In this episode, Dr. Kaveh Shonjania argues that despite the billions of dollars spent on clinical and quality improvement research, most of the interventions that are studied are shown not to work and those that do work produce only marginal benefits for some patients.
Dr. Shojania is the Vice Chair of Quality and Innovation for the Department of Medicine at the University of Toronto and past Editor-in-Chief of BMJ Quality and Safety. He joins Drs. Blair Bigham and Mojola Omole to discuss a study published in CMAJ recently, entitled Inappropriate Use of Clinical Practices in Canada: A Systematic Review, in which the authors sifted through 174 studies to identify ineffective clinical practices that are either overused, effective practices that are underused, or other practices that are just misused..
Dr. Shojania wrote a short commentary related to the study, entitled What problems in health care quality should we target as the world burns around us? In which he called for health research resources to be shifted more towards research on the social determinants of health, for a greater return on investment. Drs. Bigham, Omole and Shojaniadiscuss how this might actually work in practice.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
In this episode, Dr. Kaveh Shonjania argues that despite the billions of dollars spent on clinical and quality improvement research, most of the interventions that are studied are shown not to work and those that do work produce only marginal benefits for some patients.
Dr. Shojania is the Vice Chair of Quality and Innovation for the Department of Medicine at the University of Toronto and past Editor-in-Chief of BMJ Quality and Safety. He joins Drs. Blair Bigham and Mojola Omole to discuss a study published in CMAJ recently, entitled Inappropriate Use of Clinical Practices in Canada: A Systematic Review, in which the authors sifted through 174 studies to identify ineffective clinical practices that are either overused, effective practices that are underused, or other practices that are just misused..
Dr. Shojania wrote a short commentary related to the study, entitled What problems in health care quality should we target as the world burns around us? In which he called for health research resources to be shifted more towards research on the social determinants of health, for a greater return on investment. Drs. Bigham, Omole and Shojaniadiscuss how this might actually work in practice.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
Dr. Mojola Omole:
Hi, I'm Mojola Omole.
Dr. Blair Bigham:
And I'm Blair Bigham. This is the CMAJ Podcast. Jola, today's topic almost didn't make the cut.
Dr. Mojola Omole:
Yeah. I wasn't overly keen about this topic, but you led us here. So tell us what we're talking about today?
Dr. Blair Bigham:
Yeah. Today we're talking about overuse and underuse, inspired by both a systematic review published in CMAJ that found that many medications and procedures are used more than they should be, or aren't used enough in healthcare, and I don't think that would be a surprise to anybody.
Dr. Blair Bigham:
But I really did push for it because I think that when we look at what we do in healthcare and why we do it in healthcare, we see that we have this really traditional model of care, this really traditional model of research, that for a lot of root causes of poor health are probably missing the boat.
Dr. Mojola Omole:
Yeah. I thought that was interesting, and I'm interested to learn more about this topic. I guess coming from my surgeon brain, when I was at Harvard, we had a joke that we never let progress get in the way of tradition. And so for me, I was like, "Yeah. Of course, we underuse and overuse certain things."
Dr. Mojola Omole:
And so it would be interesting to learn a little bit more about this from our guest today, about how to make healthcare more efficient.
Dr. Blair Bigham:
I think this is going to be a really interesting podcast and I'm excited to get into it.
Dr. Mojola Omole:
Okay. Let's go.
Dr. Blair Bigham:
The study we're talking about on this episode is titled Inappropriate Use of Clinical Practices in Canada: A Systematic Review. The authors had sifted through 174 studies to identify ineffective clinical practices that are either overused, effective practices that are underused, or other practices that are just misused. The goal was to improve patient outcomes and to relieve pressure on our healthcare system, which is overstretched, by weeding out inefficiencies.
Dr. Blair Bigham:
Our guest on this episode has dedicated much of his career to studying these sorts of quality improvement initiatives. Dr. Shojania is the Vice Chair of Quality and Innovation for the Department of Medicine at the University of Toronto, and past Editor-in-Chief of the British Medical Journal's, Quality and Safety Journal. Kaveh, thanks for joining us.
Dr. Kaveh Shojania:
Thanks very much, Blair. It's good to be here.
Dr. Blair Bigham:
Kaveh, we're going to be getting into the broader issues with QI studies in a moment, but first, I was wondering if you could quickly summarize the CMAJ paper?
Dr. Kaveh Shojania:
Well, I think as you indicated, it was interested in the degree to which there are things that we know should be given to patients but aren't, that would be called underuse, and things that shouldn't be given to patients because they're ineffective or maybe even net harmful and that would be overuse. And what this review did was collapse underuse and overuse into a single term, “inappropriate care”.
Dr. Kaveh Shojania:
And what they did, a bit different than some other studies have done is they were really reviewing papers studying this problem. So you could obviously question the degree to which a paper studying a problem mirrors the actual epidemiology, but this is hardly the first time this has been done. What they found was that across hundreds of studies, there were lots of examples of provenly beneficial treatments and tests not being used, underuse, or again, one of the species of inappropriate care that they were interested in.
Dr. Kaveh Shojania:
And they actually found, less than I think they had expected, examples of overuse, but it was still a noteworthy problem. And so this was really supposed to be like a cry to arms to inform efforts to make more appropriate care or reduce the prevalence of inappropriate care.
Dr. Blair Bigham:
I have so many questions for you. I don't even know where to start but quality improvement initiatives, they seem so intuitive, right? Weed out the ineffective practices, increase the ones that actually move the needle, and then you get safer, more effective, a more efficient healthcare system with a healthier population. But tell me what's wrong with that story?
Dr. Kaveh Shojania:
Sure. I guess, the first glitch, which I was aware of five or 10 years into my own involvement with the movement, is just that most efforts to so-called do knowledge translation or improve patient safety don't actually work. Now, that's actually the same in most of medicine. I think people forget that the main lesson of evidence-based medicine is that most things we thought would work turn out not to work. Like way more than most, like the vast majority.
Dr. Kaveh Shojania:
In fact, there was a paper about five or six years ago in I think PLOS One that looked at large NIH funded cardiovascular trials, and showed that pre-2000, when trial registration wasn't mandatory, 57 I think per cent of trials were positive. But after 2000, when you could no longer lie about what your primary outcome was, only 8%, 8%. Now think about that. Cardiovascular medicine and oncology are like the poster children for clinical trials.
Dr. Kaveh Shojania:
Billions of dollars of research go into pre-clinical and then clinical research. And all we have to show for it is an 8% positivity rate. And then, of those things that work, most of them have large numbers needed to treat. In the commentary, I think I use the example of statins: 33 to 100 patients need to take a statin for 10 years for one patient to benefit. Imagine if 33 to a 100 patients needed to be vaccinated for COVID to prevent one hospitalization. We would think that was ridiculous. To present one COVID hospitalization over 10 years.
Dr. Kaveh Shojania:
So what I'm starting to question is that first of all, most quality improvement interventions don't work. In fact, after 20 some years of patient safety research, the two most famous safety interventions are the central line bundle and the surgical safety checklist, and there's still controversy whether either of them work.
Dr. Mojola Omole:
So as a surgeon, the surgical safety checklist was something that was of interest to me because most surgeons hate it. Most administrators love it because it's, "Okay, we've done this and so therefore we will prevent wrong-sided surgery or having major complications." Why do you say that we don't know if it works?
Dr. Kaveh Shojania:
Well first, there was a BMJ controversy paper just a few years ago. David Urbach, who is a surgeon here in Toronto, wrote a study in the New England Journal that showed that, in Ontario, where they mandated the checklist, even when they confirmed hospital data of really high compliance, there weren't concrete impacts on outcomes.
Dr. Kaveh Shojania:
Now, the obvious response to that, which was articulated in some of the editorials and commentaries on that paper is, “Well, it's not just a checklist. It's more than a checklist,” that you shouldn't treat it as a tick-box exercise. Now that's a funny argument, though, because in fact the checklist is just a tick-box exercise. The reason it happened that way in healthcare is that in aviation, in other high-risk industries where they pioneered the sort of use of checklist, they didn't just do checklists. They had intensive teamwork training and changes of the culture, design training of all the equipment, human factors engineering, and the checklist was just part of that package. And over 30 or 40 years, they made their safety journey or arc.
Dr. Kaveh Shojania:
And then, in healthcare, we tried to do everything with this one piece of paper. The reality is that you're not often going to step back and wonder about the whole operation and your preparation. You're going to treat it like a tick box exercise and there will be lots... In fact, there have been studies where they've deliberately planted errors in the surgical... It's interesting that those studies had ethics approval where they would plant errors and then wait to see if they were detected. Obviously, they would intervene if no one detected the errors, and many of the errors make it through.
Dr. Kaveh Shojania:
And the answer to your questions, it's not just my opinion. So there was a piece in the BMJ just two years ago with two of the people who championed the checklist. I think like Atul Gawande, obviously, and I forget the other author, and actually, there was a couple of other papers that really, in better-designed studies than the original New England Journal paper, showed no benefit from implementing the surgical checklist.
Dr. Kaveh Shojania:
I guess I would say that like a lot of things in healthcare, it's easy to say that we've won a little victory when the reality is it's not clear that any victory has won. All that’s just been an administrative victory to say, "Yes, we did something about surgical safety."
Dr. Mojola Omole:
So if you say that, okay, the surgical safety checklist doesn't work the way it is, what would you propose as the alternative?
Dr. Kaveh Shojania:
It's interesting that you ask that. I would say that the only study that I know of where they showed a concrete improvement, actually in perioperative mortality probably, was this paper in JAMA in the early 2000 and teens from the VA. And what was different about that study was, again, it wasn't just a checklist, it was actually an intensive teamwork training operation.
Dr. Kaveh Shojania:
And again, teamwork training gets a lot of buzz, but the reality is, for most hospitals, teamwork training is like maybe someone comes in and gives a little talk. Maybe there's a brief role-playing exercise, sometimes not even that, and then that's it. But then in this multi-site study from the VA, they actually shut down the operating rooms for three days, except for emergency surgeries at all the participating sites. They had months of preparation, they had coaching, they had all kinds of other aspects to the intervention, but the checklist did play a role.
Dr. Kaveh Shojania:
So I guess my point is that like a lot of things in life, if you really want to do something, you’ve got to kind of do it more intensely. This is not an easy problem to solve, to have an impact on multiple types of operations, types of patients, and in terms of these basic outcomes like mortality and morbidity, that's not easy. You're living a dream if you think you're just going to have a few posters and talk about a checklist, and send your safety officer to audit occasionally in the operating room. That's not going to cut it.
Dr. Kaveh Shojania:
So I think that like a lot of things in clinical medicine, too, we give lip service, "Oh, we've done this and we've done that," but are the patients actually taking the medicines? Do they understand really what's involved? When you look closer, it's often a very different story. And I think the same is true in the surgical safety example you asked about.
Dr. Blair Bigham:
And then Kaveh, how do we reconcile things with smaller trials or less popular interventions? We've both been to a ton of journal clubs, I'm sure, and you'll have these hardliners who say, "The P value for this study is 0.07. It does not work. And if you do this, then you're overusing perhaps." And then you'll have your people who say, "But the magnitude of benefit, it was so big, and 0.07 is so close to the line and it's in the right direction as this other study. How about we go ahead and do it?"
Dr. Blair Bigham:
And it seems to be that different countries generally sort of have a different strictness when it comes to that. How do you reconcile those journal club conversations we've all been in where there's a wide range of opinions from senior physicians about how we interpret a single study? And how does that bias then come into saying, "Well, are you actually overusing something or are you underusing something?"
Dr. Kaveh Shojania:
Well, that's a very fair question, but the short answer is that studies like the one that Squires and colleagues did in the CMAJ, they basically are using guidelines and systematic reviews, not single papers. So I think at that point, the preponderance really is there. It's a P=0.06, what are we supposed to do now? I think that type of issue does come up for people interested in quality improvement sometimes when a big study fails to show what they were hoping it would show. And then you have to decide, do we really give up or do we just think we need more evidence?
Dr. Kaveh Shojania:
But for the underuse and overuse type stuff, they're pretty well talking about like grade A recommendations and guidelines.
Dr. Blair Bigham:
That makes a lot of sense. What about the popularity of Bayesian analyses now? We see some trials or some sort of network analyses where you'll hear that there's no statistically significant difference, but then you'll also hear that there's sort of high confidence of benefit. How is that going to change the field for what we are all expected to do to be more efficient going forward?
Dr. Kaveh Shojania:
Blair, I guess I would say... I'm going to sound a bit crazy here like I'm some kind of radical non-science person now, but I guess what I have started to realize is how giant an apparatus is devoted to research that in the end produces almost nothing of clinical benefit. Remember that we are living in a world, even in wealthy countries like ours, where there are neighborhoods with 20 years shorter lifespan next door to each other, right?
Dr. Kaveh Shojania:
Like the US is infamous for that. There was a piece in the New York Times of last fall, highlighting two neighborhoods in Chicago that are eight miles apart and have a 30-year difference in lifespan. What a shock, the one with the 60 year lifespan is mostly racialized people on lower incomes. They also had way more COVID than the sort of people shopping at Louis Vuitton in the other neighborhood.
Dr. Kaveh Shojania:
But Canada's not immune from that. Like Winnipeg, where I grew up, has two neighborhoods that have an 18-year difference in life expectancy. And what a surprise, shorter life expectancy has a lot of First Nations people in it and so on. And we saw certainly during COVID like how I think, still, I maybe don't have the latest statistics, but I think in the greater Toronto area, 80% of COVID cases were amongst racialized people, right?
Dr. Kaveh Shojania:
So I would say that in that context, that's why I called my commentary, what are we supposed to do while the world is burning around us? How is a new treatment where a 100 people need to be given it for one person to benefit? How is that helping? So in fact, the whole paradigm of quality improvement, but really, the biomedical enterprise in general, is that we routinely produce useful biomedical interventions and then our only duty is to make sure they get disseminated.
Dr. Kaveh Shojania:
What I am pointing out, and I think what I'm starting to realize, is that, first of all, we rarely produce useful biomedical interventions, and then our efforts to disseminate those also usually fail. So I feel that one of the problems we are dealing with - it goes back to what we all know in medical school but choose to ignore - is that public health is way more important than most of the rest of what we do.
Dr. Kaveh Shojania:
I'm not the only person who said this. Actually, Don Berwick -o both of you probably heard of him - is maybe the most-
Dr. Mojola Omole:
No.
Dr. Kaveh Shojania:
Famous person in quality improvement.
Dr. Mojola Omole:
I'm a surgeon. I hear very little things.
Dr. Kaveh Shojania:
Well, he wrote a commentary in JAMA last year, I think. I forget what it was called, The Moral Determinants of Health, something like that, instead of The Social Determinants of Health. But he pointed out that basically, with a few exceptions, most physician offices and hospitals are repair shops, and we're mostly repairing the damages inflicted by what many people would call the social determinants of health. And yet almost none of the health system or the research enterprise is aimed at those problems.
Dr. Kaveh Shojania:
I think one of the examples I gave maybe in the article was, look, right now the World Health Organization says that pollution kills more people than tobacco now. I think it's like 9,000,000 people a year and, actually, just before the lockdown, there was a New England Journal paper in 650 some cities showing that small to modest changes in air quality produced detectable changes in all-cause mortality within 48 hours.
Dr. Kaveh Shojania:
Now, in that context, we see massive numbers of trials of new inhalers, endless permutations of inhalers. Why aren't we doing more research to have either cleaner air or ways to prepare the health system for predictable boluses of patients? Actually, during wildfire season in 2020, there were papers from BC, Australia and California showing clearly significant upticks in emergency visits. And actually, one of the Australian studies showed an increase in mortality.
Dr. Mojola Omole:
When I first read your commentary, I was like, so we should stop doing quality improvement because I was about to start one at my hospital, but I think what you are saying is not to stop quality improvement, but to shift what we're looking at when we're doing quality improvement studies.
Dr. Kaveh Shojania:
Yes, that would be one way of putting it.
Dr. Blair Bigham:
Tell us, how did you start your journey into patient safety and quality improvement?
Dr. Kaveh Shojania:
Well, specifically when I finished my residency at Brigham and Women's Hospital in Boston, I took the role as the first hospitalist fellow in the country at the University of California, San Francisco, because the two people who'd coined that term worked there. They'd coined the term in a New England Journal paper in 1996. And so my supervisor at the time asked what I thought we should work on, and I said, "You know what? I don't think there'll be that much longevity in just research about the hospitalist model. Why don't we harness the fact that now you're going to have a whole bunch of doctors who are not dividing their time between their offices and the hospital, or between their research labs and the hospital, and maybe focus on measuring and improving hospital quality." And my supervisor and I did a little bit of initial writing and thinking and so on.
Dr. Kaveh Shojania:
And then the IOM report came out and I coincidentally had been part of an early grant to look at autopsy-detected diagnostic errors, and so we had an in with the agency funding all this patient safety work. And so I thought, "This makes sense. I'm going to be a doctor who focuses on the hospital. The hospital we know can cause lots of problems." There were lots of studies that highlighted how often people were harmed while they were in the hospital.
Dr. Kaveh Shojania:
And then a few years later, as the interest broadened from patient safety to quality improvement in general, I thought getting back to what I mentioned earlier, that the main lesson of evidence-based medicine is that most things don't work. And so if they do work, we better make sure people are getting them. And if we know they not only don't work but waste a lot of money or cause harm, we better de-implement them. So I thought this is a very reasonable field to stake out.
Dr. Blair Bigham:
So why is it so difficult to transfer knowledge into practice? For those things that we know that we really should be doing generally, it's hard to sort of talk yourself out of one study or one systematic review because it was so well done. Why is it so hard to align physician practices with what should be agreed upon as the best thing to do?
Dr. Kaveh Shojania:
There's so many ways I could answer that. I guess I would say, so first of all, when has ever there been a reliable way of predicting social action? People will always quote some business, like proverbs about this and that, but the reality is that those are all just anecdotal. Things are often ideologically driven. It's a hard thing to make an entire group of people behave in a certain way, in a predictable and a reliable fashion. So that's one problem.
Dr. Kaveh Shojania:
And then the other thing is of course, there's many competing forces, right? We can talk about patient safety all we want, but the reality is it's a volume-driven business, right? You're trying to get people in and out very quickly. Even when we call on other sectors to sort of give us an example like aviation or nuclear power, these other higher... they're not usually having all the different goals that we have in medicine, like trying to satisfy so many different targets, like getting people efficiently through and also giving them the best possible treatment and the best possible experience, and doing it an equitable way. That's not what all of these other industries have to do. So there are a lot of barriers.
Dr. Kaveh Shojania:
The last thing I'll say is that we also don't do the obvious things like staffing, say nurses are overworked, underpaid, understaffed. We don't do anything about that. There's tons of evidence that there's a dose response relationship between more nurses and better outcomes.
Dr. Blair Bigham:
Totally.
Dr. Kaveh Shojania:
Instead, we do one root cause analysis after another wondering, "Oh my gosh, how did this bad thing happen?" When it's obvious that there are some structural problems with how we deliver care, how we organize and finance it.
Dr. Blair Bigham:
I'm convinced that in the ICU... there's never been a trial on this, but in the ICU, the number one thing that contributes to your survival is good bedside nursing. That absolutely is what makes the difference for ICU survival.
Dr. Mojola Omole:
As you've been doing quality improvement over time, was there one study or one moment that changed for you to start thinking, "You know what? This is not working?"
Dr. Kaveh Shojania:
Maybe it was when I started to see... The central line bundle was a very interesting example for me because I was one of the people who argued for taking a more evidence-based medicine type of clinical research approach to patient safety. There was actually a point-counterpoint in JAMA where, after this big patient safety report that we wrote came out, a couple of my former mentors actually criticized what we do because they said, "You're talking about things like infection control and central lines, and blood clots," because actually, VTE prophylaxis was our highest rate of practice at the time. It was not yet such a big thing. "Why wasn't there more stuff about teamwork and culture, and informatics?" And we said, "Well, there's just not that much evidence about that yet."
Dr. Kaveh Shojania:
And so then the central line bundle came out, the trial, the study in the New England Journal. It was like an uncontrolled trial missing lots of data, but the New England Journal wanted to show that they were doing something about patient safety, so they published it. And I thought, "Well, in some ways, this is exactly what I was hoping for, an evidence-based example of a harm and how to reduce it."
Dr. Kaveh Shojania:
But then I realized, well, first of all, this is like a famous problem I guess, but it's a pretty narrow one, right? It's like you could eliminate every central line infection in the world probably and there wouldn't be an obvious detectable change in outcomes. There's also the confounding problem that the people who get these infections are already sick and this and that.
Dr. Kaveh Shojania:
Anyway, and then there was a controlled trial that came out from the UK that showed it was all secular trends. And then, with Choosing Wisely and those sorts of initiatives, there started to be more interest in sending less blood cultures, and I actually think a lot of the impact of the central line bundle is just from not even sending the blood cultures anymore.
Dr. Kaveh Shojania:
So I thought, here we have an example where after 15 years on a narrow target, we're still not even sure if it really works. And I just thought there's no way with the burden of harm that is out there, that we can continue in this whack-a-mole type of approach. I don't know why, in the rest of clinical medicine, we seem to proceed in this way, but I'm also questioning that. I'm questioning the degree to which that's the best approach anywhere, but definitely in quality improvement. And I think it was my experience watching that and the surgical checklist to some extent.
Dr. Blair Bigham:
So Kaveh, if we wanted to quantum leap and wrap up all the time, energy and money that are spent sort of traditionally, where would you reallocate that to have a greater impact?
Dr. Kaveh Shojania:
Well, it doesn't sound sexy to donors, that's for sure. But as I said, one of the things I would do, for instance, is... actually, here two concrete examples. I think I might have mentioned them in the article. So right now, there's a gazillion medicines looking at dementia. Now, obviously that's of great interest. Many people have dementia and many more will get it, but the reality is the most likely thing to happen is that we're going to have another statin-equivalent, a drug that hundreds of patients will have to take for one person to maybe benefit.
Dr. Kaveh Shojania:
Instead, we could be doing a lot more to develop senior friendly care, get people to be supported in the community, have better long-term care instead of what we saw during COVID, and so on. Similarly, for respiratory research, as I mentioned, instead of having endless permutations of inhalers, why aren't we doing more to partner with people working in other sectors on clean air? To give a concrete example, as you know, I'm sure, London passed some kind of rule 10 or 15 years ago that you couldn't drive in certain areas without paying.
Dr. Kaveh Shojania:
Now, I don't know if that worked, but we could be doing research about that to identify ways of improving air quality and preparing the health system to deal with predictable surges in patients. We could be doing more research like that.
Dr. Blair Bigham:
Kaveh, most of our podcasts end on the need for an improved health in one way or another, but what we find is that the means to actually change those determinants lie outside of healthcare or outside of my toolbox as a doctor. How are physicians best able looking forward to realign their efforts to actually have an impact on what seemed like gargantuan targets?
Dr. Kaveh Shojania:
It's a great question and I thought about it a lot. Actually, when I was a student visiting Boston, that's how I got into the residency there. My resident was Jim Kim and he went on to be the head of the World Bank, as you may know. And I remember finding out that he had a PhD in anthropology and his friend Paul Farmer, who sadly died a couple of months ago…. Paul, won a MacArthur Genius Award while he was a resident and I was visiting as a medical student. I thought, "Oh my God, what a place."
Dr. Kaveh Shojania:
And anyway, I asked Jim, "Why are you and Paul even in medicine? You're both obviously socialists for progressive activist types and you have PhDs in anthropology." And Jim said, "Because in the United States, the only way you can do anything with social justice is through healthcare." And so I thought, well, that's interesting. And so, definitely, I realized that in healthcare, we don't have the expertise to deal with a lot of these problems with the social determinants of health, but we have the money and, realistically, we're not going to hand back the money, but I do think we could partner more effectively with people in other sectors to at least direct some of these funds their way, and partner with them.
Dr. Kaveh Shojania:
There's no way we're going to solve... we can't keep being a repair shop. We have to more proactively work with people in schools, the criminal justice system, urban planning and so on, to improve these things at a more than just a marginal rate, which is how we've been doing it mostly in biomedicine.
Dr. Mojola Omole:
How do we start... because for me, it sounds as if this has to start with medical school, in terms of training medical learners about the importance of this. Everybody wants to have a certain career, whether it's to become a surgeon or to become an internist. And what you're saying is that we need more activism within the... when we talk about social determinants of health.
Dr. Mojola Omole:
So how do we start with our medical learners in terms of training them to want to have an interest in this? Because I think I find that at least when I'm mentoring medical students now, they're much more socially aware whether it comes to gun violence-
Dr. Kaveh Shojania:
I find that too. Yes.
Dr. Mojola Omole:
-climate change, and they're all very interested in doing that, but then they all want to become a surgeon, which I'm like, Meh. So how do we encourage them or how do we maybe even develop a curriculum within the medical system that encourages us to start focusing instead of being a repair shop to become... I don't know what the opposite of that is.
Dr. Kaveh Shojania:
Yeah. No, it's a great question. And, actually, I'm holding a think tank sort of brainstorming session in a few weeks in the Department of Medicine at U of T on precisely this question, because I gave a Grand Rounds in which I articulated a lot of the ideas that were in my CMAJ commentary. And a lot of people stepped forward to say, "Oh my God, I would love to work on these sorts of problems."
Dr. Kaveh Shojania:
And I, also, the few people that I knew who already were working on, say, food insecurity, homelessness and so on, they were mostly mid-career and senior people. And they all said that when you're starting out the current system makes it too difficult for people to take on these problems because you need to show early wins. You need a quick paper that shows that something didn't work or something did work. And the things that we're talking about now, they don't lend themselves to that.
Dr. Kaveh Shojania:
Imagine what it's like to try to develop like a successful community project that really moves the needle in some meaningful way. That's like a 5 or 10 year effort. And so we are trying to figure out how we can remove some of the inadvertent obstacles and create more positive supports. I don't have the answer, but I agree with you, anecdotally, this is what the younger generation wants to work on. And I want to make sure that we empower them to do that or at least remove some of the inadvertent barriers to doing so.
Dr. Blair Bigham:
Kaveh, we could talk forever, but we're going to wrap it up now. Thank you so much.
Dr. Kaveh Shojania:
Thank you.
Dr. Blair Bigham:
Dr. Shojania is the Vice Chair of Quality and Innovation at the Department of Medicine at the University of Toronto and past Editor-In-Chief of BMJ Quality and Safety.
Dr. Mojola Omole:
So Blair, that completely changed my mind about this topic of overused...
Dr. Blair Bigham:
Oh, I'm so glad. I thought I was going to lose a friend because I pushed so hard for this one.
Dr. Mojola Omole:
Yeah, you probably, you were close to it. I was close, but it honestly changed my mind about this topic and going beyond the article and just about the enterprise of quality improvement, because oftentimes you say, "Okay, I want to do a QI project." And this really made me rethink: hy are we doing this? What is our end goal?
Dr. Blair Bigham:
So Jola, what did Kaveh say that really sort of flipped this switch for you?
Dr. Mojola Omole:
Well, I think it flipped the switch in the sense of basically saying that some of these interventions that we're studying are not the most impactful. He didn't say anything that was new, but coming from someone who's dedicated their career to quality improvement, to now say, "You know what? We should be focusing on, maybe the equity part of quality improvement and dealing with the upstream, that instead of being a repair shop, we have to figure out a way to start preventing people to come to need us."
Dr. Mojola Omole:
And that to me, was really exciting because when I mentor medical students, a lot of them, this generation is very engaged on other things outside of medicine, whether that's climate, whether that's gun violence, the social determinants of health, and being able to put both of those together is fascinating for me. So I'm very happy that we ended up doing this episode.
Dr. Blair Bigham:
What do you do though, Jola, when the repair shop is so busy when there's so many broken cars and so few mechanics? I just think of my last shift. I was run off my feet. I came home and I went to bed. When we're so busy and so overwhelmed in our current system, how are we supposed to find time and energy to sort of reimagine and recreate a better future?
Dr. Mojola Omole:
I think part of that is there has to be a different distribution of learners going into different fields. I do not think that we sell public health to learners in a very positive light. I think we also have to be very open about it, in the sense of, it is much more attractive financially to be an ophthalmologist than to go into public health. And so that also has to be taken care of.. There is disparities amongst specialties, but we don't really tell students that, "Hey, you know what? This is the stuff you can and do in public health.”
Dr. Mojola Omole:
You'd be like Dr. McNeil, who is a surgeon, who is very invested in changing the environment. So we don't really show students this. You do need some people still in the repair shop, but you need people before the repair shop trying to get people healthy, and we don't have that. T
Dr. Blair Bigham:
The problem is, like you said, Jola, we only get remunerated for fixing cars. The system is almost set up to stay in the past and not advance just by the way it incentivizes people to practice. We all have a living to make and it's hard to dedicate time to sort of these forward thinking innovations when you're so stuck in the day to day.
Dr. Mojola Omole:
Exactly. But I think we're getting close to it in terms of the critical mass and the people who want there to be a bit of a difference.
Dr. Mojola Omole:
So thank you for joining us today for a very spirited episode. I'm Mojola Omole.
Dr. Blair Bigham:
I'm Blair Bigham. Please remember to share, like, or comment on this podcast, wherever it is that you download it. It's the best way for us to spread the message and get the word out.
Dr. Mojola Omole:
And until next time, be well.