly glasses for him. We also worked together opportunities that become obscured when Fourth-year medical student, Baylor College of Medicine, Houston, Texas; email: angly@bcm.edu; to secure him a job interview. you are all the way at the top. ORCID: https://orcid.org/0000-0001-9534-2342. Acknowledgments: The author thanks his mentors As a medical student, I no longer do a First published online October 18, 2022 for their continued guidance and support. lot of case management work, but the experience changed my outlook and Funding/Support: None reported. taught me the power of the “net good.” Other disclosures: None reported. In my previous role, it could be easy to become discouraged by the sheer To the Editor: In health care, we Ethical approval: Reported as not applicable. discrepancy between what was needed oen t ft ry to change practice from the top Ryan Howard, MD, MS and what was available. Despite this down. Far-reaching regulatory policies Surgery resident, Michigan Medicine, University of dichotomy, it was always possible to impose rules and quality metrics that Michigan, Ann Arbor, Michigan; email: rhow@med. be a force for net good and have an push clinicians to improve performance. umich.edu; Twitter: @rhowMD; ORCID: https://orcid. org/0000-0001-9877-9603. incrementally positive effect on the Unfortunately, these efforts rarely individuals with whom we worked. improve quality and can even cause First published online October 25, 2022 unintended harm. As future physicians, a quest for this net References good is important to keep in mind, as As a trainee, I witnessed the power of a 1 Rosenbaum L. Reassessing quality a “cure” or some perfect intervention is radically different approach: bottom-up assessment–The flawed system for fixing a flawed system. N Engl J Med. frequently an unattainable goal for many change. In 2016, my institution began 2022;386:1663–1667. of our patients. Regardless, we can always focusing on combating the opioid 2 Howard R, Waljee J, Brummett C, Englesbe work to help patients more effectively epidemic. In true top-down fashion, M, Lee J. Reduction in opioid prescribing manage chronic conditions, or at the bare leadership mobilized, millions of dollars through evidence-based prescribing guidelines. JAMA Surg. 2018;153:285–287. minimum, provide them with empathy. were invested, and entire research centers 3 Vu JV, Howard RA, Gunaseelan V, Brummett This felt abundantly clear on a palliative were established. I was a fourth-year CM, Waljee JF, Englesbe MJ. Statewide care rotation, as many of the patients had medical student interested in surgery implementation of postoperative opioid reached the bounds of what medicine and had witnessed how oen o ft pioids prescribing guidelines. N Engl J Med. could oer ff . Even then, it was possible were prescribed aer s ft urgery. I wanted to 2019;381:680–682. Academic Medicine, Vol. 98, No. 5 / May 2023 541 Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.

Journal

Academic MedicineWolters Kluwer Health

Published: May 25, 2023

References