Transcript Residency Redesign in Internal Medicine

Residency Redesign in Internal
Medicine
American College of Physicians (ACP)
Society of General Internal Medicine (SGIM)
Association of Program Directors in Internal
Medicine (APDIM)
Common Themes
Interest in Internal Medicine, especially
General Internal Medicine has declined, in
part because training differs from practice.
Increase ambulatory training.
– Quality of ambulatory clinics must improve.
– Consider block outpatient (and inpatient) time.
Develop core curriculum, with reasonable
expectations for achievement.
Common Themes (cont’d)
High-quality training must be linked to
high-quality, patient-centered care.
– Emphasis on EBM, quality improvement,
patient safety, cultural sensitivity, health
disparities, professionalism, life-long learning
– Close resident supervision with graded
independence
– Better assessment of resident competency
Residents must have experience and
training in multidisciplinary team care.
Common Themes (cont’d)
Maintain three-year residency with
flexibility to innovate.
– ACP and APDIM propose two years “core”
training, with third year tailored to individual
career goals.
– SGIM suggests reconsideration of meaning of
Board certification.
Assign residents on the basis of
educational needs, acknowledging risks.
Common Themes (cont’d)
Faculty teaching should be monitored,
assessed and rewarded.
– Faculty development essential
– Promotion and rewards for educators
GME funding needs to be unlinked from
hospital-based care.
ACP and SGIM suggest revision of
medical school curriculum.
American College of Physicians
Overall Goals
High quality, relevant experience with
satisfied trainees
Effective education to facilitate acquisition
of necessary competencies
Acquisition of the abilities needed to
remain current and to understand and
adapt to changing circumstances of
healthcare
Weinberger SE, Smith LG, Collier, VU. Redesigning training for Internal
Medicine. Ann Intern Med. 2006;144:927-932
ACP
Concerns
Interest in general Internal Medicine
careers down (54 to 27% from 1998 to
2003), possibly from:
– Stress during residency
– Inadequate ambulatory experiences
– Unenthusiastic senior resident and faculty role
models
Weinberger SE, Smith LG, Collier, VU. Redesigning training for Internal
Medicine. Ann Intern Med. 2006;144:927-932
ACP Recommendations
Undergraduate
1. Use premedical education to decompress 1st
year
2. Flexible 3rd year with well-functioning practice
environments
3. Enthusiastic role models
4. Late 3rd-4th year
1. Revisit pathophysiology, mechanisms of disease
2. Understand translation of knowledge into practice
3. Improve analytic, interpretive skills, preparing for lifelong learning
4. At least one high-intensity clinical experience
Weinberger SE, Smith LG, Collier, VU. Redesigning training for Internal
Medicine. Ann Intern Med. 2006;144:927-932
ACP Recommendations
GME
1. Structure of residency
– Retain 3 year duration
2 years of “core” training
1 year “customized” (future generalist: hospital
and/or ambulatory emphasis; future
subspecialist: “complementary” experiences)
2. Integrate education and service, limiting
patient load per resident
Weinberger SE, Smith LG, Collier, VU. Redesigning training for Internal
Medicine. Ann Intern Med. 2006;144:927-932
ACP Recommendations
GME (cont’d)
3. Enhance ambulatory training
– Increase ambulatory time
– Eliminate dysfunctional clinics
– Create block ambulatory time (no inpatient)
4. Utilize team care (including
ambulatory/inpatient teams)
5. Develop “core” teachers with specific
education competencies, reward them
Weinberger SE, Smith LG, Collier, VU. Redesigning training for Internal
Medicine. Ann Intern Med. 2006;144:927-932
ACP Recommendations
GME (cont’d)
6. Stress professionalism
– Patient-centered, culturally sensitive,
evidence-based care
– Patient partnerships
– Lifelong learning
– Self-evaluation, self-reflection
– Social activism on behalf of patients
Weinberger SE, Smith LG, Collier, VU. Redesigning training for Internal
Medicine. Ann Intern Med. 2006;144:927-932
Society of General Internal Medicine
Concerns
Ambulatory training seldom adequate
– Inadequate infrastructure for longitudinal care
– Case mix disproportionately complex
– Time insufficient to develop continuity skills
– Variable quantity, quality of block rotations
Vacations taken during block
Ambulatory residents are back up if emergency
absence elsewhere
Holmboe ES, Bowen JL, Green M et al. Reforming Internal Medicine Training
J Gen Intern Med 2005; 20:1165–1172.
SGIM
Concerns
Changed inpatient setting
– Patients sicker, LOS shorter with residents
time taken with non-clinical tasks
– Multidisciplinary teams have replaced
physician-centric model
– Work hour rules promote fragmentation
– Error research implicates poor supervision,
evaluation, teaching
Holmboe ES, Bowen JL, Green M et al. Reforming Internal Medicine Training
J Gen Intern Med 2005; 20:1165–1172.
SGIM
Concerns
Problematic curriculum
– No consensus as to core curriculum
– Little study of best educational
setting/experience for acquisition of specific
elements
– No definition of minimal competency to be
achieved in each content area
Holmboe ES, Bowen JL, Green M et al. Reforming Internal Medicine Training
J Gen Intern Med 2005; 20:1165–1172.
SGIM
Concerns
Little specific instruction re health
disparities and cultural competency
Little specific instruction re life-long
learning
GME financing does not match training
needs, educational settings
Holmboe ES, Bowen JL, Green M et al. Reforming Internal Medicine Training
J Gen Intern Med 2005; 20:1165–1172.
SGIM
Recommendations
1. Patient-centered care taught by example
of high-quality interdisciplinary care
2. Better inpatient-ambulatory balance
3. Explicit teaching re health disparities,
including teaching in social sciences
4. Define “core” knowledge, skills, attitudes
5. Greater flexibility in certification and in
pathways to specialization
Holmboe ES, Bowen JL, Green M et al. Reforming Internal Medicine Training
J Gen Intern Med 2005; 20:1165–1172.
SGIM
Recommendations
6. Better resident evaluation, a moral and
ethical responsibility
7. Redesign clinical work, educational
processes around interdisciplinary teams
8. Better supervision by faculty
9. Link GME funding to training
environments that lead to satisfactory
patient outcomes
Holmboe ES, Bowen JL, Green M et al. Reforming Internal Medicine Training
J Gen Intern Med 2005; 20:1165–1172.
SGIM
Recommendations
10. Specific preparation for life-long learning
11. Reforms in undergraduate and
continuing medical education as well
12. Collaboration to foster education
research and disseminate best practices
Holmboe ES, Bowen JL, Green M et al. Reforming Internal Medicine Training
J Gen Intern Med 2005; 20:1165–1172.
Association of Program Directors in
Internal Medicine
Concerns
Education not patient-centered, linked to
patient safety
Residents not exposed to career options
Interest in IM, especially GIM, is down
Core principles for redesign:
– Link high-quality education and patient care
– Redesign must be comprehensive
Fitzgibbons JP, Bordley DR, Berkowitz LR et al. Redesigning resident education in Internal Medicine:
a position paper from the Association of Program Directors in Internal Medicine Ann Intern Med.
2006;144:920-926.
APDIM
Concerns and Solutions
Educational environment
– Too much inpatient emphasis
– Sick inpatients not followed as outpatients
– Outpatient clinics often chaotic
– Poor outpatient care drives all but the sickest
away, distorting outpatient learning
experience
Fitzgibbons JP, Bordley DR, Berkowitz LR et al. Redesigning resident education in Internal Medicine:
a position paper from the Association of Program Directors in Internal Medicine Ann Intern Med.
2006;144:920-926.
APDIM
Concerns and Solutions
Educational Environment: Solutions
– Assign residents based on educational need
– Continually evaluate effectiveness of
education
– Emphasize on EBM and team approach to
quality and safety
– Use carefully graded supervision
Fitzgibbons JP, Bordley DR, Berkowitz LR et al. Redesigning resident education in Internal Medicine:
a position paper from the Association of Program Directors in Internal Medicine Ann Intern Med.
2006;144:920-926.
APDIM
Concerns and Solutions
Inappropriate inpatient rotations
– Insure diversity of diagnoses, time for reflection
– Provide team leadership experiences
– Use hospitalists
Ineffective ambulatory experiences
–
–
–
–
Provide continuity of care with team
Explore use of community-based practices
Provide ambulatory block rotations (no inpatient)
Teach QI principles in ambulatory setting
APDIM
Concerns and Solutions
Restrictive Program Requirements
– Allow for innovation, e.g., IM-RRC’s
Educational Innovations Project
Outdated curriculum
– Develop core curriculum
Fitzgibbons JP, Bordley DR, Berkowitz LR et al. Redesigning resident education in Internal Medicine:
a position paper from the Association of Program Directors in Internal Medicine Ann Intern Med.
2006;144:920-926.
APDIM
Concerns and Solutions
Outdated curriculum (cont’d)
– Maintain 3-year duration
Year 1: Balanced experience in ambulatory,
inpatient, general, subspecialty
Year 2: Supervisory experiences and increased
independence
Year 3: Tailored to career goals. Focus on team
leadership skills and provision of safe, efficient,
cost-effective care
Fitzgibbons JP, Bordley DR, Berkowitz LR et al. Redesigning resident education in Internal Medicine:
a position paper from the Association of Program Directors in Internal Medicine Ann Intern Med.
2006;144:920-926.
APDIM
Concerns and Solutions
Faculty issues
– Monitor and assess faculty teaching
– Provide for faculty development
– Change promotion and reward system
GME funding
– Transparent allocation to match to educational
needs
– Evaluate “competence” of teaching hospitals
Fitzgibbons JP, Bordley DR, Berkowitz LR et al. Redesigning resident education in Internal Medicine:
a position paper from the Association of Program Directors in Internal Medicine Ann Intern Med.
2006;144:920-926.
APDIM
Risks/Obstacles
Student life-style, compensation issues
Dysfunctional health care system
Expense of competency-based
advancement of residents
Residents not vital to hospital operation
may become observers and expendable.
“Ideal” training environment may not
prepare for later experiences.
Fitzgibbons JP, Bordley DR, Berkowitz LR et al. Redesigning resident education in Internal Medicine:
a position paper from the Association of Program Directors in Internal Medicine Ann Intern Med.
2006;144:920-926.
APDIM
Recommendations
Immediate
– Year 3 experience with multidisciplinary team
leadership, instruction in systems-based practice,
clinical quality improvement and patient safety
Short term (1-2 years)
–
–
–
–
Define core knowledge, skills, attitudes
Individualize Year 3
Institute faculty development programs
Experiment with new approaches, e.g. EIP
Long-term (3-5 years)
– Change faculty promotion and reward systems
– Change GME funding