Future of Graduate Medical Education

Martin Olsen MD

Disclosure

Dr. Olsen is a consultant for Gaumard Scientific and a co-holder of patent 7,866,983

Part 1Areas of attention for the

ETSU Ob/Gyn residency

program

Initiatives for 2012-13Continue Research growth

Enhance ultrasound curriculum

Next Site VisitTentatively scheduled for October 2013

Current Required Procedural Evaluation

The ACGME Outcomes Project

 

Evaluating Surgical Competency

In a New Model for Graduate Education

Dee E.Fenner, M.D.

CREOG TASK FORCE

Future Procedural Evaluation?

Page 2

Part 2The view from above

Which statement best describes your

enthusiasm for the topic of GME financing?

A) This discussion is likely to affect my life, so I am excited to hear about it.

B) If Dr. Olsen wants to talk about it, I’ll listen since I am a respectful person

C) Wake me when this is over

Transforming Graduate Medical Education to Improve Healthcare Value

NEJM 2011 Hackbarth G, Boccuti C

Medicare spent $9.5 billion 2009

Minimal accountability

Medicare’s costs exceed actual costs by about $3.5 billion

Some hospitals place excess into their general fund

Financing Graduate Medical Education—Mounting Pressure for Reform

NEJM 2012Iglehart JK

Obama administration plans to reduce Indirect Medicare Payments by $9.7 billion over 10 years

“IME adjustments significantly exceed actual added patient care costs…”

Advocates incentive programs that can be earned by meeting performance standards

7 Senators have asked Institute of Medicine to conduct independent review of GME financing

Recommendation- An outcomes based evaluation system… new physicians measured for their competency

Plug the Leak: Align Public Spending with Public Need

Girard et al: J Grad Med Ed Sept 2012 293-95

“..GME funding is no longer linked to prior public service…has become principally a means to fulfill the career aspirations of new doctors and the resource needs of of individual hospitals…”

“…unregulated market rewards an entrepreneurial approach to physician training….”

…we have a two year deadline before the health care system will be inundated with 32 million or more newly insured.”

Plug the Leak…“The only effective means of centrally guiding

the composition of the physician workforce is through leveraging CMS funding…”

“A strategically designed mandatory public health service….”

“…the time to act is now…”

“… our national leaders must plug the chronic leak of dollars into medical specialties we do not need…”

Faculty Financial Pressures

Faculty are under increasing pressure to generate revenue

Faculty research suffers as a result of financial pressures

In many institutions, faculty work more hours than residents

Increased difficulty in faculty recruitment is likely

Faculty have less time and rewards for teaching

Results? Predictions?At the hospital level, Graduate Medical Education will

move from a revenue generating activity to a revenue neutral activity or even a financial loss

Hospitals will pick up the tab for some specialty and subspecialty education

Increase in structured self learning activities by residents is likely

Faculty will spend less time with residents, hence a need will exist to maximize the educational value of the time expended

An increased role for physician extenders/ education extenders may occur

Criticisms of Current Teaching methods

Medical trainees regularly demonstrate that it is more important that they never be wrong than it is that they take chances and think creatively

Educators may reward the student who parrots the safe answer and punish the trainee who risks looking bad by original thinking

Misch DA Andragogy and Medical Education-Are Medical Students Internally Motivated to Learn Advan Health Sci Ed 7:153-160 2002

AndragogyThe art and science of adult education

Malcolm Knowles is the father of Andragogy

Controversial

Unproven

To it’s adherents, Adragogy principles approach the level of dogma

Misch DA Andragogy and Medical Education-Are Medical Students Internally Motivated to Learn Advan Health Sci Ed 7:153-160 2002

Knowles ConceptsThe need to learn

The learner’s self concept

Role of learner’s experience

Readiness to learn

Orientation to learning

Motivation

More Self Directed Learning

Just like attending physicians study for recertification on their own time, residents study at home away from the institution

As work hours decrease, home time may increase

Computerized self teaching and assessment mechanisms may increase

Time with attendings could decrease but be of more intellectual value

What About Work Hours?

What are the Work Hours Restrictions for Residents in the United Kingdom?

A) 88 hours

B) 78 hours

C) 68 hours

D) 58 hours

E) 48 hours

What did US Neurosurgery Residents say about Work Hours Changes in 2011?

A) Residents supported the changes and look forward to additional future limitations

B) Residents thought the changes were appropriate but no further changes will be needed

C) Residents did not answer a single question in favor of the new duty hours limits

Duty Hour Reform through the Eyes of Neurological Surgery Residents

J Grad Med Ed Dec 2012 p 415-16.

Residents predicted decreased surgical volume and increased medical errors because of suboptimal handoffs.

5% of residents had committed a medical error at the end of a long shift

8% had been in a life threatening event after a long shift

36% occasionally or frequently violated duty hours

A Thematic Review of Resident Commentary on Duty Hours and

Supervision Drolet, Soh, Shultz Fisher J Grad Med Ed Dec 2012 p 454-459

Review of comments from a 2010 Survey- reported NEJM

874 of 2561 residents had free text comments

Approximately 20% return rate

2% of U.S. resident physicians

95% of “overall impression” comments were negative

Resident Concerns16 hour duty limits for interns would negatively

impact education

Limits would diminish preparation for more senior roles later

Decreased patient safety

Decreased quality of care

Scheduling issues

Poorer resident quality of life*

Faculty SupervisionRelatively undiscussed

Text disagrees with table, but it seems that residents are comfortable with increased supervision

“ Residents’ perceptions of the duty hours limits offer important information for accreditors, regulators, and leaders making decisions on future refinements to the duty hours limits.”

Future Work Hours Changes?

Nationally, Both Ob/Gyn and Surgery Educational leaders are comfortable stating publically that today’s residents are less prepared for practice than in the past

Some information exists that Surgery may secede from the ACGME

There is no money to extend residency duration

In the presenters opinion, it is unlikely that today’s residents will experience additional restrictions during their residency experience.

The Next Accreditation System– Rationale and BenefitsNEJM 2012

Nasca TJ, Philibert I, Brigham T, Flynn TC

ACGME serves the public trust by enforcing standards

Physicians are no longer independent actors but are now leaders and participants in team oriented care

A key element of NAS is measuring and reporting outcomes

Competencies should become less abstract and more meaningful

NAS– Why?Create an entry point into the maintenance of

certification, licensing and lifelong learning

Enhance the competence of future physicians in areas that are relevant to a well performing, efficient and cost effective healthcare system

NAS in a Nutshell

Continuous Accreditation Model Annually submitted data, other requested data

Program trends

Milestones as roadmap to competencies

Scheduled program site visits replaced by 10 year self studies

Standards revised every 10 years • Frequent institutional visits (CLER)

Common and specialty program requirements

Milestone data submitted on each resident twice a year

New Core Faculty surveys

New scholarly activity input (no CVs)

Site visit every 10 years

What is a Milestone?A marker that a resident has achieved goals and

objectives for his or her level

Exact mechanisms still under development

CLER VisitsReview institutional activities in the areas of safety,

QI, supervision, professional responsibilities

Integration of residents into patient safety programs –

Integration of residents into QI and efforts to reduce disparities

Establishment and implementation of supervision policies

Oversight of transitions of care

Oversight of duty hours

Part 3- Medical Simulation and GME

A) 20 years

B) 50 years

C) 100 years

D) 500 years

E) more than 1000 years

How long has Medical Simulation been around?

Resident Morale

When a resident is in the Operating Room, he or she knows that the care of the patient takes priority over education.

In the simulation lab, the resident knows that education is the only priority.

Bath J, Lawrence P. Why we need open simulation to train surgeons in an era of work hour restrictions. Vascular

2011;19:175-77.

Less time in hospital will ultimately lead to less competent surgeons

A number of reports exist which demonstrate diminishing operative exposure among residents

Numbers of open cases are decreasing BUT the complexity of the open cases conversely has increased

Fundamentals of Laparoscopic Surgery (FLS) certification is required before sitting for the American Board of Surgery examination; the authors imply other areas of surgical treatment should be treated similarly.

Is Surgical Simulation Training Effective?

Levine R, Kives S, Cathey G, Blinchevsky A, Acland R, Thompson C. The use of lightly embalmed (fresh frozen) cadavers for resident laparoscopic training. J Min Invas Gynecol 2006;13:451-56.

Banks EH, Chudnoff S, Karmin I, Wang C, Pardananis. Does a surgical simulator improve resident operative performance of laparoscopic tubal ligation? Am J Obstet Gynecol 2007;197:e1-541.e5.

Beyer L, De Troyer J, Mancini J, Bladou F, Berdah SV, Karsenty G. Impact of laparoscopy simulator training on the technical skills of future surgeons in the operating room: a prospective study. Am J Surg 2011;202:265-72.

Types of Surgical Simulation

Live animal models

Animal tissue

Cadaver

Low fidelity task trainers

Virtual reality

NEW- Full body high fidelity surgical simulator

What is Virtual Reality Surgical Simulation?

Hysteroscopic polypectomy

Surgical Chloe

A New Method to Assess Competency and

Improve Patient Safety

Patient Safety VisionA full body high fidelity surgical simulator can present in the emergency environment with an unknown diagnosis. After the diagnosis in made, the simulated patient can be transported to the Operating Room where a procedure is performed. Post-operative care can also be assessed.

Chloe in Baghdad

Abdominal Wall, Abdominal Insert

Fascia is incised

Uterine Assembly 2 showing ectopic pregnancy and dermoid cyst

© Gaumard Scientific Company, 2011. All rights reserved.

Surgical Chloe- Abdominal Cavity

Let’s Run a Scenario

Patient in OR- Ectopic Pregnancy with Pelvic

Masses

Signs of Trouble

Insight to the Situation

Treatment Begins

Problem Solving

Debrief

Future of Medical Simulation?

Medical School Education

Likely RRC requirement

Medical Liability Insurance?

Board Certification?

Licensure?

Questions

Competency Based Goals and Objectives