HCPro.com - Residency - DO NOT USE Top Stories

Residents say cause of death reporting often inaccurate

Fri, 17 May 2013 14:58:00 GMT

When residents list the cause of death on a death certificate, it may not always be the correct one.

Researchers recently surveyed more than 500 residents in New York City, and nearly half said they had knowingly listed an inaccurate cause of death on a death certificate, according to a recent report published by the Centers for Disease Control and Prevention. Only about a third of respondents said they thought cause of death reporting was accurate, according to the survey.

Residents often faced systems barriers to reporting causes of death accurately, such as reporting systems that wouldn’t accept certain causes. Sometimes, they couldn’t accurately list a cause after a patient handoff, or admitting hospital personnel or medical examiners had asked them to change a cause of death, researchers found.

Misreporting the cause of death may have serious implications on public health research. The researchers suggest providing more training on death certificate completion and updating reporting systems to allow physicians to enter accurate information.

Reduced work hours may increase errors among residents

Fri, 29 Mar 2013 04:02:00 GMT

New research may support what medical educators have feared – that the ACGME’s recent work hour reductions may increase actually increase errors.

Researchers from Johns Hopkins University studied the effect of reduced work hours in residents and published their findings in the JAMA Internal Medicine online edition this week.

The researchers compared three groups of trainees; two groups had 16-hour work limits, and one group had a 30-hour limit, Cheryl Clark recently reported on the study for HealthLeaders Media. Researchers found residents who worked shorter shifts had fewer educational opportunities, had to deal with more hand-offs, and generally were forced to cram more work into the same amount of time, increasing the likelihood for errors, HealthLeaders reports.

Physicians hold group appointments to see more patients

Fri, 29 Mar 2013 04:00:00 GMT

Some physicians are turning to group appointments—seeing groups of patients with the same the medical condition at the same time—in response to limited resources, the Washington Post. The Family Physicians Foundation in Jacksonville, FL, even trains residents and physicians how to conduct group appointments for the diabetes patients.

Proponents of group appointments say they give physicians the opportunity to see more patients and may help ease physician shortages. They also allow physicians to spend more time with patients (as a group), and give patients information about a variety of issues that arise for patients with similar health concerns. However, most doctors aren’t comfortable facilitating group appointments and some patients don’t want to sit through other patients’ concerns, the Post reports.

Lawmakers introduce legislation to fund more residency positions

Thu, 21 Mar 2013 15:24:00 GMT

Lawmakers in the House and Senate introduced legislation last week that would increase the number of federally-funded residency positions.

Reps. Allyson Schwartz (D-PA) and Aaron Schock, (R-IL) reintroduced legislation to increase the number of residency slots by 15,000 over the next five years. Their bill would allow hospitals to apply for additional positions through one of two pools. One pool would award positions based on how long programs have trained residents in addition to their Medicare Cap limits. The other pool would use priority criteria to award positions. No program could receive more than 75 additional positions annually.

Sen. Bill Nelson (D-FL) also introduced legislation increasing the number of federally funded residency positions by 15,000 over five years, the Orlando Business Journal reports. The Association of American Medical Colleges (AAMC) estimates the legislation could cost $9 to $10 billion over ten years, the Journal reports.

It’s not certain these proposals will gain much support in Congress. The Journal quotes an AAMC staffer as saying “honestly, with everything that’s going on, I’m not quite sure there will be a hearing or how quickly it could move.”

Daschle recommends GME reforms in recent Health Affairs post

Thu, 14 Mar 2013 04:00:00 GMT

Former U.S. Senator and healthcare reform advocate Thomas Daschle says reforming GME is a critical part of addressing healthcare costs and workforce issues.

“Aggressive efforts should be made to streamline and reduce the cost of residency training,” Daschle writes in a recent Health Affairs post. His recommendations include reducing “excessive” indirect medical education payments, creating pay-for-performance programs for residency programs, and giving residents the option to “test out” of portions of training to accelerate residency.

Daschle also suggests the United States could reduce healthcare costs and resolve provider shortages by:

Increasing transparency in the healthcare sector to better ascertain how many physicians are needed
Creating incentives for providing primary care
Promoting team-based care in all healthcare settings
Reducing reliance on international medical graduates

Burnout, personal distress may decrease resident safety

Thu, 27 Dec 2012 04:00:00 GMT

Mitigating sleepiness and fatigue in residents has long been the focus of efforts to improve resident and patient safety, but reducing burnout and personal distress may also play an import role, according to a recent Mayo Clinic survey.

The survey evaluated quality-of-life measures in appoximately 300 internal medicine residents over five years, asking residents to use validated scales to report factors like sleepiness, fatigue, depression, physical well-being, and mental well-being. Residents were also asked about their involvement in unsafe incidents, including car accidents.

About 10 % of residents reported being directly involved in a car accident during the survey period, about 40% reported a near-miss accident, and 20% reported falling asleep while driving. Fatigue and sleepiness increased the odds a resident was involved in a car accident. High levels of burnout, depression, or diminished quality of life in multiple areas also increased the odds of a resident reporting a car accident.

Reducing burnout and depression and improving resident quality-of-life should also be part of graduate medical education reforms, the survey’s authors concluded. However, the most effective way to do so is unknown and requires further study, according to the authors.

Tip of the week: Get creative with low-cost social activities for residents

Thu, 27 Dec 2012 04:00:00 GMT

Planning social activities for residents or improving your program or materials on a shoestring is more possible than you might think. With little or no extra money in their budgets, coordinators have organized fun activities for residents or introduced cost-saving innovations.

"Funds are getting tighter and tighter," says Mary Sarah Thanas, C-TAGME, senior administrative assistant for the Combined Medicine-Pediatric Residency Program at the Yale University School of Medicine in New Haven, Conn. Social activities are crucial for boosting residents' morale and helping them balance their lives outside the hospital, but many programs no longer have-or never had-funds budgeted for these activities, Thanas says.

Some ideas for sponsoring resident social activities without a big budget include:

Hosting a party or other special event in February, an off-peak month when hotel and catering costs are lower-it's also the mid-year point when resident morale is low.
Having the registrar collect a fee for resident and fellow verifications. The money goes to a chief residents fund, which is used to hold social events.
Soliciting faculty and alumni donations for resident activities that aren't covered in your program's budget.

For more low-cost, creative ideas for residency programs, read the full article in the January 2013 issue of Residency Program Alert.

Single, unified accreditation system for GME in the works

Sat, 01 Dec 2012 04:00:00 GMT

Single, unified accreditation system for GME in the works

Residency programs can expect more change in the coming years as graduate medical education moves toward a single, unified accreditation system by July 2015.

On October 24, the ACGME, the American Osteopathic Association (AOA), and the American Association of Colleges of Osteopathic Medicine (AACOM) announced their commitment to pursue a unified accreditation system.

The change will give all physician trainees the same path to prepare for practice and ensure consistent standards for evaluation and accountability for resident competency across all programs, according to a press release issued by the ACGME.

Under the plan, the ACGME will eventually accredit the approximately 1,000 osteopathic GME programs currently accredited by the AOA.

The transition to a single system will happen as the ACGME works toward implementing the Next Accreditation System (NAS).

As the ACGME was developing NAS, the AOA was considering changes to its own accreditation standards to emphasize quality improvement and performance focused on results, says Boyd R. Buser, DO, a trustee of the AOA board of directors and dean of the University of Pikeville-Kentucky College of Osteopathic Medicine.

"It seemed like the right time for us to get together and talk about what's best for graduate medical education accreditation and what's going to be best for the American public seeing these doctors," Buser says.

Creating one path for physician training

Details about how the transition will happen and what it means for residency programs are still in the works. According to a press release issued by the ACGME, the three organizations will discuss:

Modifying ACGME accreditation standards to accept AOA specialty board certification as meeting ACGME eligibility requirements for program directors and faculty
Recognizing GME programs accredited solely by the AOA as accredited by the ACGME
The AOA and AACOM's participation in accrediting GME programs solely through their membership and participation in the ACGME

The change will not affect medical school, board certification, or licensing for practicing physicians, says Mike Campea, director of the Division of Media Relations for the AOA.

Benefits of a single accreditation system

The unified accreditation system will provide the ACGME and AOA the opportunity to exchange best practices and will make it easier for internship, residency, and fellowship training programs to select the best candidates, Buser says. Ultimately, that should translate to better care for patients, he says.

Both ACGME- and AOA-accredited programs may benefit from the unified accreditation program, says Franklin R. Medio, PhD, president of Consulting Services for the Health Professions in Charleston, S.C.

Medio has worked with both allopathic and osteopathic programs over the course of his career and is a former associate dean and DIO for graduate medical education at the Medical University of South Carolina, a former GME representative for several Association of American Medical Colleges resident committees, and the former director of education at two osteopathic medical schools.

Some of the strengths of osteopathic programs include training physicians in the same settings where they will later practice, emphasizing a holistic, patient-centered approach, and keeping program directors in the same position for long periods of time, Medio says.

Allopathic programs have expertise in developing didactic curriculum materials, focusing on research and scholarly activity, and securing adequate support personnel for their GME programs.

A unified accreditation system will also help eliminate concerns about differences in the quality of GME programs, says Medio.

However, both groups will continue to face the significant challenge of training faculty to properly evaluate residents' performance and competence, especially in underperforming residents, he says.

Combining two cultures

The ACGME, AOA, and AACOM expect the transition to a unified accreditation system to be seamless for trainees entering residency programs; however, it's not clear yet how the change will affect program directors and coordinators.

Because AOA- and ACGME-accredited programs currently share six core competencies (AOA programs have a unique seventh competency) for residents to meet, most changes will likely be related to accreditation requirements and site visit surveys, Medio says.

In addition, several members of the osteopathic education community have expressed concerns about maintaining their separate professional identities, he says. Among allopathic communities, some worry that all programs may not rise to the same level of rigor and training.

No one is sure how this will affect current programs, Medio says, but he believes the "rising tide will float all boats" and the unified system will improve quality across all programs.

The path to a single system

Buser is a member of a joint task force of AOA and ACGME representatives who have discussed the unified system since early 2012.

Now that the organizations have committed to pursuing the unified accreditation system, they'll work together to define a process to establish the new system by July 2015, he says. The group's next step is to create a memorandum of understanding to define the tasks and timeline to reach their goal.

The groups will discuss melding program standards and bridging some historic and cultural differences between allopathic and osteopathic medical training programs, Buser says. However, the distinctions of osteopathic medicine will be maintained, he says.

Changes were already on the horizon with the alterations to accreditation planned by both AOA and ACGME, Buser says.

"Everyone is going to have to agree upon and get used to doing some things differently," he says.

Your role as an educator

Sat, 01 Dec 2012 04:00:00 GMT

Your role as an educator

Residency program coordinators may not have an MD after their name or a spot on the faculty roster, but that doesn't mean they don't play an important role in teaching residents.

"Every coordinator who works in residency education is an educator," says Carissa Van Spronsen, surgical education coordinator at Grand Rapids (Mich.) Medical Partners. "I see the role as an educational role, whether our title is that or not."

As GME program requirements have become increasingly complex, coordinators often need to educate faculty, staff, and residents about how their programs work, says Michele Silver, MEd, assistant director of education and program coordinator at the University of Florida general surgery education program in Gainesville.

Uncover your teacher talents in the areas you're best suited to teach residents about:

Career development
Program requirements
Resources to aid residents in their training

Expanding your role as educator not only helps residents thrive, it also allows you to add another skill to your job description for further recognition as a program administrator.

Teaching residents career skills

While program coordinators may not teach residents clinical knowledge, they have an opportunity to help residents learn skills that will benefit them throughout their careers.

Program coordinators aren't doctors or surgeons, but they're experts when it comes to the educational program, Silver says.

Coordinators should take time to explain to residents the training requirements specified by the ACGME, professional boards, and the healthcare facilities where they work, she says.

Residents may not know how many weeks of training they need to complete in a year or how to meet their requirements if they need to take extensive sick time or maternity leave.

Residents may risk graduating late if they take too much time, so educating them on more administrative policies can make a difference in their careers.

Establish yourself as a teacher for such topics by �presenting sessions during orientation that review the ins and outs of your specialty's requirements. You may also review:

The program manual
Attendance policies
Schedules
Processes and expectations for submitting evaluations
Documentation processes for resident activities
Licensing requirements (if applicable)?

Residency is many trainees' first professional experience, and coordinators have an opportunity to teach them skills that will be part of their work as physicians, Van Spronsen says. Coordinators can teach residents how to log duty hours or cases in the ACGME website, as well as the importance of completing these administrative tasks.

"This is the groundwork for their future," she says.

Van Spronsen has also helped trainees in her program develop leadership skills through tasks such as setting the yearly rotation schedule.

By giving chief residents the opportunity to change the schedule and making them responsible for implementing the changes, �obtaining feedback from staff, and reaching a compromise, they learned leadership skills they'll need as physicians working in the community, she says.

Providing educational resources

Coordinators can step into an educator role by �sharing educational resources throughout their programs. Silver helped her program establish a �surgical library, gathering books that had been donated by �companies or left by former residents to create a �physical library.

Residents are often inundated with websites and other sources of information, and coordinators can help them navigate and consume the information they need, Silver says.

Coordinators should also be familiar with the ?terms and concepts associated with competencybased �education and the program's curriculum and how �residents are assessed.

Understanding these �concepts will help coordinators ensure that their programs meet all ACGME educational and assessment requirements.

Armed with this knowledge, coordinators can be instrumental in developing interactive activities that support didactic learning opportunities, such as question and answer sessions that use audience response systems or game show formats, such as Jeopardy!

Coordinators can also review educational documents, such as goals and objectives. The two are often mistakenly interchanged, which can result in ACGME citations.

Goals should be broad statements of learning, or what residents should achieve. Objectives are the quantifying statements associated with goals. Objectives specify what the learner will be able to do at the end of the rotation and are measurable.

Watch for clarity of goals and objectives and ensure they are competency-based for each rotation and each postgraduate year.

Hosting an educational retreat

Silver has organized an educational retreat for her program every year since she joined the department nine years ago.

Planning an educational retreat is another way coordinators can establish themselves as educators, as well as encourage discussion about educational issues throughout their programs.

In September, the department closes the operating room for the half-day educational retreat, which focuses on nonclinical educational topics. Themes from past retreats have included:

Using simulation to educate and assess resident skills
Setting milestones to assess progress in training
Educational leadership
Giving and receiving feedback

Residents, faculty, and occasionally medical students and physician extenders participate in the �retreat. �During the afternoon, participants split into three �working groups to address a different challenge �related to the theme. For example, during the feedback-themed retreat, working groups discussed giving feedback, turning feedback into action, and what do when feedback fails.

Each group develops an action plan and presents it to the larger group to obtain feedback. Members of the group are responsible for implementing the plan and reporting their progress at the bimonthly education staff meeting.

The educational retreat is not only a great way for �coordinators to facilitate education, it also turns faculty and residents into "tentacles" of the education office as they work to implement their action plans throughout the program, Silver says.

For more information on how to structure an educational retreat, see the diagram on p. 6.

Being recognized as an educator

Silver and Van Spronsen say part of the reason they want to encourage other coordinators to develop themselves as educators stems from their frustration that coordinators are often seen as secretaries.

When other members of the department recognize the educational aspects of the coordinator's role, it often encourages coordinators to expand their roles even more, Van Spronsen says. But even without official recognition, any coordinator can work to grow into an educator, she says.

Attending conferences, reading academic journals and publications that relate to your specialty, and working with your program director to learn additional tasks you can take on are good ways to start growing as an educator, Van Spronsen says.

Tips for developing your inner educator

By developing your role as an educator, you "go from a person who's quietly taking notes in meetings" to becoming a more active part of your program and demonstrating that your position is more than clerical, says Michele Silver, MEd, assistant director of education and program coordinator at the University of Florida general surgery education program in Gainesville.

Silver offers these tips for coordinators who want to grow as educators:

Use your knowledge and experience. Nobody knows the program better than you.
Make it known to your colleagues that you're interested in education.
Ask questions.
Get more hands-on experience. Join residents and faculty for rounds or visit the operating room.
Attend lectures and conferences.
Sometimes you have to speak up. Suggest educational improvements or volunteer to take on a new task.
Enroll in a degree of certification program (such as �TAGME) to learn more about what's going on in the field and feel more credible.

Teaching goes beyond residents

Residents aren't the only ones who can benefit from �coordinators' knowledge and expertise. Coordinators can also play an important role in translating program requirements to program directors. They communicate with the ACGME in language the organization uses, which isn't �always the same language physicians use, says Michele �Silver, MEd, assistant director of education and program coordinator at the University of Florida general surgery education program in Gainesville.

As an example, she mentions part of the continued �accreditation form for GME that asks programs to "describe an activity that fulfills the requirement for experiential learning in identifying system errors." When coordinators take time to understand the requirements, they can help educate program directors, faculty, and staff about how to meet them.

In addition to program requirements, the program �coordinator should take the time to educate the program director or another program representative on his or ?her systems. This ensures that if the coordinator is out ?for an extended amount of time, program functions can carry on.

Give him or her a tour of your office, highlighting the following:

Filing system, so that he or she knows where all the �important files are.
Online or software systems that you use, so that he or she will be able to monitor compliance with deadlines. You can also review reports you prepare for the program director, such as:

File review reports
Evaluation summaries
Procedural case reports
Exit interviews

Take a proactive role in educating new program directors as well. Set up weekly meetings to introduce them to the program one piece at a time. Focus on what you do by reviewing the responsibilities you had with the previous program director.

Also touch on the issues involved in managing a training program so that you can both come to an understanding �regarding roles, responsibilities, and expectations.

In addition to giving the tour previously described, also consider creating a transition book and reviewing it with the program director. Include the following in the book:

Lists and contact information for faculty, residents, and staff
Copies of the ACGME Institutional Requirements, �Common Program Requirements, and clinical specialty requirements
ACGME website and program-specific login information
Overview of the educational program and philosophy
Curriculum with goals and objectives
Three to five years of procedural data
Board results
State and federal requirements that affect GME

Talking about trainees

Sat, 01 Dec 2012 04:00:00 GMT

Talking about trainees

Communicating with patients about resident physicians' status as trainees can be a balancing act. Institutions need to inform patients when resident physicians provide their care while ensuring that patients are comfortable receiving care from a physician identified as a trainee.

Residency Program Alert asked Jennifer Reemtsma, MEd, director of medical education at Children's Medical Center in Dallas, what residency programs need to know when it comes to communicating about trainees.

Q. What are hospitals required to tell patients about physicians who are trainees? What laws or accreditation standards govern communication about trainees?

JR: Currently, there is no law that requires hospitals to inform patients or their families of the status of a trainee. However, ACGME Common Program Requirement VI.D.1.b. states, "Residents and faculty members should inform patients of their respective roles in each patient's care."

The intent of this requirement is to ensure patients' right to know who is providing their care, and the role that each party plays.

Q. What are institutions' greatest concerns when it comes to talking to patients about trainees? What are patients' greatest concerns about trainees?

JR: Hospitals may have concerns that in some cases, discussing the status of trainees with patients may cause the patient unwarranted concern about the quality of care they are receiving.

For example, a medical resident has graduated from medical school and has the title of MD or DO, and if deemed appropriate by his or her residency training program director, is capable and qualified to do certain clinical activities under what the ACGME terms "indirect supervision" or "oversight." This means that the attending physician does not need to be physically present for that specific activity. The concern lies in that the patient could interpret the word "trainee" to mean that the resident is new to field medicine, and therefore would not want the resident to handle any part of their care.

Q. What information should hospitals provide patients about trainees, and why?

JR: Hospitals should ensure that patients have a clear understanding of who all of the clinicians on their care team are, and what their particular role will be in their care. It should be made clear not only who is a trainee, but what that title actually means.

For example, simply telling a patient that you are a resident physician does not ensure that the patient knows what "resident physician" actually means. A clear explanation should be given about what a trainee's title means as far as background and education. This allows the patient to ask clarifying questions and feel at ease with the members of the care team.

Q. How should trainees identify themselves to patients?

JR: Trainees should identify themselves with their appropriate title. For example, it would be appropriate for a resident to say, "Hello, I'm Dr. so-and-so, one of the residents on your care team," or "Hello, I'm Dr. so-and-so, the senior resident on your care team."

Q. What mistakes do institutions make when communicating to patients about trainees?

JR: In most cases, the biggest mistake is not communicating with patients about trainees at all. Patients have the right to know who is providing their care, what each team member's role is, and what the "chain of command" is concerning their care team.

Q. How can institutions communicate more effectively about trainees?

JR: Institutions may want to put together an informational flier for patients and families, defining each role clearly-not only about trainees, but also defining other titles such as physician assistant, advanced practice nurse, and attending physician.

Q. Should institutions have policies about how trainees should introduce themselves to patients?

JR: Putting a policy in place specifically concerning requirements for introductions would not necessarily be effective, as it would be difficult to enforce. However, institutions should ensure that expectations for introductions are clearly explained prior to the trainee having any contact with patients.

Q. How can institutions train trainees to introduce themselves to patients?

JR: Most hospitals have a comprehensive orientation when new trainees start at their facility, and this training should take place at that time, prior to trainees seeing any patients. Other times that this training could take place is on individual ward teams or in ethics training sessions. It is crucial to let trainees know why making an introduction is important.

Book excerpt: Building a curriculum for professionalism

Sat, 01 Dec 2012 04:00:00 GMT

Book excerpt: Building a curriculum for professionalism

Editor's note: The following is an excerpt adapted from HCPro's book A Practical Guide to Teaching and Assessing the ACGME Core Competencies, Second Edition by Elizabeth A. Rider, MSW, MD, FAPP, and Ruth Nawotniak, MS, C-TAGME. This text is excerpted from Chapter 6: Competency 6: Professionalism.

The complexity of professionalism in medicine presents a challenge to educators seeking to teach and evaluate this competency. We know that physicians do not acquire professionalism via their upbringing, osmosis, academic coursework, one or two workshops during training, or other short-lived interventions.

Instead, medical educators and leaders must explicitly define, clarify, teach, and model the values and capacities we expect physicians to learn and exhibit, and faculty role models must have a thorough knowledge of professionalism.

Designing curricula for professionalism requires attention to its various components, including the knowledge base of professionalism (i.e., the social contract and roles and attributes of both the healer and the professional); the moral and ethical development of learners and faculty members; authenticity; and the learning environment, including the hidden curriculum (HC) and organizational culture.

Professionalism and moral reasoning

Moral reasoning and judgment are essential components of professional behavior, and they apply to both the awareness of moral issues and the demonstration of appropriate moral actions in medical education and clinical care.1 Bebeau found that education in the health professions did not promote moral judgment, but that the addition of ethics instruction increased moral reasoning and judgment.2

Self and Baldwin documented a significant positive relationship between levels of moral reasoning and measures of clinical excellence in medical students, residents, and practicing physicians.3 In a study of malpractice claims against orthopedic surgeons, Baldwin and colleagues discovered that orthopedists in the low-claims group had significantly higher levels of moral reasoning than orthopedists in the high-claims group.4

It appears that medical education may profoundly influence moral development. Feudtner and colleagues describe the "ethical erosion" reported by medical students.5 Patenaude et al.6 presented striking results from their study: Entering medical students used higher-stage moral reasoning orientations than the same students at the end of their third year. Residents also fail to make age-expected growth in moral reasoning abilities during their training.7

A disconnect exists between the professed values of medicine and the actual practice that learners observe, making it hard for them to determine what values to learn, and resulting in increased stress, burnout, isolation, loss of empathy, ethical erosion, and a stunting of moral development.8 According to Rabow and colleagues, "When physicians are distanced from themselves and from such values as honesty and altruism, patient safety may suffer."9

It appears that socialization into medical culture comes at a high price. Consequently, those involved in medical education must work to promote the moral development of its learners.

Educating for professionalism: The hidden curriculum and organizational culture

Attention to the learning environment, including the HC and organizational culture, is essential to the teaching and learning of professionalism. The social and organizational environments of training institutions have a profound influence on professional identity formation. To improve professionalism education, we need to bring the formal curriculum and its moral, ethical, and humane values into alignment with the HC so that the HC consistently models these values.

Role-modeling has the most powerful influence on learners' understanding of professionalism.10 Negative role-modeling experienced during clinical training undermines the attitudinal messages of the formal curriculum. Learners internalize and perpetuate attitudes and behaviors of their role models,11 and they feel caught between their moral principles and the pressures to suppress their moral principles to fit in with team members.12 The culture of medical education can erode learners' idealism and social consciousness. Coulehan and Williams describe socializing phenomena that make it difficult to be a caring physician, including the development of detachment, a sense of entitlement, and a nonreflective professional practice.13

By the students, for the students: Report could help medical students find the best fit in a residency program

Sat, 01 Dec 2012 04:00:00 GMT

By the students, for the students: Report could help medical students find the best fit in a residency program

A hospital's patterns of care in areas such as patient preference and use of resources could have a major impact on shaping residents' personal practices as physicians, according to a report from two students in the Geisel School of Medicine at Dartmouth. "What Kind of Physician Will You Be?" shows variations in medical care among 23 academic medical centers and teaching hospitals in the United States, drawing data from the Dartmouth Atlas of Health Care.

The report is intended to encourage medical students to consider the habits they want to develop during residency and the ways those habits will impact the healthcare they deliver, according to author Anita Arora, MD, a 2012 graduate of the Geisel School of Medicine at Dartmouth and a current resident in internal medicine at Yale.

"We believe that fourth-year medical students should take into account the way physicians at academic medical centers deliver healthcare-in other words, the style and cultural practice that determines a hidden training curriculum," Arora states.

Major variation in key areas

Arora presented the first edition of the report that looks at practice patterns across academic medical centers to her fellow fourth-year medical students in February. She then conducted a survey asking what the report meant to students and whether it would affect how they choose residency programs.

Many students responded that the report would not affect their decisions because it came so late in the residency application process, but students also told Arora that the research was interesting and would have influenced their decisions if it had come earlier. Encouraged by the feedback, Arora teamed up with Alicia True, Geisel School of Medicine at Dartmouth Class of 2015, to bring the report to a national level.

The report focuses on three main areas:

End-of-life care and management of chronic illness
Surgical procedure rates
Patient care quality indicators

In all three instances, the authors note the wide variation in treatment plans and use of resources among the 23 hospitals. For example, the report ranks hospitals based on a measure known as the hospital care intensity (HCI) index, which combines the number of days patients spent in the hospital and the average number of inpatient physician visits during the final two years of life; the highest HCI index is more than three times greater than the lowest among the medical centers. The intensity of care provided by teaching hospitals influences several aspects of residents' training, such as organization of care, reliance on specialists, and use of resources and hospice care.

Similarly, the variation in procedure rates among the hospitals could lead to major differences in surgical training, particularly when it comes to those procedures with several different treatment options.

As the report notes, "an orthopedic resident trained in Salt Lake City is likely to learn a treatment style for osteoarthritis of the knee where surgery is more probable than a resident in New York City, who might more readily prescribe physical therapy or analgesics."

These treatment styles may or may not take into account patient preferences, and residents training in facilities that place greater emphasis on clinical guidelines may not learn to give patients the information necessary for them to make informed decisions about their care. The report authors encourage medical students to consider these variations when looking at residency programs.

Improving institutions at the residency level

Arora notes that beyond being a resource for medical students and residents, the report can be used by healthcare organizations to determine areas in which there is room for improvement.

"Every institution on this report can improve in one or another measure," she says. "I think it would be interesting for the head of a residency program to go through all of these measures and say, 'Now why do we have so many patients who in their last six months of life are spending time in the ICU?' "

According to Arora, institutions can use the report's data in several ways:

Determine what they are doing well
Examine what other institutions are doing differently
Collaborate with and learn from other hospitals
Improve areas of weakness

"I think that in healthcare, we are all trying to find what best practices are and I think we have all the answers, they are just all in different places," Arora says. She points out that patient preferences play a major role in determining the best plan for patient care. Residency programs, she says, should ensure that residents understand the importance of learning to talk to patients and having discussions with them regarding end-of-life care and treatment options.

"Where are we going with our patient care? I think that's the type of question that could permeate and should permeate most discussion around healthcare," Arora says. The data presented in the report could be a way for residency program directors to initiate such discussions.

Taking steps to improve areas of weakness could help make organizations' residency programs more attractive to medical students who are just starting to consider where they want to complete their residency.

"These finding challenge the assumptions that quality is uniformly high at these prestigious institutions, and in turn that an institution's reputation should not be the sole measure of the quality of a training program," David Goodman, MD, MS, director of the Center for Health Policy Research at The Dartmouth Institute for Health Policy and Clinical Practice, noted in a teleconference shortly after the report's publication.

Attracting students, engaging residents

Goodman speculates that the findings could lead medical students to train at a different hospital than one they originally might have chosen. The report could also serve to make students more aware of the environments they are entering when they begin their residency.

In the same teleconference, Arora stated that she did incorporate the data into her personal ranking of residency programs during the application process.

"I want to be the type of physician who uses care efficiently and incorporates patient conferences," she says. "In my interviews at programs, I would speak about this research and definitely took more notice of those places that were more open and interested in the Dartmouth Atlas data."

It's unlikely, however, that the data from the report will prompt residents to leave their current programs. Arora notes that a large part of being a resident it getting used to a specific hospital and learning to work within a particular system, which can make moving to a new residency program a daunting thought.

She says that residents who may be unhappy with the way their institution handles certain aspects of patient care could bring the report to the attention of the program's leadership and offer to spearhead a project to address areas needing improvement.

"I can see this being one of those residency projects around quality improvement," Arora says.

Residency program directors could use the report to engage residents in quality improvement efforts, to the benefit of the entire organization. Encouraging open discussions about the strengths and weaknesses of a program might improve a resident's experience and motivate residents to consider all aspects of patient care, not just the technical side of medicine.

"Teaching hospitals need to continue to improve the quality of care and not be complacent about the care that they are providing," says Goodman. "It's important that care be of high quality, and also meeting the preferences of informed patients."

Residency Program Alert, December 2012

Sat, 01 Dec 2012 04:00:00 GMT

Single, unified accreditation system for GME in the works

Residency programs can expect more change in the coming years as graduate medical education moves toward a single, unified accreditation system by July 2015.

Under the plan, the �ACGME will eventually accredit the approximately 1,000 osteopathic GME programs currently accredited by the AOA.

The transition to a single system will happen as the ACGME works toward implementing the Next Accreditation System (NAS).

As the ACGME was �developing NAS, the AOA was considering changes to its own accreditation standards to emphasize quality improvement and performance focused on results, says Boyd R. �Buser, DO, a trustee of the AOA board of directors and dean of the University of Pikeville-Kentucky College of Osteopathic Medicine.

Creating one path for physician training

Details about how the transition will happen and what it means for residency programs are still in the works. According to a press release issued by the �ACGME, the three organizations will discuss:

Modifying ACGME accreditation standards to accept AOA specialty board certification as meeting �ACGME eligibility requirements for program directors and faculty
Recognizing GME programs accredited solely by the AOA as accredited by the ACGME
The AOA and AACOM's participation in accrediting GME programs solely through their membership and participation in the ACGME

The change will not affect medical school, board �certification, or licensing for practicing physicians, says Mike Campea, director of the Division of Media Relations for the AOA.

Benefits of a single accreditation system

Allopathic programs have expertise in developing didactic curriculum materials, focusing on research and scholarly activity, and securing adequate support personnel for their GME programs.

A unified accreditation system will also help eliminate concerns about differences in the quality of GME programs, says Medio.

However, both groups will continue to face the significant challenge of training faculty to properly evaluate residents' performance and competence, especially in underperforming residents, he says.

Combining two cultures

No one is sure how this will affect current programs, Medio says, but he believes the "rising tide will float all boats" and the unified system will improve quality across all programs.

The path to a single system

Buser is a member of a joint task force of AOA and ACGME representatives who have discussed the unified system since early 2012.

Now that the organizations have committed to pursuing the unified accreditation system, they'll work together to define a process to establish the new system by July 2015, he says. The group's next step is to create a memorandum of �understanding to define the tasks and timeline to reach their goal.

Changes were already on the horizon with the alterations to accreditation planned by both AOA and �ACGME, Buser says.

"Everyone is going to have to agree upon and get used to doing some things differently," he says.

Your role as an educator

Residency program coordinators may not have an MD after their name or a spot on the faculty roster, but that doesn't mean they don't play an important role in teaching residents.

Uncover your teacher talents in the areas you're best suited to teach residents about:

Career development
Program requirements
Resources to aid residents in their training

Expanding your role as educator not only helps residents thrive, it also allows you to add another skill to your job description for further recognition as a program administrator.

Teaching residents career skills

While program coordinators may not teach residents clinical knowledge, they have an opportunity to help residents learn skills that will benefit them throughout their careers.

Program coordinators aren't doctors or surgeons, but they're experts when it comes to the educational program, Silver says.

Coordinators should take time to explain to residents the training requirements specified by the ACGME, professional boards, and the healthcare facilities where they work, she says.

Residents may not know how many weeks of training they need to complete in a year or how to meet their requirements if they need to take extensive sick time or maternity leave.

Residents may risk graduating late if they take too much time, so educating them on more administrative policies can make a difference in their careers.

Establish yourself as a teacher for such topics by �presenting sessions during orientation that review the ins and outs of your specialty's requirements. You may also review:

The program manual
Attendance policies
Schedules
Processes and expectations for submitting evaluations
Documentation processes for resident activities
Licensing requirements (if applicable)?

"This is the groundwork for their future," she says.

Van Spronsen has also helped trainees in her program develop leadership skills through tasks such as setting the yearly rotation schedule.

Providing educational resources

Residents are often inundated with websites and other sources of information, and coordinators can help them navigate and consume the information they need, Silver says.

Coordinators should also be familiar with the ?terms and concepts associated with competencybased �education and the program's curriculum and how �residents are assessed.

Understanding these �concepts will help coordinators ensure that their programs meet all ACGME educational and assessment requirements.

Coordinators can also review educational documents, such as goals and objectives. The two are often mistakenly interchanged, which can result in ACGME citations.

Watch for clarity of goals and objectives and ensure they are competency-based for each rotation and each postgraduate year.

Hosting an educational retreat

Silver has organized an educational retreat for her program every year since she joined the department nine years ago.

Planning an educational retreat is another way coordinators can establish themselves as educators, as well as encourage discussion about educational issues throughout their programs.

In September, the department closes the operating room for the half-day educational retreat, which focuses on nonclinical educational topics. Themes from past retreats have included:

Using simulation to educate and assess resident skills
Setting milestones to assess progress in training
Educational leadership
Giving and receiving feedback

For more information on how to structure an educational retreat, see the diagram on p. 6.

Being recognized as an educator

Tips for developing your inner educator

Silver offers these tips for coordinators who want to grow as educators:

Use your knowledge and experience. Nobody knows the program better than you.
Make it known to your colleagues that you're interested in education.
Ask questions.
Get more hands-on experience. Join residents and faculty for rounds or visit the operating room.
Attend lectures and conferences.
Sometimes you have to speak up. Suggest educational improvements or volunteer to take on a new task.
Enroll in a degree of certification program (such as �TAGME) to learn more about what's going on in the field and feel more credible.

Teaching goes beyond residents

Give him or her a tour of your office, highlighting the following:

Filing system, so that he or she knows where all the �important files are.
Online or software systems that you use, so that he or she will be able to monitor compliance with deadlines. You can also review reports you prepare for the program director, such as:

File review reports
Evaluation summaries
Procedural case reports
Exit interviews

Also touch on the issues involved in managing a training program so that you can both come to an understanding �regarding roles, responsibilities, and expectations.

In addition to giving the tour previously described, also consider creating a transition book and reviewing it with the program director. Include the following in the book:

Lists and contact information for faculty, residents, and staff
Copies of the ACGME Institutional Requirements, �Common Program Requirements, and clinical specialty requirements
ACGME website and program-specific login information
Overview of the educational program and philosophy
Curriculum with goals and objectives
Three to five years of procedural data
Board results
State and federal requirements that affect GME

Talking about trainees

Residency Program Alert asked Jennifer �Reemtsma, MEd, director of medical education at Children's Medical Center in Dallas, what residency programs need to know when it comes to communicating about trainees.

Q. What are hospitals required to tell patients about physicians who are trainees? What laws or accreditation standards govern communication about trainees?

The intent of this requirement is to ensure patients' right to know who is providing their care, and the role that each party plays.

Q. What are institutions' greatest concerns when it comes to talking to patients about trainees? What are patients' greatest concerns about trainees?

JR: Hospitals may have concerns that in some cases, discussing the status of trainees with patients may cause the patient unwarranted concern about the quality of care they are receiving.

Q. What information should hospitals provide patients about trainees, and why?

Q. How should trainees identify themselves to patients?

Q. What mistakes do institutions make when communicating to patients about trainees?

Q. How can institutions communicate more effectively about trainees?

Q. Should institutions have policies about how trainees should introduce themselves to patients?

Q. How can institutions train trainees to introduce themselves to patients?

Book excerpt: Building a curriculum for professionalism

Professionalism and moral reasoning

Self and Baldwin documented a significant positive relationship between levels of moral reasoning and measures of clinical excellence in medical students, residents, and practicing physicians.3 In a study of malpractice claims against orthopedic surgeons, �Baldwin and colleagues discovered that orthopedists in the low-claims group had significantly higher levels of moral reasoning than orthopedists in the high-claims group.4

It appears that socialization into medical culture comes at a high price. Consequently, those involved in medical education must work to promote the moral development of its learners.

Educating for professionalism: The hidden curriculum and organizational culture

By the students, for the students: Report could help medical students find the best fit in a residency program

Major variation in key areas

Many students responded that the report would no

Tip of the week: Encourage coordinators to teach residents career skills

Tue, 27 Nov 2012 13:54:00 GMT

Program coordinators have an opportunity to help residents learn skills that will benefit them throughout their careers. Program coordinators aren't doctors or surgeons, but they're experts when it comes to the educational program, says Michele Silver, Med, assistant director of education and program coordinator at the University of Florida general surgery education program in Gainesville.

Coordinators should take time to explain to residents the training requirements specified by the ACGME, professional boards, and the healthcare facilities where they work, she says. Residents may not know how many weeks of training they need to complete in a year or how to meet their requirements if they need to take extensive sick time or maternity leave. Residents may risk graduating late if they take too much time, so educating them on more administrative policies can make a difference in their careers.

Establish yourself as a teacher for such topics by presenting sessions during orientation that review the ins and outs of your specialty's requirements. You may also review:

The program manual
Attendance policies
Schedules
Processes and expectations for submitting evaluations
Documentation processes for resident activities
Licensing requirements (if applicable)

This week’s tip is from Residency Program Alert.

News and briefs: California braces for health reform with shortage of primary care physicians

Tue, 27 Nov 2012 13:50:00 GMT

An expected 2 million Californians are expected to gain access to healthcare when the Affordable Care Act goes into effect in 2014 and could strain the state’s primary care physician workforce even further, according to a recent Marin Independent Journal article.

The state could need as many as 2,000 additional primary care physicians, yet fewer medical students plan or are encouraged to work in primary care, according to the article.

To cope with the shortage, groups like the California Academy of Family Physicians are seeking more funding for residency training, the Independent Journal reports. Currently, California has 309 family medicine residency openings each year.

News and briefs: Physicians call for more research on resident fatigue and medical errors

Tue, 27 Nov 2012 13:46:00 GMT

Reducing residents’ duty hours has been the focus of efforts to improve patient safety, but little research has been conducted isolating resident fatigue as the cause of medical errors, two physicians argue in a recent New England Journal of Medicine article.

Since Libby Zion’s death due to a lethal drug interaction in 1984 was attributed to residents’ exhaustion, efforts to improve patient safety have centered on mitigating resident fatigue, Lisa Rosenbaum, MD, and Daniela Lamas, MD, write in the November 22 article entitled “Resident Duty Hours – Toward an Empirical Narrative.”

However, only one randomized trial studying the effect of fatigue on medical error has been conducted, Rosenbaum and Lamas write. They propose that the ACGME allow research exemptions for residency programs to evaluate the effects of duty hours and other factors, such as resident supervision, simulation-based learning, and patient care hand-offs, on patient safety.

“Each assumption—that sleep deprivation makes for bad doctors, that ours will become a generation of shift workers, that one standard of training suits all trainees—is distinct in substance. But they all similarly lack substantiation,” the authors write. “To continue implementing changes without rigorous data is simply not safe.”

Notice: Your subscription will have a new name in the coming weeks!

Tue, 27 Nov 2012 13:05:00 GMT

Very shortly, Residency Program Connection will be replaced with Residency Program Insider. In addition to the name change, we’ve improved your reading experience with expanded content and enhanced design. We hope you enjoy the new look!

Your new issues will now arrive weekly on Thursdays.

We thank you for being a loyal subscriber.

Please add our address residency-program-insider@list.hcpro.com to your email address book to ensure you receive your issues.

Tip of the week: Use a portfolio to assess residents' care

Tue, 20 Nov 2012 15:03:00 GMT

The resident portfolio may be a repository for the written results of resident work efforts, such as self-reflections and evaluations, case studies, patient care logs, procedural logs, presentations, and quality improvement projects. A portfolio can be used as a mechanism for tracking growth in the competencies, with the goal being a mastery of the competencies, by a specific time within the training period.

Components that may show competency in patient care include:
Invasive procedure/case logs
Monthly faculty evaluations
Direct faculty observation and evaluation of invasive procedures, including obtaining consent, confirming the site, conducting a timeout, and advising patients regarding adverse events of outcomes
360-degree evaluations
Safety training courses

This week’s tip is from A Practical Guide to Teaching and Assessing the ACGME Core Competencies, by Elizabeth Rider, MSW, MD, FAAP; and Ruth Nawotniak, MS, C-TAGME.

Social media is playing a larger role in resident selection

Tue, 20 Nov 2012 15:01:00 GMT

The influence of social media websites like Facebook is seeping into the admissions process at medical schools and residency programs, according a recent study conducted by researchers at the University of Miami Miller School of Medicine.

Six hundred medical school and residency program admissions professionals responded to the Miller School’s social media survey. While only nine percent of respondents said they used social media sites to evaluate applicants, 19 percent said they used some kind of Internet search to get more information about applicants. And about half of respondents said they believed applicants who posted unprofessional content on social networking sites could compromise their chances of admission.

The study’s authors concluded social networking sites will affect the selection of medical students and residents and that formal guidelines about professional behavior on social networking sites could help protect applicants against “unforeseen bias in the selection process.”