Future of Graduate Medical Education Martin Olsen MD

Future of Graduate Medical Education Martin Olsen MD

Disclosure Dr. Olsen is a consultant for Gaumard Scientific and a coholder of patent 7, 866, 983

Part 1 Areas of attention for the ETSU Ob/Gyn residency program

Initiatives for 2012 -13 Continue Research growth Enhance ultrasound curriculum

Next Site Visit Tentatively 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?

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Part 2 The 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 2012 Iglehart 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: 153160 2002

Andragogy The 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 Concepts The 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 Concerns 16 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 Supervision Relatively 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 Benefits NEJM 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 Visits Review 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

How long has Medical Simulation been around? A) 20 years B) 50 years C) 100 years D) 500 years E) more than 1000 years

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: e 1 -541. e 5. 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 Vision A 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