Improving oversight of the graduate medical education enterprise: one institution's strategies and tools.

Accreditation organizations, financial stakeholders, legal systems, and regulatory agencies have increased the need for accountability in educational processes and curricular outcomes of graduate medical education. This demand for greater programmatic monitoring has placed pressure on institutions with graduate medical education (GME) programs to develop greater oversight of these programs. Meeting these challenges requires development of new GME management strategies and tools for institutional GME administrators to scrutinize programs, while still allowing these programs the autonomy to develop and implement educational methods to meet their unique training needs. At the Medical University of South Carolina (MUSC), senior administrators in the college of medicine felt electronic information management was a critical strategy for success and thus proceeded to carefully select an electronic residency management system (ERMS) to provide functionality for both individual programs and the GME enterprise as a whole. Initial plans in 2002 for a phased deployment had to be changed to a much more rapid deployment due to regulatory issues. Extensive communication and cooperation among MUSC's GME leaders resulted in a successful deployment in 2003. Evaluation completion rates have substantially improved, duty hours are carefully monitored, patient safety has improved through more careful oversight of residents' procedural privileges, regulators have been pleased, and central GME administrative visibility of program performance has dramatically improved. The system is now being expanded to MUSC's medical school and other health professions colleges. The authors discuss lessons learned and opportunities and challenges ahead, which include improving tracking of development of procedural competency, establishing and monitoring program performance standards, and integrating the ERMS with GME reimbursement systems.     

Implementation of a college-wide GME core curriculum.

As health care delivery and its associated costs have been scrutinized carefully over the past decade, educational institutions have been expected to demonstrate how a particular educational requirement such as residency training brings benefit to the purchasers and users of their health care services. As part of this trend, the Accreditation Council for Graduate Medical Education recently enacted new accreditation standards mandating the inclusion of curricular elements that expose residents to basic concepts and principles of the non-technical areas of health care across a variety of topics, including ethics, cost containment, socioeconomics, medical-legal issues, communication skills, research design, statistics, and critical review of the medical literature. The authors report the efforts at the Medical University of South Carolina to overcome obstacles and successfully implement an institution-wide core curriculum program, dealing with the kinds of topics mentioned above, across 47 specialty and subspecialty programs with over 500 residents and fellows. The seminal events and critical strategies are described, along with lessons learned along the way. The following were key elements to success: (1) adhering to a strategic plan assigning oversight of residency education to the graduate medical education (GME) office; (2) gaining strong support from the dean and other college officials; (3) creating a stepwise centralization of residencies in college via the GME committee; (5) making the first core curriculum element one that had an excellent chance to succeed; (6) having core curriculum sessions begin in evenings and weekends to not interfere with regular curriculum, but later, when the value of the curriculum became evident to departments, moving the sessions to be within the week; (7) having the philosophy of the GME office be to maintain a flexible approach and serve departments.     

Baylor College of Medicine's support of Tulane University School of Medicine following Hurricane Katrina.

The authors describe how Baylor College of Medicine (BCM), with three other Texas medical schools, "adopted" virtually all the 620 medical students and 526 house officers of Tulane University School of Medicine and continued their education for eight months after most of New Orleans, including Tulane, was flooded on August 29, 2005, after Hurricane Katrina. Soon after, BCM's president asked all senior staff to take whatever actions were necessary to sustain Tulane, and on September 7, leaders from BCM and three other Texas medical schools met to plan the relocation of Tulane's students and programs. The authors explain how problems were overcome (e.g., locating the scattered Tulane students and staff, finding them lodging, obtaining their records, and providing financial aid and counseling), and how high-quality educational experiences were maintained for both Tulane's and BCM's students and residents while assisting Tulane's faculty in numerous ways, helping Tulane plan the enrollment of its following year's students, and undergoing Liaison Committee for Medical Education and Accreditation Council on Graduate Medical Education site visits to BCM.After the BCM-Tulane experience, BCM developed a disaster-management plan (available online) that could help other schools as they plan for disasters. The authors also offer lessons learned in the areas of communication, cooperation, curriculum, collaboration, contact with accrediting bodies, and compassion. They close by stating that when BCM faculty are asked "how could you take Tulane's medical school in?" their response is, "how could we not?" They continue: "In medical education, a frequent discussion is how to teach humanism and professionalism; we teach it best by modeling it."     

Do global rating forms enable program directors to assess the ACGME competencies?

PURPOSE: In 1999 the Accreditation Council for Graduate Medical Education (ACGME) mandated that GME programs require their residents to be proficient in six general competencies. The purpose of this study was to ascertain whether an existing global rating form could be modified to assess these competencies. METHOD: A rating form covering 23 skills described in the ACGME competencies was developed. The directors of 92 specialty and subspecialty programs at Thomas Jefferson University Hospital and the Albert Einstein Medical Center in Philadelphia were asked to rate residents at the end of the 2001-02 and 2002-03 academic years. RESULTS: Ratings for 1,295 of 1,367 (95%) residents were available. Residents were awarded the highest mean ratings on items tied to professionalism, compassion, and empathy. The lowest mean ratings were assigned for items related to consideration of costs in care and management of resources. Factor analysis indicated that the program directors viewed overall competence in two dimensions of medical knowledge and interpersonal skills. This factor structure was stable for groups of specialties, and residents' gender and training level. Mean ratings in each dimension were progressively higher for residents at advanced levels of training. CONCLUSION: Global rating forms, the tool that program directors use most frequently to document residents' competence, may not be adequate to assess the six general competencies. The results are consistent with earlier published research indicating that physicians view competence in just two broad dimensions, which questions the premise of the six ACGME competencies. Further research is needed to validate and measure six distinct dimensions of clinical competence.     

Attaining resident duty hours compliance: the acute care nurse practitioners program at Olive View-UCLA Medical Center.

The institution of resident duty hours limits by the Accreditation Council for Graduate Medical Education (ACGME) has made it difficult for some programs to cover inpatient teaching services. The medical literature is replete with editorials criticizing the hour limits and the resulting problems but is nearly silent on the topic of constructive solutions to compliance. In this article, the authors describe a new program, initiated in 2003 at the Olive View-UCLA Medical Center, of using acute care nurse practitioners to allow for compliance with the "24 + 6" continuous duty hours limit, as well as the 80-hour workweek limit. Each post-call team is assigned a nurse practitioner for the day, allowing residents to sign out by 2 pm while ensuring quality care for patients. Nurse practitioners participate in evaluation of residents and, in turn, are evaluated by them.Using this system, the authors report 99% compliance with ACGME work-hour restrictions, with average work hours for inpatient ward residents decreasing from 84 to 76 hours per week. Physician satisfaction with the new system is high; anonymous evaluation by residents and faculty returned average scores of 8.8 out of 9 possible points.The authors report that using nurse practitioners on post-call days provides excellent, continuous patient care without impinging on scheduling and without sacrificing responsibility, continuity, or education for the residents. This system has several potential advantages over previously described work-hour solutions. Addition of a nurse practitioner to the post-call team is an effective solution to the problem of compliance with resident duty hours limitations.     

Surviving Hurricane Katrina: reconstructing the educational enterprise of Tulane University School of Medicine.

Hurricane Katrina was one of the greatest natural disasters to ever strike the United States. Tulane University School of Medicine, located in downtown New Orleans, and its three major teaching hospitals were flooded in the aftermath of the storm and forced to close. Faculty, students, residents, and staff evacuated to locations throughout the country. All critical infrastructure that normally maintained the school, including information technology, network communication servers, registration systems, and e-mail, became nonoperational. However, on the basis of experiences learned when Tropical Storm Allison flooded the Texas Medical Center in 2001, Baylor College of Medicine, University of Texas-Houston, University of Texas Medical Branch in Galveston, and Texas A&M School of Medicine created the South Texas Alliance of Academic Health Centers, which allowed Tulane to move its education programs to Houston. Using Baylor's facilities, Tulane faculty rebuilt and delivered the preclinical curriculum, and clinical rotations were made available at the Alliance schools. Remarkably, the Tulane School of Medicine was able to resume all educational activities within a month after the storm. Educational reconstruction approaches, procedures employed, and lessons in institutional recovery learned are discussed so that other schools can prepare effectively for either natural or man-made disasters. Key disaster-response measures include designating an evacuation/command site in advance; backing up technology, communication, financial, registration, and credentialing systems; and establishing partnership with other institutions and leaders.     

A consortium-based research education program for residents.

With growing pressures to consolidate and reorganize health care delivery systems, graduate medical education (GME) consortia can draw faculty from affiliated members to assemble educational programs. The authors report on consortium-based research education seminars of a quality that many residency programs would be unable to develop and support on their own. Drawing a diverse faculty from consortium members and area universities, the OHEP Center for Medical Education's annual Research Workshop Series focuses on the design of research projects; data analysis and hypothesis testing; and written and oral presentation of scientific research. Each spring, OHEP sponsors a research forum in which the best research projects from consortium members are presented by the resident-researchers, who compete for recognition and prize money. Further, of the 128 presentations made thus far at the annual OHEP Research Forum, 25% were subsequently published. The consortium's research education program has been well received by residents, is cost-effective, and is an integral component of the research curricula of many area residency programs. Including research training in GME provides residents an opportunity to become more competitive for fellowship, faculty, and leadership positions.     

Assessing the new general competencies for resident education: a model from an emergency medicine program.

The Accreditation Council for Graduate Medical Education (ACGME) has promoted six areas that should be addressed during graduate medical training, or "general competencies" (GCs). According to the ACGME, these GCs should be reflected in the educational processes of all residency programs. In promulgating these competencies, however, the ACGME has not provided examples of core content, methods of implementation, or methods of evaluation. The authors propose a practical method for modifying an existing evaluation format, providing a template other programs could use in assessing residents' acquisition of the knowledge, skills, and attitudes reflected in the GCs.     

Honoring the "E" in GME.

Medical educators should realize that the public's complaints about doctors--that they don't care enough about their patients, don't know enough to practice the best medicine, and don't do enough to maintain the public's trust--are exaggerations of the truth but highlight areas demanding improvement in the educational component of graduate medical education (GME). In addition to continuing to prepare residents for the demanding technical challenges they will face as physicians, those involved in GME need to (1) enrich significantly the educational content of residency programs; (2) promote the coordination, strengthening, and potential consolidation of the institutional responsibility for these programs; (3) reorder programs' priorities to make room for the added educational content, which means limiting service requirements to those necessary to meet prospectively defined educational goals; and (4) recognize the power of the hidden curriculum in communicating professional values, and thus modify significantly the way residents are treated. The author explains these recommendations in detail and notes a variety of ways that the Association of American Medical Colleges intends to help educators make these needed changes. He concludes by stating that a "time bomb" is ticking: many sectors of the public and many patients are becoming impatient with doctors. "Listening hard to their complaints and finding appropriate remedies is a must if we are going to ... answer our critics ... and continue to provide America with the world's best doctors."     

Perspective: beyond counting hours: the importance of supervision, professionalism, transitions of care, and workload in residency training

The medical education community's conversations about residents' duty hours have long focused solely on the number of those hours. In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) enacted its most recent iteration of standards regarding duty hours. Those standards, as well as a 2008 Institute of Medicine report, look beyond the quantity of duty hours to address their quality as well. Indeed, the majority of the 2011 ACGME standards specify requirements for the qualitative components of residents' working and learning environments, including supervision of residents; professionalism, personal responsibility, and patient safety; transitions of care; and clinical responsibilities (including workload). The authors believe that focusing on these qualitative (rather than quantitative) components of the resident's working and learning environment provides the greatest promise for balancing patient care with resident education, thus optimizing the safety and effectiveness of both. For each of the four qualitative components that the authors discuss (enhancing supervision, nurturing professionalism and personal responsibility, ensuring safe transitions of care, and optimizing workloads and cognitive loads), they offer agendas for faculty development, educational program planning, and research. Thus, the authors call on the medical education community to expand its discussion beyond counting duty hours to focus on these critical issues that ensure quality resident education and patient care and to implement necessary strategies to address them.     

Perspective: Creating the next generation of general internists: a call for medical education reform

The United States is faced with an increasing shortage of physicians in the primary care workforce. The number of medical school graduates selecting careers in primary care internal medicine has fallen dramatically since 1985. Although political, financial, and organizational reform of the medical system is necessary, these changes will address only part of the problem. Endeavors designed to ameliorate this current crisis in primary care practice must also address the education and training of future primary care internists. Learners require specialized training in primary care internal medicine to be able to provide high-quality, patient-centered, outcome-oriented care. This article examines the impact of educational interventions in undergraduate medical education (UME) and graduate medical education (GME) on primary care internal medicine career choice and makes suggestions for future educational changes. Suggested UME changes include providing early longitudinal clinical experiences and providing the option for an integrated ambulatory third year of training. Suggested GME changes include early, sustained exposure to general internal medicine and differentiated training tracks for residents interested in primary care. Key among these changes are that medical students and residents must have adequate mentorship from primary care internists and clinical experiences in highly functioning primary care settings established as patient-centered medical homes. Academic centers have a unique opportunity to contribute to these imperatives by reengineering the practice of primary care in a way that embodies the core values of effective, patient-centered care.     

A mid year comparison study of career satisfaction and emotional states between residents and faculty at one academic medical center

Background  

The Accreditation Council for Graduate Medical Education's (ACGME) new requirements raise multiple challenges for academic medical centers. We sought to evaluate career satisfaction, emotional states, positive and negative experiences, work hours and sleep among residents and faculty simultaneously in one academic medical center after implementation of the ACGME duty hour requirements.     

An international summer school on health informatics: a collaborative effort of the Amsterdam Medical Informatics Program and IPhiE--the International Partnership for Health Informatics Education

PURPOSE: Today, the need for health informatics training for health care professionals is acknowledged and educational opportunities for these professionals are increasing. To contribute to these efforts, a new initiative was undertaken by the Medical Informatics Program of the University of Amsterdam-Academic Medical Center and IPHIE (IPhiE)-the International Partnership for Health Informatics Education. In the year 2004, a summer school on health informatics was organized for advanced medical students from all over the world. METHODS: We elaborate on the goals and the program for this summer school. In developing the course, we followed the international guidelines of the International Medical Informatics Association-IMIA. Students provided feedback for the course through both summative and formative evaluations. As a result of these evaluations, we outline the lessons we have learned and what consequences these results have had in revising the course. RESULTS: Overall the results of both the summative and formative evaluation of the summer school showed that we succeeded in the goals we set at the beginning of the course. Students highly appreciated the course content and indicated that the course fulfilled their educational needs. The decision support and image processing computer practicums however proved too high level. We therefore will redesign these practicums to competence requirements of medical doctors as defined by IMIA. All participants recommended the summer school event to other students. CONCLUSIONS: Our experiences demonstrated a true need for health informatics education among medical students and that even a 2 weeks course can fulfill health informatics educational needs of these future physicians. Further establishment of health informatics courses for other health professions is recommended.     

What Are the Pathology Education Requirements for All Nonpathology ACGME-Accredited Programs in an Academic Center?

This study aimed to determine institution-wide graduate medical education (GME) requirements in pathology (exclusive of pathology residency and fellowships) at an academic center. All documents related to residency review committee (RRC) program requirements were searched for the key words "pathology," "laboratory," "autopsy," and "morbidity." For each occurrence, it was determined whether a pathology education requirement had been identified. Requirements were categorized and tabulated. The Accreditation Council for Graduate Medical Education (ACGME) lists 135 nonpathology programs; 66 programs exist at Duke University Medical Center, of which 54 (82%) had pathology education requirement(s). Twelve education categories were identified. Teaching/conferences were the most common (52%). Thirty-nine percent required consultation/support. Sixteen programs were required to perform gross/microscopic examination. Trainees in medical genetics are required to have a pathology rotation. Elective rotations should be available for trainees in 6 programs. Pathology departments at academic centers face significant institution-wide pathology education requirements for clinical ACGME programs. Didactic teaching/conferences and consultation/support are common requirements. Opportunities exist for innovative teaching strategies.     

The role of gross anatomy in promoting professionalism: a neglected opportunity!

Professionalism is one of the six areas of competency defined by the Accreditation Council for Graduate Medical Education (ACGME). Unprofessional behavior is the single most common cause for disciplinary action against medical students in their clinical rotations, residents, and clinical practitioners. The Association of American Medical Colleges (AAMC) and the National Board of Medical Examiners (NBME) will like to see professionalism taught and evaluated across medical school. Gross Anatomy, with cadaver laboratory dissection, is in a unique position to preside over a rich number of activities where behaviors of professionalism can be taught, practiced, and rewarded. Such activities will be comparable to the behaviors of professionalism taught in clinical rotations. This article highlights the essential involvement and tools that can be used to teach, evaluate, and promote behaviors of professionalism accessible in the laboratory with cadaver dissection.     

The Georgia State Telemedicine Program: initiation, design, and plans.

This paper describes the genesis, implementation, and operation of the Georgia Statewide Telemedicine Program, a full-service system that provides a comprehensive range of clinical and consultative services to all residents of the state through a hub-and-spoke network. When completed, it will consist of several tertiary-care centers and a set of secondary hubs at medical centers throughout the state. Each hub will, in turn, serve several remote sites. The system enables connectivity throughout the network, and the overall coordination, implementation, and oversight is provided by the Center for Telemedicine at the Medical College of Georgia. The evolution of the system is described, together with lessons learned from the experience.