Interview with Anita Vanka, MD and Robert Stern, MD [Podcast]

[00:00] Intros

[00:40] Career backgrounds

[02:15] Teaching clinical skills

[04:33] What are OpenNotes?

[08:32] Documentation for a new audience

[11:14] Language matters

[26:47] AI and the future of documentation

[36:06] Anita and Rob’s favorite well-designed things

[39:17] Outros

Transcript:

Dr. Craig Joseph: Welcome Anita Vanka and Rob Stern to the podcast. Where do we find you both today?

Dr. Anita Vanka: I am calling in from my office here at Beth Israel Deaconess Medical Center in Boston.

Dr. Robert Stern: And I am just down the road a little bit here across the street. I am at Brigham and Women’s Hospital; the two hospitals are very close together.

Dr. Craig Joseph: Can you wave to each other through the window? Is it that...

Dr. Anita Vanka: It's pretty close. Rob and I often meet for lunch. Like, right between our hospitals.

Dr. Craig Joseph: Like a neutral zone, so to speak. Fair enough. Anita, why don't you tell us a little bit about what you do and how you started doing those things?

Dr. Anita Vanka: Yes, definitely. So, as background, I am a hospital medicine physician here at Beth Israel Deaconess Medical Center. I'm actually celebrating my 20th anniversary here at the VA. When I came here to do my residency. I originally hailed from the Midwest, where I went to both undergrad and medical school at the University of Illinois College of Medicine. And just so I did my residency in internal medicine here. I loved inpatient medicine and the acuity of care that we get to see in the general medical wards. Loved working with the teams. So decided to go into hospital medicine. And over the last 16 years I've kind of also really developed my career as a medical educator. Both in the residency space as well as in the space with our medical students. And our faculty has held a variety of roles, in these various spaces. But most recently, I am the residency program director here at DMC. And I also co-direct our education fellowship for our faculty here.

Dr. Craig Joseph: All right, I'm tired. That seems like a lot. Rob, why don't you give us your background?

Dr. Robert Stern: I am from the Sarasota area originally but then jumped around in a lot of different places before ending up in Boston for my medical training. So, I am actually trained as a hematologist oncologist. So I know lots of people listening to what that is, but just to say it's blood and cancer medicine. I did my training here in Austin and then now on faculty at Brigham and Women's Hospital and the dean of Harvard Cancer Institute taking care of patients with blood disorders. And then relevant to our conversation today, I helped oversee the first two-year clinical skills course for our medical students at Harvard Medical School. So, I'm kind of in the classroom, figuring out how do we take a medical student who puts their stethoscope backwards the first day they walk in? How do I take them to the point where they can actually intelligently talk to patients, figure out what's causing chest pain, do that physical exam with the stethoscope the right way. So that's a lot of my non-clinical work.

Dr. Craig Joseph: Rob, I feel like you see me. I feel like you're looking at me, with the whole stethoscope on the wrong way thing. I recall being a medical student, and this was back in the day when the first two years were pretty much basic science, and you hardly ever touched or talked to a patient. And, the final summit, the fourth semester. So right before we started clinicals, they would throw us into clinics with little, short white coats and they call that physical diagnosis. And we were supposed to be, you know, learning physical diagnosis. And the joke was there was a commercial back in the day where a soap opera actor said, "I'm not a real doctor, but I play one on TV,” and then proceeded to to give medical advice, which was great. There was nothing wrong with that. But we would say, I'm not a real doctor, but I play one on physical diagnosis. So yeah, that's hard.

Dr. Robert Stern: I was going to say it wasn't one of my great joys on this. On one of their first days is the students inevitably don't know they have to turn this head at this telescope. And so they're listening and they're listening and they're not hearing anything, and they're not hearing anything, and they're frustrated. And then you go over to them and you turn it 180 degrees, and then they listen, and they hear a heart and the joy that you see on their face, it just makes it all worth it.

Dr. Craig Joseph: Anita, I reached out to you because you wrote an article with one of my favorite people lists for me and among others that talked about how to document in the age of OpenNotes. And I was fascinated and asked, hey, can we talk about this? So let's just kick off and talk about I think most of us probably know what documentation is. We're writing progress notes, and I think we're talking mostly focused on the outpatient area. But many people maybe don't know what OpenNotes is. So tell us what OpenNotes is.

Dr. Anita Vanka: Absolutely. And I just have to start by saying Liz is definitely, I think, everyone's favorite person. How could she not be? It's truly been such an amazing journey to be able to work with her and learn from her as I've been involved with this effort.

So to backtrack, OpenNotes. So first of all, just the concept of OpenNotes really started here actually at the be back in 2012. I want to say, Doctor Tom Delbanco, who's a co-founder of OpenNotes, had this kind of vision and initiative about what would it be like to have patients read their notes in real time and be partners with their clinicians on their own medical journey? And it was a pilot implemented here where patients were, given access to their notes in the outpatient setting. And through that, Tom and his colleagues, including Liz, had done a lot of work and studies showing that there was so much benefit to this. I think, contrary to what many people may have feared or had reservations about, I know I did when I first heard about it, and it actually showed to help improve our partnership with patients.

It had shown that patients had better understanding of what was going on with their illness, that there was better ability to carry through plans, medications and such. And in fact, so not only did it show that patients had better trust in their physicians and their care team by being able to be partners with them in the notes, but also the way we wrote notes was really important in building that trust and partnership, and the way we use certain words in the medical vernacular could sometimes have the unintended opposite effect of where patients could feel biased and stigmatized.

And so a lot of work was published in that space. As you know, I know from a more national level, Tom and his colleagues succeeded in really bringing this to life for everyone. Where in 2019 we had the Cures Act, where it was a federal law that mandated that every patient have access to their medical record in real time. And this included not just the progress notes or admission notes, but also other aspects of their record as well. And there are few, like very few, rare, permitted exceptions. But in general, patients do have access right away. So that's kind of how we think about the concept of OpenNotes was started and what it ultimately led to.

Dr. Craig Joseph: Patients have always had access to their notes, but almost no one had seen notes because to get access, you'd have to request your medical record. And usually there was a charge because the paper was involved. But now it's kind of just out there for most of us. We can see our notes.

So, Rob, you're involved with first year medical student training. I recall mine, which was or actually probably wasn't. First year was probably a third year. Hey, there's this thing called a scope note, and they told me what that stood for, and threw me to the wolves. So I'm assuming now that it's a little bit different.

Dr. Robert Stern: Yes. Medical, educational, it's become, more regimented, in terms of training, clinical skills, teaching, much earlier in training, you know, as the movement in medical schools had been to get students into clinical spaces earlier, there's a recognition that if you're going to get them in clinical spaces earlier, you also have to teach clinical skills earlier. And it's still variable from school to school. But generally, students are being exposed to clinical skills teaching at a much earlier stage of training than they were before. And historically, as we've started to teach, why than just, hey, here's a scope note not having any idea what that means beyond what you use to kind of wash your face in the morning. The idea was we were teaching students to write notes for basically two purposes, and then kind of doing a third, but avoiding it.

So one was, you know, it's written as a way of communicating to other providers. Two notes were written as a way of communicating to your future self. So what was I thinking at the time I wrote this, when I had to go back and see the patient six months from now, nine months from now, and then third, and we kind of avoided talking. These notes were being written for billing. But no one really wanted to talk about that third piece. And so we were teaching students to write very detailed histories of present illness. We were teaching them to put a lot of information, especially in the key mark space, for example, for our mark fellows, we were teaching them to talk a lot about papers and survival data, and all of this information, life expectancy.

With the advent of OpenNotes, what we realized is there's now there's four really important purpose for note in this new audience, which was the patient. We do not write it. Note that not only accounted to other providers, not only spoke to our future self, not only met billing requirements, but also was going to be readable and build patient relationships as opposed to hurt patient relationships. And so we said, how do we take what we are already teaching students? We have a rubric for students submit their note and they get feedback. How do we incorporate that patient-centered aspect to how we teach notes? Because they're going to be doing this whether we like it or not. This is the world our students are going into. So how do we prepare them for that world?

Dr. Craig Joseph: I'm continually impressed about how we've moved forward. I mean, in detail. Talk about all of the feedback I got on my progress notes. I never got feedback and my notes. I recall writing very long, was just like two-and-a-half-page note, back in the paper days in the ICU for a patient, and it was very detailed and you could read it and it would actually say nothing because I didn't know what was important. So, I just threw everything and the kitchen sink. So, kudos to you both in medical education, in general, that we're moving in the right direction to get to kind of focus on those things.

Let me call out one thing that you would mention is, hey, so we have a new audience because of OpenNotes and because of certain laws, and that is the patient. They're much more likely to see it. And you would say we want to minimize the potential harms and so on. And so what are some of those harms that Rob was talking about.

Dr. Anita Vanka: Great question. And this has really been described well by several colleagues who have worked with Tom Delbanco in this area. And we can see that patients, depending on the words used or the phrases or the language use, that patients can feel stigmatized, biased, feel like they're being questioned, by their condition when in fact that may not be the case. And then so that's one harm like in the moment. And then the kind of it can perpetuate forward. Right. So we can see that bias can continue to be transmitted through the medical record impacting future care of that patient, and whether it's by the same clinician or others.

And there have been several studies showing that not only can it impact how we may perceive the patient, it can actually impact our clinical decision making and the actual appropriate care of the patient. There was actually one study in which the authors had taken a case vignette written about a patient presenting in a single cell crisis, and had written it in two different ways. And had residents and medical students who read both notes. And when they assess their perceptions, they found that those who got the vignette that was probably written in a way that were more accustomed to seeing, but it contained many words that really we know can perpetuate bias and stigma, such that patients were perceived to be in a more negative light, and they were more likely to not get the appropriate pain management, or care. And then we also know this very well, that there is a lot of racial bias in medicine. There's a lot of racism in how we think about writing. Notes can continue to perpetuate those same biases as well. So a lot of harms unfortunately.

Dr. Craig Joseph: Can we just for fun, talk about some of these words. I'll throw out one. And Rob tell me what you think: non-compliant.

Dr. Robert Stern: Common. We see this a lot. So what is a non-compliant patient? A non-compliant patient is we, as the health care provider, having the right answer in a patient, not doing what we tell them they should do. Right? Like the idea of not complying is we gave you all of the tools, we gave you what you're supposed to be doing, and you chose not to do it right. It creates this dynamic where one, we are all knowing as physicians, and that obviously what we said is what the patient should be doing. And to the patients, it is that they're failing for not complying with what we're saying. I can I take this? I know this is not exactly what people mean when they say it, but you can imagine a patient who hasn't lived in our medical language for years and years when we write noncompliant, that's how they may be doing it.

And so I think that what we have to do when we're thinking about our words is forget ourselves, forget what we intended, forget what we've lived now for many years being in this world, and come to a crash and imagine yourself looking at that word. If I'm non-compliant as a patient, you're making a judgment about me. It doesn't get into the fact that, you know, maybe I couldn't afford to pay that. Maybe I couldn't go to that appointment because I had no one else to pick my daughter up from school, and there was just no way I could get to the doctor's office. Right? It's paid everything with a single crash. And does it allow for all of the complexities that can come under patient behavior?

Dr. Craig Joseph: It's funny because those were words that were specifically was one that I was kind of trained to use. So, you know, patient didn't do what we recommended that they do. So they are now non-compliant.

Another word that I think has a charge that maybe people don't think about is the word deny. And it kind of implies like while they're saying that they said that, but I'm not 100% sure that's accurate.

Dr. Anita Vanka: Right. And I think one thing is, I also think that is compare how we were taught to write the subjective to how we write the objective. Even just a labeling of that is interesting, right? Like we call the objective part of the know our physical exam findings versus what the patient is telling us is subjective. What it's actually their facts, right? It's their story. It's what they're experiencing. So we would never write. I deny hearing a murmur. Right. There's no murmur on exam. So why do we need to write that? The patient denies fever, chills, you know, whatever it is. Instead, just say a patient had no fever or, yeah, a patient is without pain.

Dr. Robert Stern: The one that we think about, we don't even think twice about is chief complaint, right. What is the complaint, like are we saying that when a patient comes in and tells us they have a chest pain like that, it's a complaint that they have? I mean that it is a symptom they're having. But by labeling it their chief complaint, just think about what that means for a patient.

Dr. Craig Joseph: Yeah. Well, that's like a core part of being a doctor is taking the chief, what is the chief complaint? Right. You're not. And it's again, it gets back to our health care system. And I'm putting system in air quotes here that we deal with illness. We're not so good at dealing with wellness and that kind of. That's one of the signs right there. Right. The that you all, if you're coming to see me or having a conversation, clearly you have a complaint. Otherwise we would never need to talk to one another.

Dr. Anita Vanka: But it's interesting how it started by using that word complaint, which is what we're all taught, rather than just saying concern. I'm coming to you because I'm concerned.

Dr. Craig Joseph: Yeah, well, we've been kind of bouncing around and teasing this article that you wrote, anything that Rob, I know you kind of support. So what are some of those things I, you know, there are ten guidelines ranging from person first language. I want to dig into that a little bit and avoid abbreviations and acronyms. Just two things. Can we talk about some of those and some of the other ones that you think are important that you discovered?

Dr. Anita Vanka: Sure. So I think number one, with the using person first language, it really gets to really understanding that your patient is a person that they're defined by who they are, not just by their condition or by their chief concern or their symptoms that they're presenting with. I think all of us here, the three of us have trained at a time where we refer to patients as like, go see the diabetic in room 58, or my favorite, vascular part. They must be such a vascular past, right? What should we think about it? Like how that sounds like it's referring to someone who has a lot of vascular disease risk factors. But when we use language like that, first of all, it's very dehumanizing to that individual, I think we don't do it with malintent. I think we do it because that allows us to have some distance from the fact, from the emotion of it, which can be very challenging, I think, when we're caring for patients and such.

But what happens then is then I think you run the risk of not seeing them as a person. So what we teach our students, or when we think about these best practices is really referring to who this individual is as a person. So this is a 43-year-old person, 42-year-old woman, 43-year-old man, who has diabetes rather than this is a 43-year-old diabetic. I do want to say, you know, in that study, when we did these focus groups with patients and such, that we did learn that there are some individuals who do prefer to be kind of identified or labeled by their condition, predominantly, and from the community they're from. So that's important to them. And I think it gets to the second principle of referring to your patient as they want to be called. So we know medical vernacular, it's like you're almost free when you start practicing in the clinical sphere. It's like you're being indoctrinated into the secret language of medicine. And I remember when I used to co-direct this course with Rob and teaching medical students, like they would always be asking, well, what is that abbreviation? What does that mean?

And I would even like forget when did I actually learn to abbreviate something this way? Like you just, it just happens, right? That language and I think it happens out of probably convenience. We're all pressed for time and using shorthand and we just developed this code to speak. I think it allows us to also distance ourselves from some of the moments that can be really tough when you're caring for people. But what happens is when you pepper your notes with abbreviations and acronyms is, first of all, it can be actually confusing to yourself. When you go back to look at this note, it can be confusing to your fellow clinicians if they're not using the same abbreviations or acronyms. And it can be really confusing and hard for your patients to see.

There was an editorial written not that long ago about a patient saying the word S.O.B. or the acronym S.O.B. peppered all over their notes. Right. And in medicine, we use that very commonly to mean shortness of breath. But to someone who is not in medicine, that can be quite jarring to see, because you don't actually understand what that means. As much as that is a best practice that we've defined and hear from patients and others, it's probably the hardest one, I think, to implement because of the shorthand we use when we're writing notes all the time.

Dr. Craig Joseph: In healthcare technology world, we used to, we still do, we have computers that we put on wheels on a cart and move it around. And, oftentimes we would refer to those amongst ourselves as a computer on wheels or a COW.

Dr. Anita Vanka: Oh, yes, we still do. Yes, yes, a COW.

Dr. Craig Joseph: Yeah. So, there's, at least in my world, it was a famous revelation that, a patient got very offended because she overheard two nurses talking, and one of them said, well, there's a cow over in room seven, and she thought they were referring to her. In fact, they were referring to the computer on wheels. At that hospital, at least, we started calling it something else.

Dr. Anita Vanka: Yeah, we call it what I was now.

Dr. Craig Joseph: Wow. Or, or the computer is another way I know.

Dr. Anita Vanka: Why don't we just call it what it should be called?

Dr. Craig Joseph: Because we're in medicine and it's, you know, it's with all the kind of using the abbreviations or using big words. Sometimes we go the other way. Right? You know, I like tachycardia. That's one of my favorite words. But in fact it's just high heart rate. You know, we're a profession and we're not much different. I am saying, though, that a lot of professions do have these abbreviations or use these very precise terms with the work that they do. And, and sometimes we kind of just assume that. And again, 20 years ago, no one was reading our notes besides us.

Dr. Robert Stern: One of the things that I think you bring up there and these, and I talk about this a lot when we're teaching, when we're working with students, when we're working with faculty, is we still make mistakes around us, right? We will still accidentally embed the word tachycardia in our plan that we're writing for the patient to read. So, you know, as we talk about these best practices, it's not to say that we've mastered this. This is where all learning and its breaking habits that we all have, even for Heath and I, who are supposed to be quote unquote experts at this, we are constantly breaking our own bad habits. So I just want to call that out this is a work in progress.

Dr. Craig Joseph: Rob, are there any other kind of recommendations from Anita's paper that you wanted to highlight?

Dr. Robert Stern: So, there's a bunch, you know, one of them that really rings true for me, especially in my world as a hematologist oncologist, is say what you write and write what you say. So, the idea here is that a patient is to go home and they, or a loved one, open this up and read through your assessment plan. And the first time that they know you might be thinking about cancer as a cause for their weight loss, or their low white blood cell count, or their cough, should not be when they read their note. That is how you get a one quarter sphere. It's going to how you cause patients not to come back to see you. So write what you say. Say what you write. If you're worried about something, if it's going to go into, you know, it's got to be talked about in the room. The first time of patient should be finding out about something is not when they're reading their note. So that's one step in is keep physical exam descriptions objective.

And I think for me this really kind of hit home on a personal level, which was my amazing mom, who is in her early 70s, had a cold and she was having some difficulty hearing afterwards. And she went and saw an ear, nose, and throat doctor who was focused on her hearing. And she said it was a fine visit, you know, nothing amazing, but nothing that really bothered me. And then she opened up this note when she got home. And the first thing she read is this. So these older woman, you know, knuckle hole and my mom is a beautiful, wonderful person. But this is something that plays on insecurities she's had. And any trust that that provider may have felt gone in for some words and for what? Why? For someone who was listening, you know, assessing her ear. Did that need to be the first line of response here? But just really think about why am I putting this in? Is this building patient morale, is this a necessary statement? So let's keep the physical exam attractive and then empower your patients with encouraging words into their next choices.

So we talked about language are not-compliant, denies, chief complaint. That's one side of the point. The other side of the coin is when you're writing your assessment plan, think about if I have a patient reading. This is the language that's going into my recommendations for testing, recommendations for lifestyle changes, medication use are those ones that patients and I read this to encourage that to carry out. I'm a medicine doctor. I am only as good as that patient is willing to do what I recommend. I'm not. I'm not opening up their body. I'm not correcting something in the O.R., so for a patient to be ready to take the medicine, I recommend you make the lifestyle changes to the lab test. They have to trust that it's the right thing to do, and they have to have it in. So I think about my assessment as a way to build that buy it. Because if I can, they're much more likely to carry through what I recommended.

Dr. Craig Joseph: We've hit a bunch of the kind of recommendations. Let me take us completely off. Off track and say, to a neither. It doesn't matter anyway. It doesn't matter anyway because all of us are going to be.

Dr. Anita Vanka: Testers over that.

Dr. Robert Stern: No, no.

Dr. Craig Joseph: That's not why. That's not why, this podcast, we're going strong. And neither the, it doesn't matter. Some might say, because, hey, we're moving to these AI scribes where especially in the outpatient setting, there'll be a microphone or some people call it a phone at this point, what that records our conversation and then generates a note for us to look at, and of course, and approve and edit if need be. But boy, oh boy, they're getting good. And so if I'm just going to have an LLM or AI write my note for me because, and that does there's many benefits to that. Of course. Then talking about all of these things seems less important. What would you say to that?

Dr. Anita Vanka: That statement, that is a great question. And I think, you know, we hear that a lot with many things in medicine and other specialties in other professions these days, but I would say the opposite is actually still holds true, that we have to know those best practices and know what we're doing. And for a couple of reasons. One is any I mean, we know we do C, and I love being incorporated into so many different uses in medicine and just the world in general. And actually here at the B and some of our ambulatory clinics, the Heidi AI is being piloted in several and ambulatory clinics, but, you know, the large language models are only as good as we train them, right? So you still have to have that intentionality of what you feel should be in the note to build that partnership and trust with your patient. We know that AI can hallucinate. And so it is important that we know what we're doing so that we use AI effectively to kind of be a partner with us in upholding these best practices and such.

And then secondly, I would say is when we are teaching learners, learners aren't going to be using AI from the get-go, I hope not. Yeah. And I hope, it's really important that they learn and think for themselves and how to be doing all of this and then learn how to incorporate AI effectively into their practices.

Such but, you know, medical science when they're first learning how to write notes and such like I don't I would hope that we're not using AI from the get-go. So it's still important for the faculty member and for the teachers to be intentional about what we're sharing with the medical students and why, and upholding those practices. So I would say for all of those reasons, like all the eyes in the world, they've really helpful. And I think it can have a great use, especially with the abbreviations and acronyms. Part of the best practices that we struggle with a lot. But I think it's still incumbent upon us to be intentional about this and to understand why these best practices are still important.

Dr. Robert Stern: And just have a need for this is embedded in what you said. But even if an AI is generating might note, that note still represents me as a physician with the relationship with the picture, and maybe at the bottom of my note, it will say this was generated with an AI product, but when the patient reads that they're still looking for my words, they're still looking for my thoughts and recommendations. And it's not a get out of jail free card. It's not.

If the AI says something that upsets the relationship with the patient that I could just say, oh, I said that I have no part of that, right? No matter who's generating that note, we are still responsible and we are at least the editors of the doubt. And it is incumbent on us for the notes to build relationship, not hurt relationship. And again, whether AI is generating it, we still have to play that integral role is to know that.

Dr. Craig Joseph: So both of you make an excellent point that these large language models are trained on the very notes that we've been producing for decades and decades and decades. And so they're going to need some new instruction. And the physical exam, of course, is something that, as you've already described, there are all kinds of ways of recording the physical exam. And oftentimes those are the only that the AI does not know what you're examining or seeing. So you're going to be talking about that in the middle of doing it. And so you can kind of make your life much easier. All right. I was worried there. I was worried that after we had this long conversation that there would be no need for it because it didn't matter anyway. It still matters. And it's always going to be your note, and you're the one that's going to have the responsibility to make sure that it's accurate and that it's appropriate. So we've established that there's a problem. We understand what the problem is. We kind of understand some of the steps to solving it. What about the old folks such as myself who've been doing this for a long time?

How do you get the message out to them that, hey, when they started, patients weren't looking at their notes. There was no concept of OpenNotes. How does that information get to them? Have you gotten any feedback from your colleagues, either positive or negative. With respect to hearing some of these findings, we'll start with you, Anita.

Dr. Anita Vanka: Definitely. I think it's just as important to have kind of a formal education of our faculty, if not more so than our learners. I think what Rob and I found in our first year of doing this curriculum is the medical students who are literally maybe a week or two into being medical students. Their reaction was, of course shouldn't say complain. Why would you say we're issue and say deny? Why would you? And because they were coming in with that experience of not having been indoctrinated into the vernacular yet, they were coming in as former patients or loved ones of patients, having read notes and understanding the impact of that. And then we held a similar session with our students, preceptors in that first year, the faculty and the discussion was much more robust because it was literally undoing kind of these years of practice where everyone had been writing notes in a certain way without any malintent, but also now learning that unfortunately, there is a negative impact when you do write your notes in a certain way. And I think that was really important for people to learn and just kind of sit with and discuss. How can you, Frazier, know to that better?

And we found also that it is important to be intentional about teaching kind of the above layers, like the teaching the teachers, because what we can see happens, as you well know, is you teach one thing in the classroom. And then when your students or your young physicians enter the workplace, we have something called a hidden curriculum, where they start to their practices, they start to undo what they've learned because they see their residents or their attendings and their faculty doing it in a different way. So a lot of that teaching that needs to also happen from the top down is important so that you don't lose what you've taught in the classroom space and lose that, too, of what we call the hidden curriculum.

Dr. Robert Stern: And I can build on that. Just to say, you know, what's been really interesting is that Anita and I started this at the medical student level. But as faculty would come to teach medical students, they would say, you know, we're being asked to write notes like this, but no one's ever come talk to us about how to do it. We've never heard of best practices around this. And so we've started to be invited to not to teach this to students, but to teach this in Grand Rapids settings to faculty. And one of the things that that kind of has done on both of these tonight is and this is maybe speaking to people who are listening to this, who are chairs of medicine, planned conferences in hospital leadership positions. We think that continuing medical education a lot around passive physiologic knowledge acquisition. We think about it as we need to learn the new drugs for diabetes. We need to understand the new pathways that are affecting LDL buildup. But we don't think as much about are we continuing to teach as all things clinical skills? Are we teaching our physicians? Our MPs? Our CPAs? Our faculty?

More generally, the evolution of how we take care of patients in regards to our clinical skills. And so I would say this is a great topic for a faculty development session. This is a great topic for grand rounds. And because the need is so good, what the feedback we've gotten when we've done this in the grand rounds setting is faculty say this is one of the most tangible, practical grand rounds I have left because it's really not pie in the sky. It's not conceptual. It's really getting into the nitty gritty and they'll print us now. They'll say, hey, I saw this patient a week out. I didn't know how to phrase this. Can we talk it through? And so just to get really nitty gritty, get practical, think about clinical skills as a continuing education piece.

Dr. Craig Joseph: I love it, I love it. I'm glad to hear, I was a little fearful that you were going to say people told you to go away. But you generally didn't get that response. We've been talking for a while about designing notes. That's really what we've been talking about.

I like to always ask the same question at the end of all of the podcast, which is, are there other things that are designed so well besides notes in your life that they it brings you, they bring you joy? So, we'll start with Doctor Vanka first. Is there something that's so well designed? You're it makes you happy whenever you interact with it?

Dr. Anita Vanka: Yes. And I promise I'm not being sponsored by Amazon to say so, but I love my Kindle. I’m an avid reader. I cannot tell you over the years how many physical books I've collected over time, how I've run out of space with them, and how many we have to donate on a yearly basis. So ever since I've had my Kindle, whether it's the app, on my phone, or the actual Kindle, I am at the number of books that I can carry and I can just. It's portable. It's easy, I love it, I do it. I will say I do miss the physical books at times. And there are times when I will actually, if I really like the book, go get the physical and just so I can have it. But for the most part, I have saved a lot of room on our bookshelves at home.

Dr. Craig Joseph: That's awesome that no one's ever said that before. Is there a particular version that you like? Of the of the physical device?

Dr. Anita Vanka: Yeah. The one that I have right now is the paperweight, which I got a couple of years ago. And I keep having to stop myself from upgrading because just to have something new and shiny, I really don't. But the paperweight, it's great. It's very light. You can read out in the sunlight and it doesn't, you know, you're not blinded by the lights. It's just, it's very easy to use and carry around.

Dr. Craig Joseph: Excellent. Doctor Stern.

Dr. Robert Stern: Yeah. So I thought about this question a lot, and I threw it out to some friends. I thought about my tennis racket. Some friends said a pizza cutter. Another friend said pizza itself. But I'm going to go really, really, like, medical nerdy here. And if I'd be truthfully honest, the thing as a hematologist that I keep coming back to that I'm always in is the platelet.

Dr. Craig Joseph: Platelet.

Dr. Robert Stern: Itself, the blood cell, the small blood cell. No DNA, no nucleus. Yet it changes shape when you need it to change shape to stop bleeding. It releases its own mechanisms. But to clot but then to not form, we're finding out it's integral in cancer metastasis and prevention of it. I can keep going with like what an amazing little thing.

Dr. Anita Vanka: I am so glad that you asked me first. I don't think I could have followed up for the platelet.

Dr. Craig Joseph: That, both of you gave really good answers. Okay. I've been doing this for a while now. Those are both very good answers. I would not have predicted platelet. Well, I want to thank both of you. This was a great conversation. Really appreciate it. I certainly learned a lot. And I think, the audience learned a lot as well and look forward to seeing how the education kind of makes its way through, not only for our young physicians, but for, let's just say I was going to say old, but more mature. Physicians, thanks again for being on the pod.

Dr. Anita Vanka: Thank you so much for having us. This is so much fun to chat with you and spend the time with them. Thank you.

Dr. Robert Stern: And we should just say, if people want to reach out to us, reach out to us. We love talking about this. I clearly can't talk forever. So be in touch with questions. Be in touch with arguments.

Dr. Craig Joseph: If I can find your email address, then most normal humans can do it. Thanks again.

Dr. Anita Vanka: Thank you so much.

Dr. Robert Stern: Thanks.