I Have Nothing to Disclose

Hot Topics in Graduate Medical Education David S. Kountz, MD, MBA, FACP Vice President, Academic Affairs New Jersey State Association of Medical Staff Services 23rd Annual Education Conference

What are the Hot Topics?  Update on residency accreditation by the Accreditation Council of Graduate Medical Education (ACGME)  Do you understand the language in your physician’s LOR? Next Accreditation System and Milestones? And new thoughts about duty hours

“We improve health care by assessing and advancing the quality of resident physician education through accreditation.”

 Recent residency match results and physician supply/demand data – what do they tell us about keeping your hospital staffed to provide necessary clinical services  Physician well-being – an unrecognized epidemic  Does your institution support your physicians to address this unrecognized tragedy?

ACGME Mission Statement

Learning Objectives

The Six Core Competencies

1. To review the ACGME accreditation process to allow Medical Staff Professionals to accurately assess medical staff candidates 2. To understand the imbalance between medical school graduates, residency slots, and implications to the makeup of hospital medical staffs, especially in primary care 3. To appreciate why physicians – especially female physicians – are at risk for burnout, depression and suicide, and what steps medical staffs have taken to address these problems

Patient Care

Medical Knowledge

Practice-based Learning and Improvement

Interpersonal and Communication Skills

Professionalism

Systems-based Practice

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Holistic Evaluation of Residents and Fellows Milestones

Operative Performance Rating Scales

Mock Orals

Nursing and Ancillary Personnel Evaluations

End-ofRotation Evaluations

Self Evaluations

Student Evaluations

Sim Lab

ITE

Clinic Workplace Evaluations

Clinical Competency Committee

OSCE

Case Logs

Patient/ Family Evaluations

Peer Evaluations

Assessment of Milestones )

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Competency Development Model

Milestone Benefits Program Benefits

Resident/FellowBenefits

Provide tools needed to define and assess outcomes

Potentially permit true graduated responsibility (proof positive that you are proficient to practice unsupervised)

Highlight curriculum inadequacies

Provides concrete metrics for evaluation

Guide curriculum development

No more “nice guy, showed up on time” feedback allowed

Allow early identification of under(and over-) performers

Sets concrete expectations for resident progression

MILESTONES Curriculum

Curriculum

Curriculum

Curriculum

Curriculum

PGY-3 PGY-1 MS4 MS3 Novice Dreyfus SE and Dreyfus HL. 1980 Carraccio CL et al. Acad Med 2008;83:761-7

Expert/ Master Proficient

Competent Advanced Beginner Time, Practice, Experience

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General Competency

Sub-competency

Developmental Progression or Set of Milestones

PC1. History (Appropriate for age and impairment) Level 1 Acquires a general medical history

Level 2

Level 3

Acquires a basic physiatric history including medical, functional, and psychosocial elements

Acquires a comprehensive physiatric history integrating medical, functional, and psychosocial elements Seeks and obtains data from secondary sources when needed

Specific Milestone

Level 4 Efficiently acquires and presents a relevant history in a prioritized and hypothesis driven fashion across a wide spectrum of ages and impairments Elicits subtleties and information that may not be readily volunteered by the patient

Level 5 Gathers and synthesizes information in a highly efficient manner

Clinical Learning Environment Review (CLER) Site Visits

Rapidly focuses on presenting problem, and elicits key information in a prioritized fashion Models the gathering of subtle and difficult information from the patient

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An Institutional Assessment  All programs within an institution evaluated simultaneously  CLER is NOT tied to program or institutional accreditation

Evaluating Obstetrical Residency Programs Using Patient Outcomes

 Six areas of focus:  Resident/fellow engagement/participation in patient safety programs  Resident/fellow engagement/participation in QI programs  Establishment and oversight of institutional supervision policies  Effectiveness of institutional oversight of transitions of care  Effectiveness of duty hours and fatigue mitigation policies  Activities addressing the professionalism of the educational environment

Asch DA et al, JAMA 2009

 Formative, non-punitive learning process for institutions and the ACGME

Effects of the Accreditation Council for Graduate Medical Education Duty Hour Limits on Sleep, Work Hours, and Safety Landragan et al, Pediatrics August 2008

Objective: To assess whether obstetrics and gynecology residency programs can be evaluated by the quality of care their alumni deliver Design, Setting, and Patients: A retrospective analysis of all Florida and New York obstetrical hospital discharges between 1992 and 2007, representing 4 906 169 deliveries performed by 4124 obstetricians from 107 US residency programs. Main Outcome Measures: Nine measures of maternal complications from vaginal and cesarean births reflecting laceration, hemorrhage, and all other complications after vaginal delivery; hemorrhage, infection, and all other complications after cesarean delivery; and composites for vaginal and cesarean deliveries and for all deliveries regardless of mode.

Evaluating Obstetrical Residency Programs Using Patient Outcomes Effect of Residency Duty-Hour Limits Reed et al, Archives of Internal Medicine, July 2007

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Evaluating Obstetrical Residency Programs Using Patient Outcomes

Take Home Points • Assessment of resident candidates to your medical staff – at least behind the scenes – is becoming more objective, standardized, and reproducible • Through CLER visits resident training is increasingly aligned with institutional priorities (quality and safety) • The quality of the training environment may influence the quality of the residents’ performance years after his/her completion of their program

Evaluating Obstetrical Residency Programs Using Patient Outcomes

Hot Topic #2 – Physician Supply and Demand

Conclusion: Where an obstetrician completed residency may provide a meaningful and consistent signal about the risk of maternal complications among that obstetrician's patients. These rankings are stable across individual types of complications and are not associated with residents' licensing examination scores

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Match Day Celebration at Rutgers – New Jersey Medical School, March 18, 2016

Actual and Projected Growth in Numbers of U.S. Medical School Graduates and Graduate Medical Education (GME) Entrantsin

GME Positions.

Mullan F et al. N Engl J M e d 2015;373:2397-2399.

So What’s the News in NJ? • 479 students in the match from RWJMS, NJMS, Cooper Medical School, and RowanSOM – 40% pursuing primary care* (highest at Cooper and Rowan; lowest at RW JMS and NJMS) – 117/479 (24%) staying in NJ for their residency (highest from RowanSOM (40%) - lowest from RW JMS (14%)) – Among those students staying in NJ for residency from RW JMS, NJMS, and Cooper, only 8/53 (15%) are training at a hospital outside of these large medical school-based academic medical centers

Growth of First-Year Enrollment in U.S. Schools of Medicine and Osteopathy since 2002. Medical Schools are Trying to Keep Up with the Projected Demand…

Iglehart JK. N Engl J Med 2013;369:297-299.

Bottom Line for the Medical Staff Professional • There has been no in students choosing students a primary care career after passage of the Accountable Care Act • Expect worsening physician shortages in all areas, not just primary care • Ongoing focus on recruitment of young physicians with incentives including loan reimbursement, salary support, etc. • NJ’s allopathic medical school graduates overwhelmingly complete their residencies in only 3 NJ hospitals

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Beckham C. Bias and Burnout: Evil Twins. Medscape Internal Medicine. http://www.medscape.com/viewarticle/856814_2. Accessed April 8, 2016.

“Quadruple Aim”: Care of the Patient and Care of the Provider

Annals of Family Medicine 2014

Maslach Burnout Inventory Criteria

Score (1-low to 10high)

1. Emotional exhaustion from work 2. De-personalization (loss of empathy when dealing with others) 3. Sense of personal accomplishment (doubt your ability to be effective) Total: < 5=low level of burnout; 6-10 mid-level of burnout; >11 high level of burnout Fiore M, Peckham C. Emergency Medicine Lifestyles – Linking to Burnout. http://www.medscape.com/features/slideshow/lifestyle/2013/emergency-medicine#3. Accessed April 9, 2016

www.action-learning.com, 2015

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Take Home Points for the Medical Staff Professional • Is that disruptive physician burned out, depressed, and potentially suicidal? – Could there be clues all around that people are missing?

• Is there an awareness of this issue among your medical staff leadership? • Do you have in place a physician well-being program; are their resources available to help struggling members of your medical staff?

Thank you! [email protected]

Physician Suicide Challenge Dr. Pamela Wible

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