Fictional Characters Bring Life to the Classroom

Published in the Winter 2012 Duke University School of Nursing Alumni Magazine

By Whitney L.J. Howell

Meet Golda and Antonio. She’s a grandmother, rearing her grandson while trying to manage myriad chronic conditions. He’s a Mexican immigrant who’s juggling the tensions of a high-stress job and a young family.

Nurse practitioner students at the Duke University School of Nursing (DUSON) spent the entire Summer 2011 semester closely following Golda and Antonio. They designed health plans to fit the patients’ lifestyles and worried about how any medical changes would affect their daily activities.

But there’s one catch—Golda and Antonio aren’t real. In fact, they’re figments of imagination of DUSON assistant professors Penny Cooper, MSN’02, C’08, RN, FNP-BC, CCRN, and Michael Scott’s, DNP, FNP-BC. They exist only on paper, and students know them simply by class-provided clinical notes. However, that was enough to launch students into intricate, and often heated, discussions about the best way to meet Golda and Antonio’s health needs.

The format for Managing Common Acute and Chronic Health Problems II, said Scott, who co-taught the class with Cooper, was a significant divergence from lecture-based courses formats. It’s a challenge for faculty to step out from behind the podium, he said, but the result is students who are prepared to be independent, proactive nurses.

“This course is a paradigm shift,” he said. “We’ve tried to demonstrate that there are ways to draw students into a discussion. We want students to see and experience for themselves the interplay between context and clinical decision making.”

By training students to look beyond rote learning and synthesize that knowledge with individual circumstances, Cooper and Scott are meeting a charge published in the Institute of Medicine’s October 2010 report The Future of Nursing: Leading Change, advancing health. The report stressed that nurses are ready to augment their roles as primary care providers who can reduce or eliminate gaps in care.

What Happens In Class
The course goal wasn’t to memorize and spout a certain number of facts about medications or conditions, Scott said. Instead, he and Cooper wanted to train students to be life-long learners —knowledgeable, well-trained healthcare providers who know where to turn for information. They wanted to produce nurses who could think beyond textbook knowledge to craft care plans to accommodate a patient’s daily routine and limitations, such as dependency on public transportation.

According to Cooper, the primary care-focused curriculum spanned roughly 20 years of each patients’ life. Students received clinical notes before each weekly class, detailing each patient’s vital statistics, laboratory test results, or life changes. Each week focused on a different content area, such as cardiology or neurology. Armed with this data, they came to class and discussed how best to address clinical, billing, and coding concerns.

The class relied on student-led conversation, Cooper said. She and Scott served as content experts who would only occasionally posit questions if the discussion began to lag. Unlike their other classes, students didn’t take tests to gauge how well they retained information. Instead, Cooper and Scott presented case studies unrelated to Golda and Antonio to evaluate how well students digested and applied their procedural knowledge. Cooper said they also required students to offer opinions during class discussions as well as reflect in writing upon certain cases. Adjusting to this format, though, was difficult.

“There was some initial resistance and discomfort with the class structure. It can be uncomfortable to change the ‘test,’” she said. “Having them do active reflection was a way to ensure that they thought about the different approaches and opinions brought forth.”

Effective and Memorable
For Mary Johnson, MSN’12, FNP, a discussion-format class was a novelty, but it was one that greatly enhanced her learning.

“This was much more effective than listening to a lecture where a professor spits out facts and you regurgitate them,” she said. “The class was like real life. We learned that we won’t always be able to do what we’d like to do medically for our patients—they will have extenuating circumstances, and we’ll have to meet them where they are.”

Talking with fellow students about specific case studies that spanned more than two decades also fit perfectly with the way Danielle DiGennaro, MSN’12, FNP, prefers to learn.

“I, personally, tend to learn best from case studies. The material clicks and sticks with me when it is related to a case,”she said. “We often had a handful of voices that were very prominent. But it was nice to hear from the class as a whole. Different colleagues brought different experiences to the class, be they RN experiences or NP clinical placements.”

The in-depth discussions about clinical conditions pushed students to think holistically about Golda and Antonio, but these small-group interactions also introduced the challenges of inter-professional communication. Some discussions, such as one about end-of-life care and Do Not Resuscitate orders, morphed into ideological fights, Johnson said, and classmates had to learn to navigate the differing, and entrenched, opinions.

Taking the Curriculum Nationwide
With such an overwhelmingly positive response to the class format, Cooper and Scott wanted to see if they could translate the
in-class experience to DUSON’s distance learning programs. The idea of fusing lively discussion with technology that connects the coasts garnered both attention and financial support.

According to Marilyn M. Lombardi, PhD, director of the new Duke Center of Nursing Collaboration, Entrepreneurship, and Technology (CONCEPT), Cooper and Scott’s desire to share the course format outside the school’s walls was a perfect fit for the first Catalyst Faculty Innovation Award. The CONCEPT Catalyst Award was created to support innovative and entrepreneurial faculty endeavors.

Lombardi stressed that entrepreneurial work doesn’t always focus on making money. In fact, many in nursing view that goal as being antithetical to the profession’s service call. She anticipates other DUSON faculty, like Cooper and Scott, will be entrepreneurial on a mainly social level—they’ll endeavor to introduce new ideas to health care delivery that will help patients.

The award gives Cooper and Scott funding to research and identify the best methods for disseminating the course curriculum to the School’s distance education students. At the time of publication, they were actively working with Duke’s videography and information technology services to bring the project to fruition. The idea is simple, but it will be a challenge to create an environment that brings students from different states and time zones together for active discussions about patient care.

“The catalyst award is the seed money that allows faculty to take risks and think beyond customary pathways for education,” Lombardi said. “What [Cooper and Scott] are using is an exciting strategy to introduce technology in support of an innovative approach to teaching and learning. This won’t be a simple matter of setting up a video conference.”

Instead, Lombardi said, the curriculum for the distance class will likely take a more multimedia, documentary approach with both visual and audio components. Using resources provided by CONCEPT, Cooper and Scott will produce 10 5-minute vignettes that cover each course module and bring Golda and Antonio to life.

Finding the right mix that reproduces the in-class experience for students will require creative collaboration with partners outside the School. The CONCEPT office exists, Lombardi said, to foster these relationships and cultivate the inventive spirit that already exists in nursing.

“We launched CONCEPT because we talk a lot about what nurses refer to as the ‘work-around culture,’” she said. “We’re faced with a care environment that isn’t set up to work optimally for patients, so nurses use the materials that they have close at hand—like cotton balls or construction paper—to create improvised alternatives to meet patients’ daily needs.”

CONCEPT gives Duke’s nursing faculty the freedom to be design thinkers, she said. Through partnerships with other schools, such as the Pratt School of Engineering or the Fuqua School of Business, faculty will have the opportunity to take their ideas further and potentially change how nurses work at the front line of care.

To read the story at it’s originial location: http://nursing.duke.edu/sites/default/files/alumni/magazine/winter_2012_issue_final.pdf

Radiology: What’s Coming in 2012

Published on the Feb. 16, 2012, DiagnosticImaging.com website

By Whitney L.J. Howell

Throughout 2011, most chatter in radiology centered around how healthcare reform would change the industry or how practitioners should manage and use newer modalities. In a look ahead at the next 12 months, many industry luminaries anticipate the same concerns will linger on the horizon even as new ones appear.

Some of the upcoming challenges touch the individual radiologist’s pocketbook; others affect practice. Regardless of the specifics, radiologists will do well to revamp how they view themselves as part of the healthcare system, said James Thrall, MD, Massachusetts General Hospital (MGH) radiologist-in-chief and former American College of Radiology president.

Financial Implications

Radiology’s biggest concern for 2012 is a holdover from last year — bundled payments and reduced reimbursement. Under the proposed accountable care model, radiology reimbursements would be wrapped up in a lump-sum amount that includes facility, physician, and technical payments.

It’s the ambiguity of these packaged payment’s impact that make them the industry’s greatest challenge this year, said, Leonard Berlin, MD, former chair of the professionalism committee with the Radiological Society of North America (RSNA).

Leonard Berlin, MD, former chair of the professionalism committee for the Radiological Society of North America

“There’s no question that there’s been a definite move to decrease reimbursement for radiology at the Centers for Medicare and Medicaid Services,” Berlin said. “All the projections for radiology reimbursement have it falling, meaning that practitioners, for 2012 and beyond, will need to find a way to maintain and manage a workload that is sometimes heavier for less money.”

The ACR is also concerned about reduced payments. Currently, the organization’s No. 1 priority is working with Congress to extend the temporary fix to Medicare’s sustainable growth rate, the formula used to control healthcare spending. The stop-gap measure, enacted in December 2011, averted a 27 percent physician payment reduction, and the ACR would like to extend the fix permanently.

“We’re also watching carefully to see if we can stop the Centers for Medicare and Medicaid Services from making any multiple procedure payment reductions,” said Cindy Moran, ACR’s government relations assistant executive director, referring to cuts in payment when two or more codes are performed to the same patient by the same physician during a single session. “But we are also assuming, with this being an election year, that we might be faced with a lame duck Congress.”

Changes could also be coming to codes that routinely appear together, said Maurine Spillman-Dennis, ACR’s senior director of health policy. CMS is analyzing whether procedure codes that are often linked 50 percent, 75 percent, and 90 percent of the time can be bundled, reducing overall reimbursement for those services.

“We are involved in an evolution toward a new payment model. The bottom line is that healthcare is turning away from the fee-for-service system and moving toward capitated services,” Spillman-Dennis said. “It will be a challenge for radiology to fight under this new care delivery model and make sure its practitioners are paid for services provided.”

To read the remainder of the article: http://www.diagnosticimaging.com/practice-management/content/article/113619/2033254