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