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Clean Hands, Humble Minds: The Semmelweis Lesson for Modern Medicine | Grand Rounds · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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  This is Pediatrics Now, brought to you by the Department of Pediatrics at UT Health San Antonio.
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  Today, I'm bringing you grand rounds. Let's listen in. Today,
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  it's my pleasure to introduce Woodson Scott Jones.
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  He, MD, he is the Vice Dean for Graduate Medical Education and the Designated
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  Institutional Official at the Joe R.
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  And Teresa Lozano Long School of Medicine at UT Health San Antonio,
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  where he is Professor of Pediatrics and the Lois L. Breedy, MD, endowed professor.
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  A board-certified pediatrician, former pediatric residency program director,
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  and retired U.S. Air Force colonel, Dr. Jones has spent his career at the intersection
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  of clinical education, professionalism, quality improvement,
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  patient safety, and health systems leadership.
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  Nationally, Dr. Jones is recognized for leadership in GME, patient safety,
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  physician well-being, professionalism, education, and practical Innovation,
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  and Academic Health Systems.
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  He has served as Faculty and Course Director for National AAMC GME Leadership
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  Development Programs, presented extensively for the AAMC,
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  ACGME, NADIO, and other organizations, and authored or contributed to publications and curricula,
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  focused on clinical learning environments, well-being, professionalism,
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  quality improvement, and the responsible adoption of AI in GME operations.
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  Today's Grand Rounds presentation, Clean Hands, Humble Minds,
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  the Semmelweis Lesson Eight Years Later, revisits the story of Ignace Semmelweis as a.
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  Lens for understanding why evidence alone rarely changes practice.
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  Drawing on the evolution of hand hygiene, central line infection prevention,
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  clinical learning environment research, organizational culture,
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  and emerging questions about artificial intelligence in medicine, Dr.
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  Jones challenges clinicians and educators to pair scientific evidence with humility,
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  trust, collaboration, and systems thinking.
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  And I, of course, just have to add that Dr. Jones was my very first mentor as
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  a young physician, when he was assigned to be my internship training officer
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  and tasked with keeping me in line.
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  Before he came to the university, he inspired me and so many other military
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  physicians throughout his military career, especially as a SAWSEC Dean.
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  And I invited him today to talk about my very favorite historical figure. So welcome, Dr. Jones.
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  Gosh, thank you, Dina. Boy, lots of memories. And I'm speaking about a humble mind.
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  You kept me pretty humble, Dina. I very much appreciate it. I still remember
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  I'd just come back from four years overseas, and I get this brilliant young
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  intern who also is moving at a million miles an hour.
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  And we had a lot of talks, Dina. And it's just been a real delight to watch
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  your career and to see you succeed.
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  And I was also very delighted you asked me to revisit this talk so many years later.
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  I say late years later because I gave this talk initially when I had come over to UT.
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  Well, I did it two years before, actually, for UT Passport. Then I did grand
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  rounds in pediatrics, and I haven't revisited it.
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  And so when I'm saying revisit, I'm revisiting some of the evidence and some
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  of the literature that's come out and, frankly, some new challenges from more than eight years ago.
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  I also, I put interested, I put co-pilot up there because I think it's very
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  important in the AI age that we begin to acknowledge when we're using AI.
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  And I'll just say that it flies fairly well most of the time.
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  However, it makes big enough mistakes. I still have to keep my hand on the stick,
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  even though I'm maybe in the cockpit a little bit more with the co-pilot these days.
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  Speaking back to eight years, I had this picture on the left as well in my slide from that.
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  Boy, time flies. This is our family at my third daughter's wedding,
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  not this summer, but last summer.
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  It's just been really exciting to watch them grow. And I know,
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  as you all know, just love to spend time with your family.
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  Goals and objectives are really important here. And I'm going to walk through,
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  spend a little bit of time on this.
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  And so when we use this term, similarized reflex, it's another way to think
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  about if you're familiar with the Heath Brothers change management,
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  they talk about the elephant.
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  They talk about the elephant, the rider, and the path. And the elephant really
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  describes the emotions. And I think one of the things they point out is if you're
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  really going to change culture, if you ignore the elephant, it's going to drag you around.
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  Those who, like us, like me, that are very analytical, we just think it's all
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  about getting in their mind, giving them data.
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  But I tell you, you don't move the elephant, you're in a lot of trouble.
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  And you've got to make it easy for change, too.
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  And health system science works a lot in that area.
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  The second objective is sort of a, well, of course, yet I find to this day I
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  don't necessarily engage in this and think about it enough intentionally when
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  I'm around my learners about how much
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  that learning environment is shaping them now and will shape them
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  for the future and that we have a real responsibility when you think about that.
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  I'll touch briefly, and it's going to be brief, but I do want to introduce us
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  to AI and what is happening very rapidly in this space.
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  And as it moves into the clinical and the educational space, I'm an early adopter.
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  I love it. I come out and running, and yet I think of some wise,
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  and I have also thought how I've tried to just push this over on some in my
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  office, and I've had to back up and say, you know, you've got to lead them along.
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  We need to be more humble about what it can and cannot do, and how do we do
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  this in a way that sticks, is wise,
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  and that our patients and our faculty also adopt it and use it well to move
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  us forward because it's coming, but we have to use the wise in it and have to
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  integrate it very wisely.
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  So with that, I'm going to jump into the story of Dr. Simmelweis.
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  And it's a really interesting story. If you haven't heard of it,
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  I'm really excited to tell you about it.
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  Well, he was trained in Vienna at the second Vienna School of Medicine.
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  It was one of the leading schools in the world at the time. It was famous for
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  its combination of laboratory work and bedside clinical medicine.
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  And this was a real time of renaissance in medicine. It was July of 1846.
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  He became the assistant chief of the first clinic, and he was under the direction of Johann Klein.
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  And among his numerous duties were instruction of the medical students,
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  assistant at surgical procedures and a regular performance of all the clinical
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  examinations on the ward.
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  And one of the most pressing problems he was facing at the time was high maternal
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  and neonatal mortality due to what was described as child bed fever.
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  13%. That's crazy. Think about that.
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  More than one in 10 would get this and a number died.
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  Well, um,
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  Curiously, on the second obstetrical ward in the same hospital had a much lower mortality rate, 2%.
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  The only difference between them lay in their function. The first was the teaching
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  service for medical students, while the second had been selected in 1839 for
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  the instruction of midwives.
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  Everyone was baffled by the contrasting mortality figures and no clear explanation
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  for the difference was forthcoming.
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  This, quote, disease was considered to be an inevitable aspect of contemporary
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  hospital-based obstetrics.
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  Hmm, sounds familiar. A product of this somewhat unknown operation in conjunction
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  with some elusive atmospheric conditions.
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  Well, Simmelweis was a very astute observer, and he noticed that the midwives
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  were delivering via side births. Well, you could test this.
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  So he ordered the students and the physicians on the ward, we're going to start
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  doing side births. He made them all do it. No change.
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  Then he noted, it was noted, that the dead mothers were brought out via or by
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  the clinician ward with the priest ringing the bell.
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  And the prevailing explanation at the time was the sight and the sound of those
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  bells that terrified the women.
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  And that was a psychological shock of knowing death was in the room and made
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  them susceptible to the fever. Well, this fit the era's thinking where emotional
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  disturbance was considered a genuine cause of illness. We actually know there is a relation today.
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  And he began, looked at this as a treatable claim. So he had the priest take
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  a different route and stop ringing the bells.
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  No change. He tried several other things.
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  And frankly, being just so intense individual experience, burnout,
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  and he took a sabbatical and he went to Venice, actually lived near Venice for four years.
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  And, uh, you know, bridge of size seems appropriate here.
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  He was taking a sigh and a break, uh, against this. Well, during this time when
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  he was on sabbatical, a friend cut his finger during an autopsy,
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  uh, on a woman who died of childbed fever.
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  And his friend at his autopsy revealed the same findings found in women who,
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  died of this childbed fever. Well, let's get him the clue.
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  It came to him that a smell stayed on their hands after autopsy,
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  even after washing with soap and water. Well, why did this matter?
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  Well, the doctors and the students would perform the autopsies in the morning
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  before rounding on the patients on the ward.
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  Guess who wasn't doing autopsies? The midwives. He also noted that the women
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  who deliver out of hospital had a rate of childbed fever more similar to the midwives.
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  He began to sort of put this together. So what should he do?
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  Well, he knew that chlorine and lime solutions were added to clean wastewater. So why not try that?
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  So he first began by requiring half of the students to clean their hands with
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  chlorine solution after the autopsies, and the others did regular soap and water.
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  Well, the rate of childbirth, childbed fever immediately fell in their patients.
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  So he ordered all physicians to do this practice. In fact, he closely monitored
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  and he berated those who did not follow this new practice.
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  He was known to tell them on the words, you're killing your mothers.
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  They did not follow this practice.
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  Well, within months, you see the intervention here. the rate of child bed fever
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  fell to that what was experienced by the midwives on their war.
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  This was a huge success. I mean, look at those numbers. If we saw that one of
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  our studies, that would be very prestigious publication and we'd be super excited.
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  And it should have been celebrated, but it was not.
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  Unfortunately, his berating of his colleagues and accusations made a lot of enemies.
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  Additionally, the philosophy of empiricism of the age, that knowledge is derived
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  from our senses and experiences, while remarkably important to scientific advancement, had its limitations.
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  Simenweiss could not explain to his colleagues what this quote,
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  what he described putrid organic matter was, and also women who birthed in the
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  community were known to die from this as well.
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  No one's doing autopsies before the women who deliver in the community.
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  Not noting it was substantively less.
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  Further, even without direct accusations, guess what?
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  It was tough for those physicians to accept their responsibility for the scourge
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  of the thousands of dead mothers that had been impacted by this present, by their practice.
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  You want to compound things, he refused to write up his findings and share it
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  despite his friends urging him to do this.
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  Well, Dr. Klein, his boss, did not renew his appointment two years later,
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  and he returned to the, quote, backwaters of Hungary from Vienna at the time.
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  However, he went to the hospitals with the same high mortality rates.
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  He instituted his practice, saw remarkable results again, and he finally wrote
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  up his experiences in 1861.
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  Well, unfortunately, the review from the foreign critics, because he's now at
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  the backwater, not at the elite institution, were not favorable.
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  They were very skeptical.
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  And he became furious, and he published his open responses, and he mocked his critics.
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  He even collected his letters and published them in 1862 in a pamphlet.
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  While history is not real clear on his demise, it is clear that his mental state
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  declined over the next several years.
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  And after he later gained iconic status, the narrative that he was driven mad
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  by the rejection of his practice came under greater scrutiny.
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  Frankly, we're not really sure exactly what happened, but we do know that his
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  wife took him back to Vienna under a false ruse and he was admitted to an insane asylum.
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  We're not sure what happened, but he sustained some injuries and he died of
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  sepsis within a few weeks.
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  This is incredibly unfortunate because it was not many years later that Louise
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  Pasteur discovered what this putrid organic matter was and Dr.
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  Lister in Scotland instituted the cleaning of the surgical equipment and subsequently
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  published the results in The Lancet in a series of six articles in March of
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  1867, we're not clear on whether he was aware at all
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  of Simmelweis' work. But even if he was.
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  Let's fast forward to 2003. I'm rounding in a former Soviet bloc country in Western Europe.
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  I'm with Western European trained doctors in this former Soviet,
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  and they trained in London, actually, and they were doing some of the leading
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  studies on the treatment of visceral lesmaniasis, kalazar.
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  And I noticed these ID doctors, pediatric ID, were not washing their hands as
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  we moved from patient to patient on the ward.
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  What am I going to do? Surely they got it. These are ID doctors.
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  They chained in London. They got to know this is important.
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  Well, I started yelling at them like, Dr. Simmelweis. No, I didn't yell at him.
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  I started washing my hands. And after we moved from room to room,
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  what did they start doing?
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  Started washing their hands. How could this be in the 21st century?
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  Well, it's the power of culture. And even though they had been trained in some
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  outstanding places, and I'm sure they always washed their hands there.
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  They came back to a culture that wasn't washing its hands and they began to
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  adopt those practices again.
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  Where do you want to adventure a guess on what was the first global patient
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  safety challenge in the date that it was initiated?
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  Well, 150 years after Semmelweis, it was the Clean Care is Safer Care Initiative.
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  And it was a major hand hygiene campaign many years later.
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  And we're still trying, 150 years later, to convince skeptics,
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  or simply even more than convince skeptics, convince people it's super important.
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  I certainly know during COVID, we got it.
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  We were very diligent with our hand washing and everything else during COVID.
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  It's interesting as I kind of pay attention today how we're even lapsing from
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  some of that same very high level of recognition of the value and the importance
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  as we move from patient to patient on our units.
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  But let's look inwardly at our own culture in pediatrics compared to others.
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  Well, I'm really pleased to say, when you think of culture of change,
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  we've done a really, really good job of moving away from blame and shame in
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  the pediatric community and really thinking systems-based in our analysis of
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  errors and the mistakes about what caused,
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  this problem or this error in the patient before looking right at,
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  the individual, the learner, the trainee, the faculty, the student,
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  and blaming them immediately.
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  I think in pediatrics, we've really led the way in this era of change.
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  However, I do pause at times when I think of and look outward to culture change
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  and engagement of communities on acceptance of new science.
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  I don't think we've done as well in pediatrics as some other specialties.
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  Think of similar ways reflexed turned outward towards families that we've been entrusted to care for.
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  If we've learned that shame and data don't move clinicians, why do we still
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  answer hesitant families with more data and, frankly, at times, a whiff of contempt.
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  I will admit I have coined a term DNFers on the newborn nursery,
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  standing for do-nothing families.
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  We've been seeing more and more of them. They don't want erythromycin,
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  they don't want vitamin K, and they don't even want newborn screens.
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  I haven't been the best role model in rounds, at least in how I speak of the DNFers.
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  I do my best when I work with them in person, but how and what am I saying to
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  our rounds impact our residents and the students?
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  This has caused me to pause.
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  And we need to keep in mind that relationship is important.
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  In relationship before rebuttal, we have to keep at the forefront.
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  And in the same lessons, and as I look at how others hear me talk of them,
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  what is being adopted is that skepticism, that cynicism, and frankly that scorn
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  of those patients who don't agree with us.
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  They can read it, they can see it as much as we go into the room.
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  And so I think we need to be very careful and thoughtful and probably even more
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  so at regaining and trying to gain the trust in the relationship of those who
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  don't trust us any longer.
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  Well, many believe that part of the problem is just this, this stove piping
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  that we've seen in how we train.
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  And for years and years, there's this idea of we have the learner,
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  the curriculum, and we have the education and our didactics,
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  and then we have clinical care and the clinical learning environment,
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  and the two are siloed with a little bit of overlap.
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  Now, the good news over the last number of decades, that has clearly changed
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  on the part of because of friends that And I know quite well Dr.
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  Eric Humbo, who headed up the milestones at the ACGME.
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  And I think we've also recognized that this isn't good. We can't really think
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  of these stow-piped environments. They are too integrated to think about as
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  separate type of environments.
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  And we've also been able to look at how have we been doing in the United States.
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  And we certainly spend the most, we spend probably the most on education as well as our health care.
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  And we are certainly not the healthiest.
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  We've gotten a lot better. We have to acknowledge that.
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  On the same hand, on the same time, our life expectancy is less.
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  Our infant mortality is double that of peer countries.
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  You guys have all heard this. I don't have to go over it. Yet,
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  on the other hand, we need to look at the green box here. And those are the
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  gains worth looking at and acknowledging. So not just pointing out how we're
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  still way behind, and we are.
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  We also need to acknowledge the gains. And I would argue that many of them are
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  due to our greater adoption of health system sciences.
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  Let me frame this a different way. You know, again, we're a very research-oriented
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  department. We are doing cutting-edge research in cancer.
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  As an institution, you know, we've moved into the top 50 in our nationally recognized nature.
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  Noted, we were one of the top institutions in our growth over the last six years
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  in the country in our growth in funded research here at UT Health San Antonio.
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  We have much to be very proud of from what we've done in these clinical trials
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  and the drugs that we're bringing to care.
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  Let me frame it to you like this.
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  What if I told you we have this new prophylactic drug for ICU patients?
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  We've studied it for two years in a statewide hospital system.
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  It saved 609 lives and amazingly saved the hospital system another $171 million.
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  I wouldn't want to buy stock in that company. I'd certainly want to implement
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  it in the hospital that I'm going to.
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  There would be grants that followed. We would see money flow left and right
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  into further development of this drug.
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  Right? I think we would all acknowledge that. But what if I was to tell you
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  this new therapy is a clipboard, a checklist, and a central bundle kit?
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  I think you all know by now what I'm talking about here. This is.
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  The central line interventions that were started by a Dr. Peter Pernivost,
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  who, unlike Sybilweiss, was highly effective at making change stick.
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  He developed the first care bundle kit. The care bundle was developed over time
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  and experience, and it started out with a focus on a checklist.
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  They had a systematic process for the central line placement with nursing holding
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  a checklist empowered to stop
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  the provider. Yes, nurses with checklists empowered to stop the provider.
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  They also had a significant buy-in from leadership. They had executives doing rounds on the units.
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  They had to adopt a unit each. They had to commit to regular visits,
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  and they had to get feedback on what was working, what wasn't working.
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  And indeed, the bundles came about through earlier projects at Michigan because
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  the staff complained to the executives on rounds that they're lacking key components
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  of the checklist, for instance, chlorhexidine,
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  to appropriate sized rapes.
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  Also, the change was part of a comprehensive unit-based commitment to improving patient safety.
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  I'll tell you it's important, too. Dr. Ponovost's work was disseminated in journals, studied well.
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  He was very collaborative in seeking feedback all along the way,
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  all the way from the bedside to those who were implementing it.
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  And from what I've heard and read about him, he's a remarkably vibrant,
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  collaborative, and a passionate person, and quite supportive rather than berating.
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  He's now a member of the National Academy of Medicine, has led the Patient Safety
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  Institute at Hopkins and he's at the university hospital university's hospital
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  system. And, uh, and I believe the Cleveland area now.
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  Again, remarkable impact from these interventions.
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  And so this adoption to scale has clearly saved lives. So eight years ago,
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  I called this the neglected third leg.
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  I think it's fair to say it's not so neglected of the third leg anymore.
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  We haven't totally fixed the very sentinel 1999 work to err as human.
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  You know, at this time, it was estimated about 98,000 people died in a given
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  year from medical errors in hospital. And it was just, that's the risk that
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  comes with hospital medicine.
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  I remember that as I was practicing during that era. That's just the risk that
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  comes from hospital medicine.
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  Well, this challenged that conditional norm. And I would say since that time,
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  we've seen, I think, remarkable progress.
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  I think if you look at the 1999 number of 44,000 to 98,000, and it's still overly
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  quoted, that's 27 years old.
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  So I do believe we have to come up to date and we have to look at some of the new data.
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  Hospital acquired conditions have fell 13% just in a three-year period from 14 to 17.
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  That's 910,000 lives.
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  That's not been significant. it. That's 20,000 plus people who went home instead
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  of dying. That's $7.7 billion.
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  I mean, that's real change. If you need a clinical example rather than an actuarial
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  one, think about heart attack admissions.
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  They dropped from 218 to 139 per 1,000 discharge, what I'm talking about,
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  adverse events during a heart attack admission.
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  So that's a third fewer harms. And that's in the highest patient volume area that we work in.
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  So while I say it's not solved roughly where it's not solved,
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  I should say, we still have one in four admissions still involves an adverse event.
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  And frankly, I tell family members
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  and others who are really keen on the latest procedure or the latest,
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  intervention or want to go get this elective procedure done in a hospital where
• 25:30
  hospitals still aren't safe places and you don't want to go there unless you really need to,
• 25:36
  and certainly covet erased a number of years infection of infection gains but
• 25:41
  it also gave us a lot of other gains and so this progress is real but we still have opportunity to,
• 25:49
  move forward and have further adoption of health system science.
• 25:55
  And so what have we seen locally? I've talked about nationally.
• 25:58
  What have we seen locally?
• 26:00
  And this is incredibly remarkable, the changes we've seen in our major participating
• 26:06
  site, which, frankly, we all are a part of.
• 26:09
  The Leapfrog Hospital Safety grade for University Hospital is at the top in the state.
• 26:15
  It's had four consecutive years of A grades through 2025. I remember coming
• 26:20
  here, and that was our goal. we were going to be an A leapfrog organization.
• 26:26
  I was at the military before that. That was a major goal. We were going to be
• 26:29
  a leapfrog A organization.
• 26:32
  We've done it. And we're the only public hospital in the system in Texas to
• 26:37
  do it. And we've done it since 2000.
• 26:39
  We did it again in 26.
• 26:42
  We're the only hospital in Bexar County with a grade A right now.
• 26:45
  Methodists had one in 24.
• 26:48
  If you want some perspective, Memorial Hermann in Houston is often cited. It's a B.
• 26:55
  Houston Methodist is a national leader in quality. It's had multiple A's like university has.
• 27:03
  Hopefully you saw the news that the Loan Institute ranked University Hospital
• 27:08
  the number one academic medical center in the country, number three in its overall
• 27:14
  ranking of the 215 hospitals ranked nationally.
• 27:17
  This looks at equity, value, and outcomes. It looks at pay equity.
• 27:21
  What's the top pay of the CEO to, frankly, the claiming staff?
• 27:26
  It looks at your community benefit. How are you serving the underserved?
• 27:30
  And it looks at the value of care. I.e., if they look at your Medicare charges,
• 27:36
  are you avoiding unnecessary costs to these patients?
• 27:40
  And so this is a huge deal. Dr. Olsen, we met a few weeks ago,
• 27:44
  was saying that he just had a major interview with the newspapers in Dallas
• 27:50
  about being the only public system and being number one in the country.
• 27:55
  Again, I remember when we started to work with CLABSI here, it seemed impossible.
• 28:00
  And CAUTI, oh my goodness, we were spending so much time. I was in the QRM.
• 28:04
  I was in the CMT meetings.
• 28:06
  Couldn't we possibly do it? We had 26 units without a central line associated infection in 25.
• 28:13
  We had 30 units without a CAUTI.
• 28:15
  Major initiatives. And we have a lot of leaders in pediatrics who are in the
• 28:19
  CMT making a difference in this area.
• 28:23
  And so, you know, as I pivot here, as I've talked about the clinical environment,
• 28:28
  we have really moved the environment.
• 28:30
  Yes, there's still an opportunity, but I think there's something for us all to be proud of.
• 28:34
  And this is critically important. And I want us to come back and say it's not
• 28:39
  just important to the patients we treat now, treat now.
• 28:44
  It's important to those learners who are under our stewardship it's important
• 28:47
  to those medical students who are rotating with us and not just important now
• 28:53
  in their training it's important with years for years to come,
• 28:58
  and if you think about it it's been an axiom guess what the trainee actually
• 29:03
  practices the way they're trained can you believe that,
• 29:06
  of course we believe it we know it, but we sometimes don't think practically
• 29:11
  how that ties day to day into what we do and how we engage and the vigor that
• 29:16
  we put into health system sciences.
• 29:18
  So I'm going to go back to the article that first moved me the most and got
• 29:23
  me super excited and engaged as an early adopter in health system sciences.
• 29:28
  And ironically, that's in the same field obstetrics that Similice worked over 150 years ago.
• 29:36
  So if you look at ASH's work, they looked at over 4,000 OB-GYN providers,
• 29:41
  and they looked at their major complication rates, nearly 5 million deliveries,
• 29:47
  looking at publicly available information out in New York and Florida.
• 29:51
  Then what they did is they grouped the 4,000 graduates on the x-axis by the
• 29:57
  hospitals that they trained in, and what were those hospitals' complication rates.
• 30:01
  So if you look at Q5, those represent the graduates out of a hospital that had the lowest.
• 30:10
  Obstetrical complication rates, whereas the Q1 hospitals all the way on the
• 30:14
  right were the hospitals that had the highest major complication rates.
• 30:20
  What do you see? So they controlled for USMLE scores, so it wasn't just an issue of medical knowledge.
• 30:26
  They found the 33% difference. Let's say that again.
• 30:31
  A 33% difference in the obstetrical complication rates from those,
• 30:37
  graduates who trained in a hospital with the lowest complication rates versus
• 30:43
  those who trained in hospitals with the highest major OB complication rates.
• 30:49
  That's significant. And I think that should cause us all to pause and think about what do we do.
• 30:56
  And not only that, then in part of another study, Ash and company did,
• 30:59
  they looked at that out to 17 years.
• 31:03
  And what they found is that it did not equalize out. It got closer,
• 31:08
  got improved, but it never came together in that despite 17 years,
• 31:13
  there still remained a difference.
• 31:16
  Where does that mean? I'd recommend you pay more attention to the hospital complication
• 31:21
  rates for your doctors and where they train rather than the reputation their
• 31:26
  program might have or their medical school.
• 31:29
  Because the data certainly seems to be pointing that you'd really better be
• 31:32
  looking at those hospitals they trained in.
• 31:37
  There's more data. So how has it matured since I last spoke?
• 31:40
  Well, we have some really interesting data in internal medicine.
• 31:45
  Now, I will point out, again, I love using AI.
• 31:49
  And some of this was pulled from AI and just got it wrong. So you notice how
• 31:53
  this says milestone and board scores impact on outcomes. Well,
• 31:56
  it just used to say milestones. And then it quoted this first article out of gray in JAMA.
• 32:01
  It's always important you go back and read those articles. Well,
• 32:04
  Actually, reading that article, it didn't show that milestones had an impact on,
• 32:12
  lower short-term mortality and re-admission rates, but it did show is that ABIM
• 32:17
  certification scores did.
• 32:20
  The other two did. Looking at the vascular literature, they looked at the milestones
• 32:26
  six months before graduation for vascular surgery graduates.
• 32:32
  Then they looked at a publicly available database of more than 4,200 endovascular
• 32:37
  abdominal aortic aneurysm repairs, and they looked at complications.
• 32:43
  And they found that surgeons with lower milestone ratings relative to their
• 32:47
  training program peers had higher rates of major postoperative complications,
• 32:55
  early in their independent practice.
• 32:57
  Well, guess what? The observations of their clinical competency committee six
• 33:01
  months before graduation had an impact on their practice.
• 33:06
  That, and if we take that seriously, That means we lean into those performance
• 33:11
  gaps and start making interventions before graduation.
• 33:16
  Another group, if you look at CHEN, they looked at professionalism and communication
• 33:21
  milestones and, again, looked at it six months before graduation.
• 33:25
  And then they look at their early graduates' patient survey experience data
• 33:31
  on what's called the CGCAPS survey that's out there, again, publicly available.
• 33:37
  And they found, guess what, that physicians who received higher ratings on these
• 33:41
  competency domains during residency.
• 33:44
  They received higher patient-reported experience. skills and practice.
• 33:48
  It's what you would expect. So it means when we see these things,
• 33:51
  how do we lean into them and begin to intervene and make a difference?
• 33:55
  It's really, really important.
• 33:57
  And then I go back and I want to point to on the right how training site imprints persist.
• 34:03
  And so they looked at, Phillips looked at medicine providers who provided,
• 34:08
  and you can look at Medicare billing and say, hey, this is a region with really
• 34:12
  high cost medicine delivery compared to another region that has lower cost Medicare billing.
• 34:18
  Then they looked at how their graduates billed for years out. Guess what?
• 34:23
  Those who practice in high billing regions continued to bill higher as graduates,
• 34:29
  and those in a lower billing region continued to bill lower.
• 34:34
  And again, I'll just briefly point to another Ash's work by Shrivovitz that
• 34:40
  looked at conservative versus is aggressive management.
• 34:43
  And what they looked at, again, looking at some of the CMS billing data and
• 34:47
  some ADIM test questions that looked at, do you appropriately treat a patient
• 34:53
  conservative or aggressive?
• 34:55
  I mean, conservative when it should be aggressive or aggressive when it should be conservative.
• 35:01
  And what they found is, is that trainees who,
• 35:05
  were in environments that had more conservative practice, appropriate conservative
• 35:09
  practice, actually on those test exam questions appropriately answered conservatively
• 35:15
  as to the management as expected.
• 35:18
  And they found that those that had more aggressive environments were more often
• 35:23
  going to miss the questions where conservative practice was expected.
• 35:27
  Again, you practice as you have been trained. That's the take-home point.
• 35:32
  And so I argue that we have a moral imperative here to ensure that our trainees
• 35:37
  are in clinical learning environments that are continuously focused on improving
• 35:41
  patient safety, quality of care, and frankly, cost consciousness.
• 35:46
  They learn from our practice. And as educators, we need to keep asking ourselves, how can we do better?
• 35:52
  What are the system things that we can improve when we see broken things in
• 35:56
  our system? So not only is it impacting that patient in front of us,
• 35:59
  we're impacting our learners for years and how they may choose to practice.
• 36:04
  And we have that moral imperative.
• 36:08
  I'll also say that, and I mentioned before, this stow piping has come together
• 36:13
  and we've seen this overlap and how we need to think of this Venn diagram as
• 36:18
  being very, very much in overlap.
• 36:21
  And so I've talked about the moral imperative. And, of course,
• 36:24
  then you've got to bring the stick.
• 36:26
  And the STIC was ACGME requirements, and they're a requirement that we began
• 36:30
  to bring these things into our practices.
• 36:33
  And one way that occurred was through the clinical learning environment report
• 36:40
  or review that the ACGME started.
• 36:44
  We were early adopters at SOSCHEC when I was the dean there,
• 36:48
  and Lois Brady was as well as the DIO here at UT. We started and published together
• 36:53
  on doing clinical learning environment walks.
• 36:56
  And, you know, this was before my talk that we did here, that I did here at UT in 2016.
• 37:03
  So when I came here in 18, I was excited about this journey that we had started
• 37:08
  at SawShack. And I recognize that many of you, many of you may not even be aware
• 37:12
  of this program. You know why?
• 37:14
  Because in my eight years here at UT, we didn't have a single career visit.
• 37:20
  It was a random and by region.
• 37:22
  SawShack that I left got two in the same time period.
• 37:26
  However, however, the key was that the hospital, UH, and us,
• 37:33
  we were meeting regularly and being prepared because we knew they could come at short notice.
• 37:39
  They would interview the CEO, myself, the dean, all in the room,
• 37:44
  and all the leaders of the hospital.
• 37:46
  They would also come in and interview residents, fellows, faculty,
• 37:50
  the patient safety leadership, our program directors.
• 37:53
  They'd walk around the hospital asking questions about the integration of GME
• 37:57
  into the patient safety and quality initiatives in the hospital.
• 38:02
  We'd get a report at the end. We'd have to sit down all together again with
• 38:06
  the CEO of the hospital, myself, the dean, and get feedback on how we were doing and how we could prove.
• 38:12
  The bottom line is even though we didn't have a visit, what did it do?
• 38:16
  It ensured that we were actively communicating with one another on a regular
• 38:20
  basis about how is GME engaged in the patient safety and the quality improvement environment at UH.
• 38:28
  And I'll say we were successful at an institutional level in many ways.
• 38:32
  We were also successful at the program level in pediatrics in,
• 38:36
  I'd say, many ways more so than a number of other large departments here at this organization.
• 38:42
  I'll talk more about at the institutional level. But we were able,
• 38:46
  like at SOSCHEC, we got partial support for UH to hire an assistant dean for
• 38:51
  health system sciences.
• 38:52
  This is Sarah Page Ramsey, who is serving in this role now. She's involved with
• 38:56
  the UHQRM and with the VA and on the CMT, and there's a number of other initiatives.
• 39:03
  I'd point out Siva. Siva, hopefully you're on this.
• 39:07
  He's our current chief resident for health system science right now.
• 39:11
  UH fully pays for that position.
• 39:15
  You guys may well remember Lindsay Urkel. She was our second chief,
• 39:19
  and one of our chiefs a couple years ago did a work with the UH nutritionists,
• 39:24
  in better capturing and recognizing our malnourished patients who are inpatient.
• 39:29
  This has not only improved their care, but this brought in a substantive amount
• 39:34
  of new CMS dollars tied to one of their major initiatives.
• 39:38
  So these chiefs have made differences and SEVA is going to continue that.
• 39:42
  I'll talk about that here in a little bit.
• 39:45
  We launched Health System Science Committee. We launched AMA modules.
• 39:51
  Now all of our incoming trainees have to complete patient safety and quality
• 39:56
  modules before they arrive.
• 39:58
  We want them to be on the same page. We want to be on the same page on our expectations in this area.
• 40:05
  We started patient safety awareness rooms. They go into a room.
• 40:08
  There's a mannequin with a number of things not quite right in that room.
• 40:11
  How many of them can they identify?
• 40:14
  Then they get debriefed on how to file patient safety reports.
• 40:18
  Right before COVID, we were looking on bringing on the non-medical driver of health orientation.
• 40:24
  COVID certainly brought this to the forefront of the importance of these non-medical drivers.
• 40:30
  We give a talk, Christina Drennan out of Trinity comes and talks about the city
• 40:35
  and our history with redlining.
• 40:37
  And aligns and shows how these same areas of the city have the lowest education,
• 40:43
  the lowest economics, have the lowest access, and some of them have the highest
• 40:49
  healthcare risk we see in the cities.
• 40:50
  And did you know, you see that red line, that red circle to the green circle? That's from the RBG.
• 40:56
  If you head out Bandera to Holotus,
• 41:00
  we have approximately an 18 to 20 year difference in life expectancy.
• 41:07
  I'll say that again, 18 to 20-year difference in life expectancy.
• 41:13
  Well, I'll say I'm proud of the work that Pediatrics is doing with screening
• 41:17
  for non-medical drivers of health down at the Robert B. Green,
• 41:21
  doing some great work down there.
• 41:23
  We don't just leave them with this beleaguered data across the institution as well.
• 41:28
  We bring in Lisa Ochoa, who you see down at the bottom. She's a vascular surgeon
• 41:33
  who left her private practice on the north side, went to the south side,
• 41:37
  started many active clinics, and increasing early detection to reduce diabetic-associated,
• 41:44
  amputations.
• 41:46
  I had coffee yesterday with Anita Fernandez, who's the vice chair of the UH
• 41:50
  Board of Managers. We were looking
• 41:51
  at workforce development in these underserved areas of San Antonio.
• 41:56
  I'm going to be going to the grand opening of the Center for Health Empowerment
• 41:59
  of South Texas, an idea of Lisa Ochoa, trying to look at a three-fold strategy
• 42:04
  of how we bring in the economic environment that incentivizes health care on the South Side,
• 42:11
  and also creating a pipeline from those schools for health care workers and
• 42:15
  how do we begin to better address the non-medical drivers.
• 42:20
  We launched the health distinction track, which is critically important.
• 42:25
  We have leaders like Mr. Bonos, who speaks annually to this group.
• 42:30
  You see some of our graduates here.
• 42:33
  Marcus was cited for his work by a senior leader at UH, and they were super
• 42:39
  excited he was going to be joining our hospitalist team.
• 42:44
  So don't underestimate the power of these initiatives and our engagement in
• 42:48
  them and how it influences and impacts hospital leaders.
• 42:52
  And I kind of mentioned that already.
• 42:55
  Well, guess what? The clear went away.
• 42:58
  Honestly, I tell you how many DIOs across the country I heard cheering. I was not.
• 43:03
  I thought it brought us and kept us at the table, kept us talking,
• 43:07
  kept us thinking about what are we actively doing.
• 43:10
  Well, we have to continue this, and we have to continue to lean into the culture
• 43:14
  now that we've lost the stick.
• 43:16
  And I would like to see more and more of our PEDS residents and others engage
• 43:20
  in this health system science track.
• 43:24
  I want to see a whole cadre of folks signing up and wanting to be our next health
• 43:28
  system science chief resident.
• 43:31
  I'm going to need your help helping Siva. He's leaning into a newborn initiative
• 43:35
  that is going to get attention.
• 43:37
  And he's going to need us to help him carry that out.
• 43:41
  Shout out to you, Siva. Let me know. We need to help you with this.
• 43:44
  Again, it shows that we're integrating and working together in these environments.
• 43:49
  And so it's a complex environment. And this is a complicated slide. And I think we all know.
• 43:56
  That the clinical learning environment is impacted by every single one of these
• 44:00
  in different ways. In fact, this isn't fully comprehensive to how each one of
• 44:05
  these pushes on the environment. But quickly, I'll just say,
• 44:09
  Program structure and duty hours, how we handle fatigue, how we handle supervision,
• 44:14
  that sets the stage in the room for speaking up and, frankly, patient safety.
• 44:20
  By the way, we do an anonymous survey each year in the fall of all of our residents
• 44:25
  on how well they're supervised. By the way, it's quite well.
• 44:28
  Well-being, autonomy, mastery, and purpose, it determines whether people feel,
• 44:34
  they can show up and they're not burned out.
• 44:38
  And if they're burned out, that impacts patient safety. That's a major issue.
• 44:43
  And so we have to lean into that environment. I think my key point here is that
• 44:47
  if you squeeze any one of these domains, it impacts another one of these domains
• 44:52
  and you can't look at them in isolation.
• 44:55
  And that culture change is more important than coercion in any one of these environments.
• 45:01
  Well, we have some other pressures on the system that I want to quickly jump into.
• 45:05
  One is commercialization.
• 45:08
  And the ACGME recognized that in this 2025 report.
• 45:13
  And there's data now. And again, some of it's mixed.
• 45:17
  Some of it's pretty clear that one particular study by Canon showed that hospital-acquired
• 45:23
  conditions after private equity acquisition increased falls and collapses up to 25%.
• 45:30
  And it was in a low-risk environment. In fact, in the same study,
• 45:33
  it also looked at surgical complications went up despite their overall surgical
• 45:39
  number, surgical site infections went up, doubled despite a drop in surgical volume.
• 45:45
  So we already have some evidence about commercialization and its negative impact
• 45:50
  on safety. And I'm concerned not just about private equity.
• 45:54
  I'm concerned about private healthcare organizations.
• 45:58
  And frankly, it's creeping into our academic centers as well,
• 46:03
  because frankly, the margins have gotten narrow and more and more push for that productivity.
• 46:13
  And so as I come back to the story of Semmelweis, we have to keep first and
• 46:18
  foremost, as we look at this health system science, as the data grows and the
• 46:22
  impact, we've got to bring culture. We have to bring environment along with
• 46:26
  us. Critically important.
• 46:28
  We have to keep front of those perspectives of being cheerleaders and yet continuing
• 46:34
  and persistently leaning into the environment, both in our hospital settings
• 46:39
  and both with our families and gaining trust, gaining investment.
• 46:43
  And getting them involved and seeing how important it is that we focus on changing
• 46:48
  the systems of the care that we work in to make an improvement.
• 46:53
  And I'm going to pivot here to another source that's coming our way,
• 46:57
  and I introduced it earlier.
• 46:58
  It was AI. I'm going to tell a story about my dad.
• 47:01
  He was a fighter pilot during the interwar time between Korea and Vietnam,
• 47:06
  and he commented on how dangerous flying was when he was a pilot,
• 47:11
  losing a pilot, almost an early assignment that he had.
• 47:14
  And he noted the very rudimentary autopilot functions at the time.
• 47:17
  And frankly, he did not trust them.
• 47:20
  And he saw an over-reliance upon them. And he locks his TV all the time now. He's 91.
• 47:25
  And all the time, he's just amazed at the major flying accidents that have because
• 47:29
  pilots do not know how to fly planes without autopilot.
• 47:34
  And he was telling me about this thing that's called slipping.
• 47:37
  And it's a way in which you can land a plane that autopilot cannot help with.
• 47:40
  And he was with a very experienced friend.
• 47:43
  He said, you know, no way you're going to land my plane. It was a prop, single prop plane.
• 47:47
  And he did this slipping maneuver and landed. And his friend looked at him and
• 47:51
  couldn't believe it. And he goes, because I always learned how to fly without
• 47:55
  having to use all the instruments in the autopilot. Think about Miracle and the Hudson.
• 47:59
  A few pilots today can land the way Scully landed because of what he did.
• 48:06
  However, on the other hand, I'm getting on a plane Monday. If my pilot gets
• 48:11
  on and says, we're deciding we're not going to use all the pilot and all the
• 48:14
  automated features we have on our plane today to fly, I think I'd get off the plane.
• 48:20
  So we need these tools, but we cannot lose what they bring, and that is still
• 48:25
  the ability to operate without them. And as we look at AI coming into this environment,
• 48:30
  how are we going to avoid de-skilling?
• 48:34
  How are we going to avoid the skills that we have not going away?
• 48:38
  So when epic crashes, or when the instrument goes down, or when the particular
• 48:44
  scenario requires those skills that we once had, that we don't lose them.
• 48:51
  Never scaling how do we make sure our trainees are still going to know how to do a good exam when
• 48:58
  hocus takes over and these bedside new instruments are doing all of it for us
• 49:04
  what when they what did we do when they go down or they get it wrong or when
• 49:08
  you say that pattern's not quite right.
• 49:11
  How do we avoid the misscalling? And how do we know, gosh, I can't always trust
• 49:15
  AI, like I told you about that particular article it pulled,
• 49:19
  in which it acted like milestones was behind every one of the studies, and really good.
• 49:24
  Well, no, they weren't. You had to go pull the study and look at it first.
• 49:28
  We need to teach our residents to use AI, and we also need to teach them to
• 49:33
  know when to overrule it.
• 49:35
  I don't have the answers here, but we need to remain humble.
• 49:38
  I have to remember not to berate and or overpush AI on people who are appropriately
• 49:45
  holding back at times and at other times need to know how to push them to consider,
• 49:53
  adoption, yet we have to do it wisely and carefully and bring them along with us.
• 50:00
  So with that, I'm going to end on saying I think physician leadership is critically
• 50:06
  important. And if you look at these on-and-roll hospitals with U.S.
• 50:10
  News & Report, 14 of 20 of them are led by physicians.
• 50:15
  And we're leaning into this space. The schools are leaning into this space.
• 50:18
  We have a number of wonderful leadership opportunities for our faculty.
• 50:23
  And I will tell you, this summer, we've launched our cross-programmatic leadership
• 50:28
  track, like we have for health system science and for educators already.
• 50:33
  We now have launched the cross-programmatic leadership track.
• 50:37
  I would love to see this program completely full. In fact, we're having to interview
• 50:42
  and think carefully about what residents or fellows we can allow into this program.
• 50:46
  We'll be launching our Health Care Administration Leadership and Management
• 50:50
  ACGME program probably in about three years from now,
• 50:54
  which again will be another leadership opportunity for our graduates and excited
• 51:01
  about where these two adventures are going to go.
• 51:05
  And so I'll go back and say that Symbol Weiss is very fondly remembered.
• 51:12
  In Hungary, even to this date. There was incredible, incredible change brought
• 51:18
  about because of what Symbol Weiss did.
• 51:22
  And yet, because in the way he engaged with it, so much was lost.
• 51:27
  And as we look at this time of change, we need to be very thoughtful of bringing
• 51:31
  culture along with us, fully engaging with our learners and in the environment
• 51:37
  and realize everything that's happened in this environment can have an impact
• 51:40
  for many, many years and come.
• 51:41
  And I'm hoping I'm inspiring you again, as it has inspired me to look at this
• 51:45
  again, eight years later, we can't slow down.
• 51:48
  And with the clear going away, we need to all take ownership,
• 51:52
  even all the more, because we've lost that external stick to bring us all to
• 51:56
  the table together to work on the clinical learning environment.
• 51:59
  So with that, I'll pause and we have a little time for questions.
• 52:09
  Thanks so much, Dr. Jones. Really appreciate it. I have one question so far
• 52:13
  in the chat, and I don't know if you can see that because it's kind of a bulleted
• 52:17
  point, about slow acceptance of various,
• 52:21
  changes, including dexamethasone. This is Dr. Weimer.
• 52:25
  Dexamethasone PO for croup, increased reflux when solid food is delayed for
• 52:29
  six months in terms of babies overfeeding, increased side effects when theophilin dose is doubled,
• 52:36
  when recommended dosage is based on blood levels, increased UTI in males when
• 52:41
  the circumcisions are discouraged for the anti-circs.
• 52:45
  What do you think about this in actual clinical practice,
• 52:51
  um due to just you know general feelings.
• 52:56
  Well again that's it's really interesting if you if you read one book one i
• 53:00
  would recommend is switch change when change is hard um,
• 53:05
  it's actually i'll be uh in our gme course at the amc next week i'll be speaking
• 53:10
  on switch and that's where i alluded to the fact that they talk about the rider
• 53:14
  the elephant the path and that's where we see the science at times.
• 53:18
  We're like, why can't you just do this?
• 53:20
  And that's where I think switch. If you look organization, they looked a lot
• 53:24
  to the social science literature.
• 53:25
  And again, talk about this idea is you can't just appeal to the analytic side,
• 53:30
  the writer side, because we're in medicine mostly, right? We want the data.
• 53:34
  You don't handle the elephant. That means you speak to people's emotion as to
• 53:38
  why we need to make these changes and you don't make change easy.
• 53:42
  So when you look at a number of those, you know, you've got to make it easy
• 53:45
  for that dexamethasone PO to be delivered.
• 53:49
  That's probably not the best example. I'm trying to think of one that's easier right now.
• 53:55
  Yeah, by the way, thinking of, well, don't get me going off on Theophilin.
• 54:00
  That's another interesting one.
• 54:01
  You've got to reduce all those barriers that make it easy for people to get
• 54:06
  the answer right, right?
• 54:08
  Every time you put up a barrier, it reduces the likelihood you're going to get
• 54:12
  adoption of this new change. So we need to think as much about that as we do
• 54:15
  the science of the change.
• 54:17
  I don't know if they'd answer it, but read Switch.
• 54:19
  It's my favorite book. In fact, Siva knows he's going to have to read it this
• 54:23
  year because I think it's super important for all of us, those of us who are
• 54:28
  going to look at change management.
• 54:34
  Dr. Jones, this is Michelle Arandas. Hey, Michelle. Thank you so much for a
• 54:37
  great talk that I think speaks to a lot of us.
• 54:40
  You made a very brief comment about, you know, the challenges in the nursery
• 54:43
  and the dynamics of bringing families along in a hesitancy culture.
• 54:48
  And, you know, I struggle because I have a very clear sense of how I handle
• 54:52
  that as a physician and somebody who worked in an environment prior to coming
• 54:56
  back to academics where I encountered a lot of this.
• 55:00
  And there is a lot in my approach for engaging the families where they are and
• 55:05
  discussions of kind of reaching a state where we're making a joint decision
• 55:09
  that's best for the child, right?
• 55:12
  But I struggle because as a program director and as a person who's training
• 55:16
  the next generation, I want to teach that same sort of general approach that
• 55:21
  keeps our families engaged.
• 55:22
  But then we have a lot of pressure from the outside organizations around,
• 55:26
  you know, sort of holding a firm line and a lot of the noise around,
• 55:31
  you know, autonomy as a practitioner and being able to stand your ground.
• 55:36
  And I just, I don't know that you have an answer, but I appreciate you bringing that up.
• 55:41
  I do think that's one of those dialogues that especially in pediatrics,
• 55:45
  where we're talking about third party patients, you know, patients that are
• 55:48
  neither the decision maker, but the affected.
• 55:51
  And then we're trying to walk that line between physician rights and responsibilities and family.
• 55:58
  I just think that's a dialogue we can keep having, hopefully,
• 56:01
  in a respectful way in the space of academics and, you know,
• 56:06
  again, giving residents in training both perspectives and an opportunity to
• 56:12
  choose what is most, you know, consistent with their desire to practice.
• 56:15
  But I just wanted to put that out there because I know, you know,
• 56:19
  it's this is an environment where we're all in and we all do express those frustrations sometimes.
• 56:24
  In rounds at the table side, you know, hopefully not at the bedside,
• 56:28
  but just to acknowledge that, you know, those of us that have been doing this
• 56:32
  for 30 some years still struggle with those with those moments.
• 56:36
  Well, I did share my struggle, right? In fact, I have to watch myself.
• 56:40
  And I, again, the DNFers, in fact, somebody quoted me back home last time I was up there.
• 56:46
  And I, and again, it's not that I don't have that conversation about what my
• 56:50
  concerns, I was in Europe when the vitamin K went oral and we saw and was hearing
• 56:55
  of the case reports of the increased complications in Germany.
• 56:59
  And I actually talked to parents about that. I share from my experience.
• 57:02
  I've actually began to focus as much on, you know, I use education in an interesting
• 57:07
  way. I go into the room and say, well, since you've not chosen to be vitamin
• 57:11
  K, let me tell you about petechiae and what you need to ensure if you go into
• 57:15
  the emergency room later.
• 57:17
  You know, I'll say, you need to make sure your doctors know you didn't get vitamin K.
• 57:20
  And if they kind of stop, you know, and your child becomes somnolent or is acting
• 57:25
  ill, they need to know your child didn't get vitamin K because they may be bleeding
• 57:28
  in their head And the doctors aren't going to think that was even a possibility or if this group is kind
• 57:34
  of, so I even use sort of this different approach to say,
• 57:38
  I want you to be educated, make sure all the doctors that see your child later
• 57:42
  know what you chose not to do so they can do the best they can do at the point in time then.
• 57:47
  Have I been successful? A little bit.
• 57:51
  Yeah. No. Some other than. Yeah.
• 57:55
  Thank you though. And I very much respect your skills with that.
• 57:58
  Oh, so I'll just say one other thing.
• 58:00
  When I was in medical education on Oleo Grand Rounds, I started what was called
• 58:04
  the SCOOP, and that's the Structured Clinical Observation of the Preceptor.
• 58:10
  What I don't do enough is grab the resident and say, come into the room.
• 58:15
  I want you to observe this conversation. And let's have an intentional dialogue after this encounter.
• 58:24
  So that was called the scoop. And I just don't, we get so busy as you know up there, Michelle.
• 58:29
  I just haven't had time at times, but I need to be very intentional.
• 58:34
  And so thank you for stimulating me in there again with that. Thank you.
• 58:41
  Thanks for the questions. That was great dialogue. I think we're going to wrap
• 58:45
  up because we've got a faculty meeting. I'm sure there are a lot more questions.
• 58:50
  Dr. Jones, really, I appreciate you so much for coming on.
• 58:53
  It's a great talk and you're always inspirational to us. So thanks so much. Good to see you, Dina.