Intersection of Surgical Outcomes and Medical Education

The RRC Perspective

APDS Panel Session IVSurgical Education Week

March 21,2012San Diego, CA

James C Hebert, MD, FACSChair – RRC-Surgery

Disclosures

• No financial disclosures• The views presented are my own

PD

CMO Resident RRC ACS

ABS

What are we trying to describe?

RRC Perspective – AccreditationSpecific Questions

1. Can you satisfy the requirement for a patient safety curriculum and nail the core competencies with the use of outcomes data in surgical education?

2. Does providing 30 day continuous data to your residents reduce the reality of training itinerant surgeons?

Specific Questions – Short Answers1. Can you satisfy the requirement for a patient safety

curriculum and nail the core competencies with the use of outcomes data in surgical education? Depends on how data are generated and reported; core processes that involve residents

2. Does providing 30 day continuous data to your residents reduce the reality of training “itinerant” surgeons? The process of just providing data will not, but integrating residents into a culture of measuring outcomes may.

Let’s analyze it further.

“…Quality isn’t method. It’s the goal toward which the method is aimed.”

Robert Pirsig, Zen and the Art of Motorcycle Maintenance

Education Goal - Safe & Competent Surgeon Demonstrated by Clinical Outcomes

KnowledgePatient Care

ProfessionalismCommunication

Practice-based learning and improvement

Systems based practice

Current Training Model

• Limited patient interactions along the continuum of care for a specific patient

- outpatient management - limited duty hours - changing culture of surgical care - more specialization• More hand-offs – “itinerant “surgery

What Currently Drives the Structure and Content of our Residency Programs?

“Curriculum”ACGME Standards

In the context of local service needs,Choose Educational Experiences

within Institution, Faculty

Identify/Develop Evaluation Idiosyncratic Tools - Formative and Summative

- Experience Tracking

“Educate” Residents

“Circumstantial Practice”

Guarantees that education is institutionally idiosyncratic, and lags rather than anticipates change in the delivery system

Clinical Outcomes – Resident Role

• Patient outcomes are primarily systems-based

• Depend on balance of supervision and independence

• Defined role of resident within system -

Data gatherer Leader

The Continuum of Clinical Professional Development

Authority and Decision Making versus Supervision

Authority and Decision MakingLow High

Sup

erv

isio

n

Low

HighPhysical Diagnosis

Internship

Residency

Fellowship

Sub-Internship

Attending

Clerkship“Graded or Progressive

Responsibility”

Expert

Proficient

Competent

Advanced Beginner

Novice

Increase the Accreditation Emphasis on Educational Outcomes

End PGY 1 Mid PGY 21

2

3

4

5

6

7

8

9

Professionalism

Communications

Medical Knowledge

Patient Care

Practice Based Learning and Improvement

Systems Based Practice

Tracking Milestones along the Continuum of Resident Training

What Will Drive the Structure and Content of our Residency Programs in the Near Future?

Design Educational ExperiencesSelect Faculty

ExpertPhysicians

who aspire toMastery

(Outcomes)

The RequiredOutcomes in Each Clinical Competency(Milestones)

External AccountabilityFor Outcomes

“Intentional Practice”

Introduction of New Competencies

Guarantees that education has the opportunity to anticipate change in the delivery system

National Evaluation Tools to Track Outcomes - Formative and Summative

- Clinical Outcomes Tracking (not just counting)

Program Accreditation

• Structure• Resources • Core Processes – (Clinical outcome measurement)• Detailed Processes- (Program specifics)• Educational Outcomes – “Milestones”

Clinical Outcomes and Accreditation

• Residents should want to train where there are excellent clinical outcomes

which implies good systems of care which implies a strong educational foundation (structure, resources, core &detailed processes)• Residents must be integrated into processes that

measure outcomes and demonstrate competent and proficient levels of achievement AND the program must demonstrate good clinical outcomes

Thank You

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