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Update in Medical Education

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Bijal Mehta

on 19 December 2014

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Transcript of Update in Medical Education

Patient Care (PC)
Competency – the thing(s) they need to do

Competent – can do all of the things

Competence – does all of the things consistently, adapting to contextual and situational needs

Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social behavioral sciences, as well as the application of this knowledge to patient care
Medical Knowledge (MK)
1999 – ACGME
The Outcomes Project

Basic Definitions
Interpersonal and Communication Skills (ICS)
Practice-based Learning and Improvement (PBLI)
PBLI (con't)
Traditional vs CBME


Primary Care
Medical Education
Update in Medical Education and State of the Residency Address

Bijal S. Mehta, MD FACP
Program Director,
Associate Director of Medical Education
Department of Medicine
December 18, 2014
My husband works for Bayer Healthcare
No financial conflicts in content of this talk
* Update in Graduate Medical Education
The Evolution of the ACGME Competencies
Milestones and the Next Accreditation System (NAS)
Clinical Learning Environment Review

*The Emergence of Simulation
* HackensackUMC-MSH IM
Program Changes/Innovations
* Conclusions/Q&A

- Core Competencies
Patient Care (PC)
Medical Knowledge (MK)
Practice-based Learning and Improvement (PBLI)
Interpersonal and Communication Skills (ICS)
Professionalism (PROF)
Systems-based Practice (SBP)

- Reflected a major paradigm shift from the process of education to the outcome of education

The DOM Leadership
Dr. Valérie Allusson
Chair and Associate PD
Director of Hosp. Services

Dr. Bijal Mehta
Program Director
The DOM Leadership/Faculty
Dr. Douglas Zaeh
Assoc. Program Director

Dr. Jennifer Knight
Clinic Director

Competency based Medical Education:

An outcomes-based approach to the design, implementation, assessment and evaluation of a medical education program using an organizing framework of competencies

The International CBME Collaborators, 2009
*Stolen from Kelly Caverzagie, MD
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

Residents must be able to competently perform all medical, diagnostic, and surgical procedures considered essential for the area of practice

Residents must demonstrate the ability to:

Investigate and evaluate the care of their patients,
Appraise and assimilate scientific evidence, and
Continuously improve patient care based on constant self-evaluation and life-long learning
Identify strengths, deficiencies, and limits in one’s knowledge and expertise

Set learning goals and improvement
Identify and perform appropriate learning activities
Systematically analyze practice using quality improvement methods and implement changes with the goal of practice improvement
Incorporate formative feedback into daily practice
Locate, appraise and assimilate evidence from scientific studies related to the their patients problems
Using information technology to optimize learning and participate in the education of patients, families, students, residents and other health care professionals

Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families and health professionals

Communicate effectively with patients, families, and the public, across a broad range of socioeconomic and cultural backgrounds

ICS (con't)
Communicate effectively with physicians, other health professionals, and health related agencies
Work effectively as a member or leader of a health care team or other professional group
Act in a consultative role to other physicians and health professionals
Maintain comprehensive, timely, and legible medical records, if applicable

Professionalism (PROF)
- Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles
- Residents are expected to demonstrate:

Compassion, integrity, and respect for others
Responsiveness to patient needs that supersedes self-interest
Respect for patient privacy and autonomy
Accountability to patients, society, and the profession
Sensitivity and responsiveness to a diverse patient population
Systems Based Practice (SBP)
- Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care

- Residents are expected to:

Work effectively in various health care delivery settings and systems relevant to their clinical specialty
Coordinate patient care within the health care system relevant to their clinical specialty
Incorporate considerations of cost awareness and risk benefit analysis in patient and/or population-based care as appropriate
Advocate for quality patient care and optimal patient care systems
Work in interprofessional teams to enhance patient safety and improve patient care quality
Participate in identifying system errors and implementing potential systems solutions

Nov. 2007 - 33 member task force created with members of ABIM/ACGME
The Milestones

Ability to perform an activity at a desired level of performance without direct supervision
Trust is (should be) based on directly observed, consistent performance over time
We constantly, often subconsciously, make entrustment decisions based on needed level of supervision- need to formalize this process
“142 is too many!!” –
Birth of 16 EPA’s (Entrustable Professional Activity)

Carraccio, et al. Shifting Paradigms: From Flexner to Competencies. Acad. Medicine. 2002; 77(5): 361-367.

The Entrustable Professional Activities of Medicine (16)
1. Manage care of patients with acute common diseases across multiple care settings.
2. Manage care of patients with acute complex diseases across multiple care settings.
3. Manage care of patients with chronic diseases across multiple care settings.
4. Provide age-appropriate screening and preventative care.
5 Resuscitate, stabilize, and care for unstable or critically ill patients.
6. Provide perioperative assessment and care.
7. Provide general internal medicine consultation to nonmedical specialties.
8. Manage transitions of care.
9. Facilitate family meetings.
10. Lead and work within interprofessional health care teams.
11. Facilitate the learning of patients, families, and members of the interdisciplinary team.
12. Enhance patient safety.
13. Improve the quality of health care at both the individual and systems level.
14. Advocate for individual patients.
15. Demonstrate personal habits of lifelong learning.
16. Demonstrate professional behavior.

The Next Accreditation System (NAS)
Definitive shift from process to outcomes
Enhance peer review system to prepare physicians for practice in the 21st century
Accelerate movement towards accreditation on the basis of educational outcomes
Reduce burden associated with current structure and process based approach

Nasca, et al. The Next GME Accreditation System – Rationale and Benefits. NEJM 2012;366(11);1051-1056

1- Communicates effectively with patients and caregivers (ICS1)
2- Communicates effectively in interprofessional teams (e.g. peers, consultants, nursing, ancillary professionals and other support personnel (ICS2)
- Appropriate utilization and completion of health records (ICS3)

The Reporting Milestones:
Interpersonal and Communication Skills

1- Monitors practice with a goal for improvement (PBLI1)
2- Learns and improves via performance audit (PBLI2)
3- Learns and improves via feedback (PBLI3)
4- Learns and improves at the point of care (PBLI4)

The Reporting Milestones :
Practice Based Learning and Improvement

1- Works effectively within an interprofessional team (e.g. peers, consultants, nursing, ancillary professionals and other support personnel) (SBP1)
2- Recognizes system error and advocates for system improvement (SBP2)
3- Identifies forces that impact the cost of health care, and advocates for, and practices cost-effective care (SBP3)
4- Transitions patients effectively within and across health delivery systems (SBP4)

The Reporting Milestones:
System Based Practice

1- Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g. peers, consultants, ancillary professionalism and support personnel) (PROF1)
2-Accepts responsibility and follows through on tasks (PROF2)
3- Responds to each patient’s unique characteristics and needs (PROF3)
4- Exhibits integrity and ethical behavior in professional conduct (PROF4)

The Reporting Milestones:

1- Clinical knowledge (MK1)
2- Knowledge of diagnostic testing and procedures (MK2)

The Reporting Milestones:
Medical Knowledge

1- Gathers and synthesizes essential and accurate information to define each patient’s clinical problem (PC1)
2-Develops and achieves comprehensive management plan for each patient (PC2)
3- Manages patients with progressive responsibility and independence (PC3)
4- Skills in performing procedures (PC4)
5- Requests and provides consultative care (PC5)

The Reporting Milestones:
Patient Care

Green, et al. Charting the Road to Competence: Developmental Milestones for Internal Medicine Training. J Grad Med Ed. 2009; 5-20.

Logical trajectory of professional development in essential elements of competency and meet criteria for effective assessment
Submission of narrative reports on 22 milestones to ACGME (twice a year in 2014)

The 22 Educational (or Reporting) Milestones

Clinical Learning Environment Review (CLER)
Institutional Level: CLER
- ACGME recognizes public need for a physician workforce capable of meeting the requirements of the rapidly evolving health care environment
- Sets expectations for an optimal clinical learning environment to achieve safe and high quality patient care
- Six Focus Areas:
Patient Safety
Quality Improvement
Transitions of Care
Duty Hours Oversight, Fatigue Management and Mitigation

*CLER Pathways to Excellence, www.acgme.org
Patient Safety
 – provide opportunities for residents to report errors, unsafe conditions, and near misses, and to participate in inter-professional teams to promote and enhance safe care.

Patient Safety
Quality Improvement
PI Committee
Engagement of residents in the use of data to improve systems of care, reduce health care disparities and improve patient outcomes.
Transitions in Care
How sponsoring institutions demonstrate effective standardization and oversight of transitions of care.

How sponsoring institutions maintain and oversee policies of supervision concordant with ACGME requirements in an environment at both the institutional and program level that assures the absence of retribution

GME Supervision Policy

Duty Hours Oversight, Fatigue Management and Mitigation
Demonstrate effective and meaningful oversight of duty hours across all residency programs institution-wide
design systems and provide settings that facilitate fatigue management and mitigation
provide effective education of faculty members and residents in sleep, fatigue recognition, and fatigue mitigation.

(i)Duty Hour Logs
(ii)Compliant call systems
(iii) Trainee Education

The most recent Duty Hours specifics
Duty hours must be limited to 80 hours per week, averaged over four week period, inclusive of all in-house call activities and all moonlighting
Minimum of one day free of duty every week (when averaged over four weeks). At-home call cannot be assigned on these free days.
Duty periods of PGY-1 residents must not exceed 16 hours in duration
Maximum of 24 hours of continuous duty in the hospital for PGY2 and above

GME Oversight
Educate for professionalism, monitor behavior on the part of residents and faculty and respond to issues concerning:

Accurate reporting of program information
Integrity in fulfilling educational and professional responsibilities
Veracity in scholarly pursuits

Overview of Simulation:
The 11 Dimensions (continued)

Overview of Simulation:
The 11 Dimensions

Simulation in Medical Education

Overview of Simulation:
The 11 Dimensions (continued)

New ways how personnel are educated, trained, and sustained for providing safe clinical care
Emphasis currently on basic science education and relatively unsystematic apprenticeship process - outdated
Adage “See one, do one, teach one” is no longer considered safe nor appropriate
Systematic training and assessment of health care personnel should become a major priority
Shift from individual performance to honing the performance of the “team”
Out with the old, in with the new…

The Emergence of Simulation

Marked growth over past two decades
Purpose: Improve patient safety and care


Aviation Accidents & Incidents
Our Milestone Map

Nasca, et al. The Next GME Accreditation System – Rationale and Benefits, NEJM 2012;366(11):1051-1056.
Weiss, et al. The Clinical Learning Environment – The Foundation of Graduate Medical Education, JAMA 2013;309(16): 1687-1688.
Iobst, et al. Internal Medicine Milestones, Journal of Graduate Medical Education Supplement 2013; 14-23.
Green, et al. Charting the Road to Competence: Developmental Milestones for Internal Medicine Training. J Grad Med Ed. 2009; 5-20.
Carraccio, et al. Shifting Paradigms: From Flexner to Competencies. Acad. Medicine. 2002; 77(5): 361-367.
Caverzagie, et al. The Internal Medicine Reporting Milestones and the Next Accreditation System 2013; 7:557-559.
Cook et al. Technology-Enhanced Simulation for Health Professions Education, JAMA 2011;306(9); 978-988.
Gaba. The Future Vision of Simulation in Health Care, Quality and Safety in Health Care 2004;13(Supple 1):i2-i10


Creation of a Simulation Lab with Simulation curriculum across IM/FP
Enhancement of Inpatient floor experience
Restructuring of rounding structure - ? Geographic teams
Implementation of hospitalist curriculum
Faculty Development
Direct Observation and Measurement of Milestones
Feedback and Evaluation
Recruitment of a 4rth year Chief Resident

Plans for the near future (cont)

Revitalization of outpatient/clinic experience
Recruit 4th faculty member as Clinic Director
Ambulatory Block structure 2015-2016
? Move clinic
Reinitiation of group/individual QI projects
Creation of Outpatient Didactic Curriculum
* Hopkins Modules
* Yale based Office Curriculum
* ACP’s High Value Cost Conscious Care

Our plans for the future (near)

The Program: PGY1 Ambulatory Block Structure

24 residents (8 in each class)
3 Year ABIM pass rate: 87%
Accreditation status: Full accreditation
Our vision: To create outstanding internists to care for patients with compassion and respect in the primary care and inpatient setting.

Changes Closer to Home: HackensackUMC Mountainside IM Residency

he Next Accreditation System is here – we will need to evaluate our residents on specific milestones in each of the 6 Competencies
Patient Care, Medical Knowledge, Problem Based Learning & Improvement
Interpersonal & Communication Skills, Professionalism, Systems based Practice
Impending CLER Visit – ACGME to assess institutional commitment to each of the following 6 domains
Patient Safety, Quality Improvement, Transitions of Care
Supervision, Professionalism, Duty Hours Management and Fatigue Mitigation
Simulation is the new way to educate and train our learners – in a safe environment for both trainee and patients
Changes are coming our way here at HackensackUMC Mountainside
Ambulatory Block Structure
Simulation Lab


The Program: PGY1 Ambulatory Block Structure

Sept. 2009 – Introduction of the Developmental Milestones (142)
A stone marker set up on a roadside to indicate the distance in miles from a given point
Define the abilities expected of IM residents as they progress through training
A technique to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion
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