Guest Post: Why you should care about how family physicians are measured

The following post consists of lightly edited excerpts from several e-mail exchanges among members of the Family Medicine Education Consortium between May 20-26, 2014.

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Colleagues,

We recently published an article documenting family physicians' frustrations with the Centers for Medicare & Medicaid Services' documentation, coding, and billing rules we are forced to work under by CMS and private insurance companies. Plenty of stories have mentioned the income disparity between primary care docs and procedural subspecialists. I have never read an article that asked why this disparity even exists in the first place. They talk about salary differences or first salaries out of residency, as if the only factor at play was competitive market forces. No journalist has cracked the code (that I've read) that understands that the root of this discrimination is the CMS billing system, which over 90% of insurance companies use. [Editor's note: this Washington Monthly article explains why Medicare's price-fixing always undervalues the work of primary care physicians.]

I don't understand why non-physicians seem so indifferent to this aspect of our work lives. Their attitude always seems to be some version of "the details of the rules are boring, you're a rich doctor, so quit complaining." These awful rules affect their patient experience. Patients complain about their doctor being rushed and not listening to them. CMS rules often cause us to behave this way.

Richard Young

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I wonder if this group would want to try to submit something to CMS about what we should really measure with patient outcomes like quality of life. Not sure who could take the lead, but having a lot of names on such a document would be a strong statement to them at least.

Hugh Silk

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Be careful what you ask for. The whole quality movement in family medicine has led us astray: it assumes there is one right answer for a medical issue, e.g., antibiotics one hour prior to major surgery. Because of the complexity of what we do, often there is no one right answer, so what do we measure?

The quality improvement (QI) movement is largely unable to risk adjust. If we propose measures for quality of life (QOL) outcomes for constructs such as energy levels, sleep quality, shortness of breath, then we create incentives for family physicians to "dump" the sickest patients, which is exactly the opposite of what this country needs. Up to now, QI has assumed that more is better, which is anti-family medicine. None of the criteria measure things we don't do to patients. The Choosing Wisely campaign offers hope for a more balanced portfolio.

Politicians, regulators, and industria-crats don't want to hear this, but a lot of the value of our services simply can't be measured. Many of our decisions have no evidence base to declare one right answer. To even accept simple disease-specific measures as an overall assessment of care quality implies that our decisions are simple and straightforward, when nothing could be further from the truth.

This is not to say that physicians and their practices should not reflect on their own performance and measure internal processes to improve local care delivery systems. There is value to performance improvement, just not as a summative evaluation of a physician or practice. So let's all sign a document that tells CMS to abandon the folly of measuring family physician quality with simplistic electronic medical record- or billing-based measures. Our worlds are too complex for the computers to keep up with.

Richard Young

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I agree what we do is very, very subjective. But the alternative is to wait to see what they decide on and be forced to practice that way. Someone, somewhere is going to hold us to something; we should decide what that is. Maybe it is relationships. Maybe it is intent to change behavior. Maybe it is QOL but with wiggle room - a movement of QOL in the right direction counts as much as better QOL.

This is the kind of conversation we need where we offer something that we think we could be measured by, not just what we don't want to be measured by.

Hugh Silk

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Submit to, or occupy CMS? Only the latter will have any meaningful impact.

Michael Fine

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I think this is a challenge for the Family Medicine community. We have a talented core group of researchers who understand both quantitative and qualitative measurement methods. Also, Direct Primary Care can remove the control of those who juggle the carrots and place the measurement that matters in the hands of the patient.

Larry Bauer

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I will be attending a symposium in about two weeks to talk about future research directions concerning behavioral change. One of the most important things we do in family medicine is to help patients make decisions around, and commitments toward, change. What can we measure that makes a difference? What is it about family medicine that helps patients in that process?

David Loxterkamp

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David, this probably comes as no surprise, but I disagree with your "most important things" statement. The most important thing we do is not to cause patients to change their behavior, but to non-judgmentally accept them as they are and to foster a lifelong conversation with them about their options and trade-offs for every health-related concern they have. How much impact do we have on causing smokers to quit long-term? About 5%. How much do we affect weight loss? Essentially none at all. We should tell our patients to go to Weight Watchers and not waste their time or society’s resources trying to "educate" them into lower weights. These outcomes are not what is so valuable about family physicians.

This is another example of why industrial QI thinking doesn’t work for much of family medicine. QI assumes there is a discrete outcome that can be declared as success or failure within a relatively short time frame: over a few Plan, Do, Study, Act cycles. One of the ways we deliver better care at a lower cost is to foster an endless series of negotiations with patients over a lifetime, constantly adjusting the options and goals as the natural history of the disease evolves and all of the other changes in their lives affect their health: births, deaths, job loss, job gain, bouts of depression, bouts of elation, and everything in between.

This is the message CMS needs to hear. Maybe a measure about how much time your family physician talked to you about your options would be valid. Of course, this shouldn’t be measured until CMS agrees to pay us to take the time to implement it.

Richard Young

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Richard, as a patient who wants a doctor to work WITH, not to be harangued by, your point is spot on. I love my family doctor because he assumes I am an intelligent individual who wants to be healthy and live a happy long life -- not a bag of organs in need of fixing.

Shannon Brownlee

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Friends, this is an interesting series of comments. I've noticed after about 177,000 patient encounters many similarities and differences. One of my responsibilities as a Family Physician is to make sure that each patient knows that he or she matters - sort of a human validation and often a role validation (father, mother, patient, guardian, etc.). AND, know that I matter, too.

Could we have a measurable energy that when combined with our context and the patient's context, delivers wholeness? The human energy field of patient and physician engaged in dyadic sharing and mutual interdependence may be measurable as technology evolves (probably with a cell phone). Their fear of short or long term loss, or that we won't connect to their reality and further mis-align them with their potential, combined with our fear that their problem might exceed our skills or our coding skills or our employer's mandates for our scope of practice and time allotment may suddenly (or over time) melt into a mutually beneficial human dance of meaning, enhancing organ and system and spiritual unction for both. Can the creative tension of this dyadic dance show merit of a financial sort to someone who might pay?

I love what I get to do. I love being a Family Physician. I'm blessed to get a close look at the human condition in the context of meaningful relationships that enable humans to better align with their values, goals and dreams. And measurable or not, my values, goals and dreams are included in the outcomes of doing Family Medicine.

Pat Jonas

A rational way forward on lung cancer screening

Over the weekend, a family physician colleague asked me to explain why the Affordable Care Act requires private health insurers to provide first-dollar coverage for preventive services that the U.S. Preventive Services Task Force assigns an "A" or "B" (recommended) rating, but allows public insurers (Medicare and Medicaid) to determine if and how they will cover these services. Until recently, the question hadn't come up, since Medicare has agreed to cover pretty much every screening test or preventive medication deemed by the USPSTF as being effective (or, as the Task Force would say, benefits outweigh harms). Low-dose CT (LDCT) screening for lung cancer in heavy smokers over age 55 is the first case to highlight the implications of this legislative leeway; given a "B" rating by the USPSTF last December, this test was nonetheless rejected by Medicare's Evidence Development and Coverage Advisory Committee (MEDCAC) at its April 30 meeting for having insufficient evidence to convince them that seniors would actually benefit from it.

If Medicare follows MEDCAC's lead and declines to cover LDCT scans, a 64 year-old with a greater than 30 pack-year smoking history and any private health insurance plan will be able to receive lung cancer screening for free, while a 65 year-old with the same medical history and Medicare coverage will need to pay $300 or more out of pocket or skip the test. That outcome would make sense to neither patients nor physicians, and unsurprisingly, the American College of Radiology released a strongly worded statement as soon as the MEDCAC decision was announced, reaffirming its support for "full national coverage of these lifesaving exams."

Outraged radiologists can rest easy. The politics of this situation mean that Medicare will likely override the advice of its advisory committee, regardless of what science says. 44 senators have already sent a letter to CMS Administrator Marilyn Tavenner urging that LDCT be covered as soon as possible. Medicare expects to release its coverage determination in November, around the time of the midterm elections, and as readers of this blog recall from the 2010 midterms, the current administration has a record of disregarding inconvenient evidence from federal health agencies when control of Congress is at stake.

I and many others who are familiar with the evidence (including the American Academy of Family Physicians) believe that the Task Force overreached in declaring lung cancer screening to be beneficial based on a single abbreviated randomized trial that focused more on the benefits of screening than the physical, psychological, and financial harms (described further in a recent JAMA Internal Medicine paper) that result from the screening cascade. Even when screenings are "free," subsequent diagnostic tests and treatments are not. Further, the USPSTF extrapolated from data on 3 years of LDCT scans to recommend that screening continue annually for up to 25 years in smokers who don't quit, and extended the upper age limit for screening 6 years beyond anyone in the trial (from age 74 to 80). What's the long-term risk of developing cancer from the additional radiation of 20 or more LDCTs, plus several additional full-dose chest CTs precipitated by a 96 percent false positive rate? How many more biopsy-related and surgical complications will occur in practice than in the trial? No one really knows, and that's why I worry.

An editorial published yesterday in the Annals of Internal Medicine makes a good argument for a middle ground between screening only seniors who can afford it and the roughly 9 million Americans who are potentially eligible for the test: "for CMS to offer coverage of LDCT screening only when it is done in facilities that are certified as comprehensive, patient-centered programs designed to maximize benefits and minimize harms." It would be nice if these conditions were met at every institution that offered screening tests to seniors, but unfortunately, many providers are more interested in maximizing profits than improving health outcomes. For LDCT, a screening test for which the jury is still very much out, this proposed policy offers a rational way forward.

Limitations of clinical protocols: the example of sepsis

Unwarranted variations in medical care contribute to poor health outcomes in the United States. In many cases, following a standard management protocol is likely to produce as good or better results than clinical judgment alone. For example, American Family Physician's Point-of-Care Guides provide high-quality clinical decision rules and tools designed to improve quality of care for problems encountered by family physicians in outpatient and inpatient settings.

Similar principles have guided the management of patients presenting to emergency departments with severe sepsis and septic shock since a 2001 randomized trial found that early goal-directed therapy, or EGDT (including central venous catheterization, intravenous fluids, vasopressors, inotropes, and blood transfusions) improved mortality compared to usual care. A 2013 AFP review, "Early Recognition and Management of Sepsis in Adults: The First Six Hours," recommended using the EGDT protocol and concluded that "timely initiation of evidence-based protocols should improve sepsis outcomes."

This conclusion was recently put to the test in a multicenter trial published in The New England Journal of Medicine. 1,341 patients presenting to 31 emergency departments in the U.S. were randomly assigned to protocol-based EGDT, procotol-based standard therapy, or usual care. Surprisingly, the trial found no statistically significant differences between the three groups in 60-day mortality, longer-term mortality, or the need for organ support.

An accompanying perspective cautioned policymakers against rushing to implement regulatory mandates to adhere to sepsis protocols in light of the increasing incidence of this diagnosis and potential harms of protocol-based care:

Protocols that force physician behavior risk promoting inappropriate prescribing of broad-spectrum antibiotics for noninfectious conditions, unnecessary testing, overuse of invasive catheters, diversion of scarce ICU capacity, and delayed identification of nonsepsis diagnoses.

Two lessons from this study for the management of sepsis and other areas of family medicine are that decision rules and protocols should be derived from replicable studies conducted in multiple settings; and that these tools can sometimes enhance, but should not supplant, best clinical judgment.

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This post was first published on the AFP Community Blog.

Health Benefits of Resveratrol: New Plaudits

Joe: My doctor told me to give up drinking, smoking, and fatty foods.

Sam: What will you do?

Joe: I think I’ll give up my doctor.

I try not to get too excited about memory benefits of supplements, because too often the claims are not substantiated by studies that are well controlled and peer reviewed. I now think resveratrol may be one of the few supplements that benefits brain function.

When I wrote my first blog on research on resveratrol benefits for brain function and memory, there were over 2,000 scientific papers.[1]Don't worry; I am only going to tell you about a few studies.

Resveratrol is an active ingredient in red wine. This compound has been credited for explaining why red-wine drinkers in France, who drink more wine than most people, are healthier than would be predicted by their lifestyle of little exercise and eating lots of cheese. The problem is most studies suggest you would have to drink a 100 or more glasses of red wine a day to get much resveratrol effect (and that effect would obviously be negated by a toxic dose of alcohol). An obviously more healthful choice is the highly concentrated pill forms of resveratrol that are now on the market.

Most of the protective biological actions associated with resveratrol have been associated with its scavenger properties for free radicals and the protective effects that it confers on the heart and diabetes. 

One important study comes from a diabetes research group in Brazil recently who reported a beneficial effect of resveratrol on diabetic rats.[2]Resveratrol (in a modest rat dose of 10 and 20 mg per kilogram per day for 30 days) prevented the impairment of memory induced by diabetes. An earlier study by another group showed resveratrol improved glucose metabolism and promoted longevity in diabetic mice.

Another benefit of resveratrol is the anti-oxidant property. The brain produces more free-radical damage than other organs, and compared with other organs the brain has especially low levels of antioxidant defense enzymes. 

One recent study has revealed resveratrol had protective effects against brain damage caused by a chemical that kills acetylcholine neurons. Injection of this toxin into the brain of rats impaired their memory performance in two kinds of maze tasks. The impairment was significantly reduced by repeated injection of resveratrol (10 and 20 mg/kg) per day for 25 days, beginning four days before the toxin injection.[3]

Another recent study examined effects on working memory in mice fed a resveratrol-supplemented diet for four weeks before being injected with a cytokine to induce inflammation and accelerate aging. Resveratrol significantly reduced memory impairment in the aged group, but not in the young adults[4]. The lack of benefit in young adults was a little misleading, in that there was a "ceiling effect" in that the young adults were not impaired by the cytokine injection.

 The practical issue for us is whether resveratrol will help cognitive function in humans, especially healthy humans. It seems likely because other substances that have strong anti-oxidant properties seem to improve memory capability. Because animal studies have shown promise for resveratrol in preventing or treatment several different conditions associated with aging, several human clinical trials have been initiated.[5]

 An impressive new study of older humans, male and female, has just been reported.[6]Twenty-three healthy, but overweight people completed 6 months of daily resveratrol intake (200 mg ― the commercial brand I take has 300 mg/capsule). A paired control group got placebo pills. A double-blind design assured that neither the subjects nor the experimenters knew which individuals were in each group during data processing.

Memory tests of word recall revealed significant improvement in the resveratrol group. Resveratrol also increased brain-scan measures of functional connectivity, which identified  linked neural activity between the hippocampus and several areas of cerebral cortex.

Because others had shown that resveratrol increased insulin sensitivity in humans, these authors examine several markers important to diabetes. Resveratrol decreased the standing levels of sugar-bound hemoglobin, a standard marker for glucose control.  

What foods besides red grapes have resveratrol? The most likely other sources you would eat or drink are blueberries, cranberries, and peanuts. It is not likely that you could drink or eat enough of such substances to get enough resveratrol to do much good. Because of the scientifically documented benefits of resveratrol, highly concentrated supplements are now on the market (I have been taking it for a couple of years) I haven't given up my two glasses of red wine each day, but I have started taking one of the supplements. I haven't seen any reports that high doses of resveratrol are toxic.

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[1] http://thankyoubrain.blogspot.com/2010/04/resveratrol-red-wine-magic-chemical.htmlApril 4, 2010.

[2] Schmatz R, et al. (2009). Resveratrol prevents memory deficits and the increase in acetylcholinesterase activity in streptozotocin-induced diabetic rats. Eur J Pharmacol. 2009 May 21;610(1-3):42-8. Epub 2009 Mar 19.

[3] Kumar, A. et al. 2007. Neuroprotective effects of resveratrol against intracerebroventricular colchicine-induced cognitive impairment and oxidative stress in rats. Pharmacology.79 (1): 17-26. DOI: 10.1159/000097511

[4] Abraham, J., and Johnson, R. W. 2009. Consuming a diet supplemented with resveratrol reduced infection-related neuroinflammation and deficits in working memory in aged mice. Rejuvenation research. 12 (6): 445-453.  DOI: 10.1089/rej.2009.0888

[5]Smoliga, J. M. et al. (2011). Resveratrol and health – a comprehensive review of human clinical trials. Mol. Nutrition Food Res. 55: 1129-1141

[6] Witte, A. V., et al. (2014) Effects of resveratrol on memory performance, hippocampal functional connectivity, and glucose metabolism in healthy older adults. J. Neuroscience. 34 23): 7862-7870.

The best recent posts you may have missed

Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from March, April, and May:

1) Family physicians are natural health system leaders (5/26/14)

Compared to all others, students entering family medicine were statistically more likely to recommend generic over brand-name medications and favor initial lifestyle change counseling to starting medication for a mild chronic condition.

2) Why conflicting guidelines can be good for patients (3/19/14)

Sure, it's easier for everyone when guidelines agree on what to recommend for a particular patient in a particular situation. But when “reaching alignment" is simply a euphemism for one guideline group exerting political pressure on others to fall into line, that isn't good for medicine or for patients.

3) "Free" health screenings have hidden costs (4/3/14)

With the goal of improving access to preventive services and medical screening, the Affordable Care Act offers free screening mammography to women. However, women often pay for the consequences of screening, even if the screening examination is free. 

4) Health insurance is not health care (4/9/14)

I believe that health insurance should be a mandatory financial mechanism for paying for unexpected, catastrophic health expenses, just as fire insurance will pay if my house burns down or flood insurance will pay if a hospital in a low-lying area is devastated by a hurricane. On the other hand, health insurance is a grossly inefficient mechanism for paying for expected care - that is, primary and preventive care.

5) Perspectives on preventable causes of death (5/20/14)

Routine social work visits and public policies that spur economic growth, reduce unemployment, and increase access to decent, affordable housing make a much bigger difference in health outcomes than do medical preventive services.

If you have a personal favorite that isn't on this list, please let me know. Thanks for reading!

Guest Post: Twitter and the Physician – On the Etiquette of Trolls

Dino Ramzi, MD, MPH is a family physician who practices in Washington State and blogs at DinoRamzi.com. You can follow him on Twitter at @dwramzimdmph.

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What is earnest is not always true; on the contrary, error is often more earnest than truth. – Benjamin Disraeli

I was recently called a troll on Twitter by academic physicians at two universities, one to which I was once affiliated. When I looked it up, I found that a troll is “a person who sows discord on the Internet by starting arguments or upsetting people, by posting inflammatory, extraneous, or off-topic messages in an online community, either accidentally or with the deliberate intent of provoking readers into an emotional response.” I wanted to strike back, but with wise counsel and some peace in my heart, I decided not to act like a troll.

The internet is proving no different than other forms of speech; it is fraught with rules of conduct and the opportunity for conflict. State medical boards, the American Medical Association and the Federation of State Medical Boards have written guidelines describing the limits to appropriate social media interactions for physicians. Most of these guidelines understandably focus on interactions with patients, but the FSMB comments on professionalism between physicians, albeit vaguely.

Having been active on social media for over a decade, I have found that the combination of anonymity and the emotions aroused by poor grammar and typos mix poorly with the power to publish at a moment’s notice. It is also difficult not to allow professional and personal unhappiness to seep too deeply into one’s writing. The unhappiness is fleeting, the posts are more permanent.

Some of the conversations I have seen and been involved in would raise the hackles of many a state medical board or academic employer. People do not speak with each other online as we would face-to-face. In academic circles, I would be invited to thoracic surgeons’ homes to dine and occasionally to spar politely with the chief of cardiology. But online, the discussion does not hide professional contempt and degenerates swiftly to the direst rants. I am aware of at least one urologist who lost an academic appointment after “losing it” during an online academic dispute.

Conversational flash points with subspecialists have included PSA screening, mammography, and most recently, CT screening for lung cancer. It is amazing how physicians react when their authority is challenged. There is a lot of shoddy science out there being accepted as fact without good grounding in clinical epidemiology. Physicians who raise doubts about the effectiveness or value of screening are frequently the target of unwarranted online opprobrium.

My primary concern is that screening is a population health measure, and while I want to understand the perspectives of subject experts, they are less qualified than primary care scientists to make decisions regarding screening policy. Make no mistake, I am a family physician and, like most generalists, have been exposed to specialists who belittle my knowledge, skills and credentials; it comes with the territory. Still, it stunning to hear disease experts repudiate the input of their more statistically-inclined colleagues. Screening, properly understood, has nothing to do with expertise in the disease. Surgical expertise and understanding of the biological behavior of various types of cancer cells does not translate into a basic understanding of epidemiology 101.

My second concern is the professionalism of the discourse. The disputes in question are essentially scientific, although the medium is better-suited for marketing than academic discussion. Claims like “you have your study and I have mine,” as I have heard, are not helpful to the integrity of the debate itself. There has to be an approach to dialogue that does not take a page out of the strategic communications handbook. In both the mammography and PSA controversies, urologists and other lobbies applied tremendous pressure on the population health experts to generate recommendations favorable to their cause, a process which undermines the credibility of science itself.

My third concern arises from my reading of the FSMB's guidelines on social media. The FSMB would suggest that physicians should be held to a higher standard of behavior, which means avoiding profanity even if goaded.

Physicians inexperienced in social media may fly off of the cuff, especially given that 140 character messages can lead to misunderstanding. Much better to ask repeated clarification, especially on the part of physicians exercised in the art of nuance, who can frequently take 4 to 5 posts to express themselves properly. When ideas are condensed, it is easy to miss two or three layers of allusion or implication. Better to take it into a medium better suited to lengthier discussions of ideas.

Remember that social media are public media where professional respect and a higher standard of behavior is expected, not for personal reasons or pride, but for the integrity of the scientific debate. We can all learn from each other, in person and online. Think before you post, or consider bouncing words written in anger off a trusted colleague before posting.

Memory Athlete Gimmicks. TIP 2: Composite Flash Card

Teaching, learning, and remembering don’t have to be complicated. In my previous Memory Athlete" Tip #1, I described a strategy based on linking mental images to particular locations in a familiar environment, such as one's home or yard. Here, Tip 2 describes my invention of a simple flash-card process that can help accomplish all three educational processes in a computer slide-show file consisting of only one slide. This one-screen file can serve as a single composite “flash-card” reservoir of information from which information can be organized and modified, saved for on- or off-line study, and always available for self-testing (in principle, as is done with conventional flash cards). Conventional flash cards are typically limited to factoids, with a word on one side and definition on the other. But composite flash cards are fundamentally different because they provide a way to capture and learn whole cohesively organized concepts as well as factoids.

Moreover, the new type of card captures many well-established principles of effective learning and memory (Klemm, 2012, 2013). Unlike the common teacher-centric mode that stresses presentation and explanation, this new system incorporates the student-centered need to encode and remember presented information, all in the same visual and conceptual space.

The principle, as in Tip #1 is also based on the idea that remembering what the information is depends largely on where it is. Here, mental images are pinned to specific spots in a table in PowerPoint and animated so that you can browse through the items in proper sequence, one at a time.

The entire process is illustrated with nine key memory-improvement concepts in a single PowerPoint slide that serves as a “home page” (Fig. 1). The memory-improvement concepts, represented by clip-art icons in sequential left-to-right, top-to-bottom order are: 1) enhance motivation, 2) allocate learning time wisely, 3) organize learning material, 4) make nets of association, 5) don’t overload working memory, 6) reduce memory interference, 7) don’t multi-task, 8) think about what is to be memorized, and 9) self-test. Readers can get construction details and download this actual slide show from a link at http://03908f9.netsolhost.com/thinkbrain/educational-consultant/(scroll down to the bottom until you see "Klemm cards").

Fig. 1. Edit view of a PowerPoint slide containing basic information about nine key concepts of effective learning and memory. In slide-show play mode, the objects (icon and associated text block) are coded for animation, so that each icon and associated bullet list appear in turn upon a mouse click. The opening screen in show mode will ordinarily be blank or contain the very first icon at upper left. Icons can have hyperlinks to other sources of information. Mouse click on an icon links to an enlarged corresponding bullet slide and its hyperlinks.

To illustrate the reasoning in Fig. 1, the mental image of the first icon conveys the self-evident idea that the fellow without a parachute is highly motivated to “hang in there.” To mentally link the bullet points, a learner could visualize him praying he doesn’t slip loose, helping him to “believe he can hang on.” Then imagine him clutching more desperately than he needs to, just to “fight boredom.” Then when he lands safely, he can be visualized as celebrating by playing his “A game” in basketball. As another example, the second icon of an alarm clock conveys the idea of managing time. Imagine seeing the clock set 10 minutes before the hour (“10 minute rule’). Then picture multiples of such a clock (“reserve lots of time”), each appearing as fast as possible (“don’t procrastinate”). Space the clocks apart (“space learning”). Silly, yes, but that is what makes such imaging memorable.

The spatial organization of the icons makes it easy to remember them and even their sequence. During recall required by self-testing or examinations, remembering the images automatically brings up the associated bullet-point ideas. To accelerate the speed at which icons can be memorized, a learner can think of associational links between icons. For example in Fig. 1, after seeing the motivation icon, an association can be made with the next icon (clock) by imagining that the parachuting people are looking at a clock to time how long it will be before they hit the ground.

Options for Use

Organizing and Presenting Information. The instruction mode is shown on the right side of Fig. 2. Cards can be created by a teacher, as the basis of a lecture, or by a student, who constructs it from lecture and/or assigned learning resources. Icons can be used as hyperlinks to separate slides that contain bullet points, text, or diagrams. Animating the objects allows them to be displayed one at a time.

Figure 2. Logic flow diagram for use of the flash card in two different modes: on the left for a single flash-card study and self-test and on the right for expanded organization or presentation of learning material. A slide show developed as shown on the right can still be used for self-test from the single flash card “home.”

A student or teacher could play the complete slide show, or whatever portion is desired at a particular time, by mouse clicking through the icons and their bullet lists, and launch into the detail slides by clicking on the ICON (as opposed to blank space); each detail slide has links on it to return back either to the bullet list or to the “home” flash card. A link is not needed to go to the next detail slide is not needed, as each slide in that path appears on a mouse click on open space. Obviously, this same home card can be played for self-testing via the flash-card mode process on the left of Fig. 2.

Before clicking, the teacher may want to ask the class what they think or know about the role of motivation in learning. During or after explaining the bullet points, the teacher may wish to pause before the next click to answer questions, orchestrate class discussion, launch a traditional slide show, show a video clip, conduct a demonstration, conduct a hands-on activity, or whatever. In an on-line tutorial, a hyper-linked audio file could provide the instruction.

When all items in the home page are displayed, students see a grand overview of the content, and, as with matrix notes, it should be easy to discern cross-cutting relationships among the ideas. In Fig. 1, for example, students might discern that organizing the material requires thinking hard about meaning and relationships or that multi-tasking creates interference effects.

Teachers can spread the instruction across multiple class periods from the same card (after class one, for example, she would resume in class two where she left off last in the flash card and repeat with each later class. Since each subsequent class period brings up the original card, teachers can click on previously displayed objects as a review. In an on-online environment, students can self-pace as they work their way through the card’s information.

The teacher may want to tell students in advance to take notes as each icon is presented. After the lecture, the computer file (the single flash card) can be e-mailed to students, and they can modify the bullet points on the basis of the notes they took in class. Alternatively, if students have computers in class, they can load their copy of the slide show and make notes directly in their copy. Once in their possession, students can customize the file and use it again and again for study and self-testing (see below). A whole semester could be taught this way, with each lecture based on its own single card.

Flash Card Self-study and Testing. Cards can be designed simply for study and self-testing (left side of Fig. 2). Extra slides to expand on a given icon’s mnemonic representation are added at will, and links to them can be created from any icon to an expanded bullet list, which in turn has hyperlinks to any number of extra slides on that topic.

The same approach can be used by students to construct their own flash cards from textbooks, videos, websites, or other information sources. This might be an improved way to document Web quests.

With a composite card constructed with each icon and text box tagged for animation, the learner simple clicks through one item at a time. Thus, the composite card serves as a study and self-test tool wherein the learner tries to memorize the icons and the ideas they represent. True self-testing is easily done when the learner anticipates what should appear upon mouse click and then adjusts recollection to correct any memory errors.

Students can study a card file in edit mode, which allows the student to see, all in one place, both the “big picture” and the fine detail of the information presented in lecture or gleaned from other sources. One typical problem in education is that academic content is dumped on students as an overwhelming mass that obscures perspective and context. Students can easily feel like a rat lost in a maze. But if they could look at the maze from the top view, they would easily see how to navigate it. When students can see and think about the total display of information on the home page screen, they may find it easier to see cross-cutting relationships. Different icons can be substituted and re-arranged (first “group” the icon and its text box) if needed to enhance the inherent meaning for a particular student. The student can even add cells to the table and insert new material and links that were not included in the original information presentation.

Perceived Benefits

The advantages of this system would seem to include the following features:

·         Comprehensive. All manner of information can be packaged into a single card. Intervals between mouse clicks can be used for other modes of information presentation, discussion, and learning activities.

·         Compact. Everything is all in one place, viewable as a holistic display, yet the user can drill down via the card’s hyperlinks to extensive detail within the slide show.

·         Flexible/extensible. Cards can be constructed for presentation of information from any source: lecture, books, websites, or whatever. A given card can be modified at any point in time, by either the teacher or the student. Information content can be expanded simply by adding new table cells. Major topics can have their own separate and independent cards. Teachers can readily adapt the system for on-line or in-class teaching.

·         Organized cohesively. Ideas are organized as topics, and subtopic ideas are shown as associated bullet points. Sequential order is preserved (left to right, top to bottom). When the user drills down to a detailed bullet point slide, “return” hyperlinks quickly lead back to the home page.

·         Studied quickly. Students can view everything at once and zoom in on parts that need further thought or rehearsal. Students can modify any part of the slide as needed during the study process.

·         Self-tested in flash-card style. Students can anticipate what should appear upon the next click and check to see if they had it correct. Any needed modifications are quickly made on the fly during self-testing. This design discourages students from glossing over the memorization process by “looking over” material without really forcing a self-generated answer.

·         Embodied key memorization principles. This one approach captures a wide range of generally accepted principles that facilitate memory. Students and teachers are enabled and encouraged to:

·         Condense content is to essentials (“less is more”―Süss et al. 2002; Norretranders, 1998).  Memory capacity is limited and easily overwhelmed by too much information. Moreover, memorization is facilitated by excluding information that one already knows or can figure out.

·         Organize material by arranging like items in the same row or order a sequence in which rows are read left-to-right, top-to-bottom.

·         Chunk items in small groups by putting like items on the same row of the table.

·         Represent ideas with images, which are far easier to memorize than words (Rigney and Lutz (1976).

·         Create a spatial organization that itself facilitates memorization (Vaughn, 2007; Sparrow et al. 2012). Composite flash cards are a form of “method of loci,” an ancient technique that works because where information is provides important cues for what information is. Such cues help in both forming and recalling memory. Because only a few images are on a given row, it is a trivial task to remember the three or four images on a given row. To create location “pegs” for images on each row, users could use the classical number coding system (Klemm, 2011), in which row one would be indexed by an image of “tie” (as in neckties), row two by “Noah” (as in the Ark), row three by “ma,” (as in mother), and so on. Thus, for example, in row one a user can visualize a necktie wrapping around the several images on that row. A user could also make a visual story line that begins with a tie linked to an image of the first item on the row, which in turn is lined to the second item, and so on.

·        Capitalize on the convenience of having all memory processes (encoding, consolidation, retrieval) operate in the same visual format and space in which information is presented. This composite card structure is akin to matrix note taking, which offers the added advantage of making it easier to see cross-cutting relationships that may go undetected in other forms of note taking (Kiewra et al. 1991). The holistic display of all information makes it easy to perceive any one item in the same context, while at the same time making it possible to see two or more items in a new context.

·        Learners can self-pace study and review. Learners can easily self-test frequently and do so in a much more powerful way than the common approach of just “looking over” the material. True self-testing is apparently under-utilized by the typical student (Pyc and Rawson, 2010; Karpicke and Roedinger (2008).

·         The process of creating a composite card is engaging. Learners simply must think about the material to decide what goes where, what images are most useful, and what are the minimally useful number of key words.  In my 50 years of learning and teaching, I have become convinced that thinking about learning material is the best way to memorize it.

·         Easily constructed and modified. Anyone who knows how to use presentation software like PowerPoint can easily make, modify, and navigate the information content.

References

Foer, Joshua. (2011). Moonwalking with Einstein, New York: Penguin.

Karpicke, Jeffrey D., and Roedinger, Henry L. III. (2008). The critical importance of retrieval for learning. Science. 319, 966–968.

Kiewra, Kenneth A.; DuBois, Nelson F.; Christian, David; McShane, Anne; Meyerhoffer, Michelle; Roskelley, David (1991). Note-taking functions and techniques. Journal of Educational Psychology, 83(2), 240-245. doi: 10.1037/0022-0663.83.2.240

Klemm, W. R. (2012). Memory Power 101. New York: Skyhorse.

Klemm, W. R (2013). Better grades. Less effort. On-line e-book. Bryan, TX: Benecton Press.

Norretranders, T. (1998). The user ilusion. Cutting cnsciousness down to size. New York: Viking Penguin.

Pyc, Mary A., and Rawson, K. A. (2010). Why testing improves memory: mediator effectiveness hypothesis. Science, 330: 335.

Rigney, J. W., and Lutz, K. A. (1976). Effect of graphic analogies of concepts in chemistry on learning and attitudes. J. Educ. Psychology. 68, 305–311.

Sparrow, B., Liu, J., and Wegner, D. M. (2012). Google effects on memory: cognitive consequences of having information at our fingertips. Science. 333, 776-778.

Süss, H. –M. et al. (2002). “Working-memory capacity explains reasoning ability—and a little bit more.” Intelligence. 30,261–288.

Vaughn, Dean. (2007). How to remember anything. N.Y.: St. Martin’s Press

There are many ways of "knowing cancer"

In my line of work, it's not uncommon for a civil debate about the evidence for a cancer screening test (such as the PSA test for prostate cancer) to rapidly degenerate into the other person questioning my motives or suggesting that the real reason I oppose disseminating or requiring insurers to pay for a test is because I secretly want patients to suffer lingering and painful deaths. ("He obviously doesn't care about truth or patients," an academic urologist once tweeted in response to my blog post on pitfalls of screening studies.) Another charge that screening advocates level at skeptical family physicians is that we "don't know cancer" because we are generalists who don't see cancer patients day in and day out. I have countered that it's entirely possible to care for patients who die from cancer and still require high-quality evidence of net benefit before widespread adoption of interventions that might prevent such deaths.

This begs a larger question, though: how can any physician or researcher who has never personally suffered from cancer claim to "know cancer"? Is it enough to have spent years or decades studying the epidemiology, diagnosis, and/or treatment of a particular type of cancer? Must one have diagnosed or treated a certain number of persons with cancer? Or can one only know cancer though enduring the trauma of having an afflicted parent, sibling, child, or spouse?

Dr. Peter Bach, a pulmonologist and epidemiologist at Memorial Sloan Kettering Cancer Center in New York City, holds the unfortunate distinction of being able to answer "Yes" to all of the above questions. He is a nationally recognized expert on lung cancer, leading a 2012 systematic review on the benefits and harms of low-dose CT screening that informed recent guidelines from the American Cancer Society and the American College of Chest Physicians (which he also co-authored). Dr. Bach has also been one of the few voices of caution regarding the U.S. Preventive Services Task Force's sweeping recommendation for annual lung cancer screening in heavy smokers age 55 and older. Here is his trenchant explanation of why the Task Force should not have relied on decision models to extrapolate beyond empirical evidence from screening trials:

The Task Force seems to have looked for findings where there was “consensus” between the models as a way of overcoming the heterogeneity between them. However, because they are starkly different on so many fronts, looking only for the overlap is reminiscent of the Texas sharpshooter and the fallacy that accompanies him. The sharpshooter shoots first at the barn and then draws the target around the greatest cluster of hits.

What has made Dr. Bach a household name in the cancer community is none of these things, however. Instead, it is his moving article about losing his wife, Ruth, to metastatic breast cancer in the May 6th issue of New York Magazine, "The Day I Started Lying to Ruth." Although I have long respected Dr. Bach for his incisive scientific publications, this was the first time I'd read him writing this personally (he also authored a series of Well Blogs in the New York Times in 2011 about Ruth's cancer diagnosis). One passage jumped off the page at me as a perfect illustration of hope overwhelming evidence when a loved one is suffering:

As he [Ruth's oncologist] wrote out the prescription for her to start the next treatment, what doctors call “second-line treatment,” I recalled a colleague of mine explaining the progression from first-line to second-line to third-line treatment. Each successive change brings more side effects with less chance of benefit. As my colleague put it, the cancer gets smarter, the treatments get dumber. Somewhere in this progression the trade-off no longer makes sense. Where that is may differ for each patient, but I’ve often thought that cancer doctors go well past that point.

None of that mattered to me, the medical professional to whom all these nuances and trade-offs should. All I could think about was the blood test telling us the tumor marker was too high. With that, any dreamy conceit—that patients should be given enough knowledge that they can weigh the risks and benefits for themselves, then come to the choice that best suits them—flew out the window. Our choice wasn’t a choice. Take the chemo.

There is no doubt in my mind that Dr. Bach would, in a heartbeat, exchange any moral authority he derives from having "known cancer" in this intimate way to have his wife back. All of us involved in confronting cancer in all its forms - specialist and primary care clinicians, advocates, patients, family and loved ones - know cancer in different ways, and none should be held up as inherently superior to any other. In debates about cancer screening, we may disagree about "truth," but like Dr. Bach, we all care about patients.