bridge over troubled water linking ume and gme monica l. lypson, md assistant dean, graduate medical...
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Bridge over Troubled WaterLinking UME and GME
• Monica L. Lypson, MD Assistant Dean, Graduate Medical Education
University of Michigan
Jeff Fabri, MD
Rita M. Patel, MD
Education Across the Continuum Standardization of Assessment
Student Portfolios to Baseline Assessment
• Monica L. Lypson, MD Assistant Dean, Graduate Medical Education
University of Michigan
• Associate Chief of Staff, VA Ann Arbor Health Care System
Institutional OSCE – Post-Graduate Orientation Assessment (POA)
Developed by the Graduate Medical Education Committee (GMEC) at the University of Michigan
It is our initial step in training our residents
It was established to determine residents’ baseline proficiency in particular aspects of the ACGME’s six general competencies
Lypson ML. et.al. Academic Medicine. 79(6):564-70, 2004 Jun.
POA CONTENT
Knowledge and skills needed during the first six to eighteen weeks of residency/internship
Emphasizes clinical situations that are often encountered without formal supervision
9 Assessment & Educational Stations
The POA as Formative Assessment
Results of the POA determine the basis for individualized “learning agendas”
Remediation is provided after the completion of each station Residents received educational materials that provide the
“answers” to the information assessed during the POA
Standardized Patient feedback is provided to the program director within 24 hours if the resident performs exceptionally well or poorly during the POA
Implementation
Administered over 4 days of Paid hospital orientation
Provided to approximately 150 PGY-1 residents in over 15 specialties
Cost Approximately $250 per resident for the assessment - $500 if you add in salary
There are some discipline specific scenarios – e.g. Pediatric cases and examples
Scores are provided to the resident and program director within 7-10 days of the POA
Subspecialty Programs
• Dentistry• Emergency Medicine• Family Medicine• General Surgery
– Preliminary Residents
• Internal Medicine– Preliminary Residents
• Internal Medicine – Pediatrics
• Neurosurgery• Obstetrics & Gynecology
• Otolaryngology• Orthopedics• Pathology• Pediatrics• Plastic Surgery• Psychiatry• Urology• PGY-2s (Residents that did not complete their Internships at UMHS)
– Physical Medicine & Rehabilitation– Dermatology– Neurology
• Critical Values / Multiple Choice – Computer Based assessment – Review and diagnose 17 short
patient scenarios– Multiple Choice Format
similar to United States medical Licensing Exam (USMLE) Step 3
– Competencies:• Patient Care• Medical Knowledge
• Socio-Cultural Communication – Standardized patient assessment – Assesses the understanding of
disease and treatment recommendations in the context of the patient’s health beliefs and socio-economic setting
– Competencies:• Interpersonal and
Communication Skills• Professionalism • Patient Care• Practice-Based Learning and
Improvement
Station Content
Station Content
• Evidence-Based Medicine (EBM) – Computer-based
Assessment– Generate a clinical
question– Residents reviewed
abstracts & identify the appropriate treatment
– Competencies:• Practice-based
Learning and Improvement
• Medical Knowledge
• Images (X-Rays)– Computer-based
Assessment– Review & diagnose 18
images– Many of the common
films reviewed in the middle of the night while “on call”
– Competencies:• Patient Care• Medical Knowledge
Station Content
• Informed Consent– Standardized patient
Assessment
– Obtain informed consent from a patient for a procedure
– Hospital & JCAHO standards and policies
– Competencies:
• Interpersonal and Communication Skills
• Professionalism
• Patient Care
• Patient Safety– Pen & Paper Assessment
– Order Writing Station
• Legibility
• Signature, Date, Time
– Respiratory Distress
• Treatment of the acute Asthmatic
– Competencies:
• Systems-Based Practice
• Professionalism
• Patient Care
• Medical Knowledge
Station Content
• Aseptic Technique – Checklist Evaluation by Expert Nursing Staff and Standardized
Patients– Create & maintain a sterile field while performing a “mock” I&D– Universal Protocol & “Time-out” procedures covered– Assessment/Remediation materials include a review of JCAHO
requirements – Improved nursing and house officer interactions– Competencies:
• Patient Care• Medical Knowledge• Systems-Based Practice
Station Content
• System Compliance / Fire Safety Station– Surgical Fire Safety (20/20)
– Housestaff involvement with a Patient fire
– Questions covering use of safety equipment & review of JCAHO requirements
– Video & Computer Based Assessment
– Competencies:• Patient Care
• Systems-Based Practice
• Pain Assessment– Pain Assessment Tools
– Educates on the appropriate medications to use for pain
– Explains hospital and JCAHO Pain assessment mandates
– PowerPoint & Computer Based Assessment
– Competencies:
• Patient Care
• Medical Knowledge
Resident Satisfaction with the POA-Survey Response Rate 93%2002-2004
Question YES
Have you learned any new clinical skills during this assessment?
70.6%
Do you think this was a useful way to spend part of orientation?
83.4%
Do you feel better prepared for some aspects of internship after this assessment?
80.6%
Do you expect to refer back to the teaching materials handed to you today?
84.7%
Would you recommend that we continue the POA next year?
84.7%
The POA was based on the following…
The University of Michigan
Comprehensive Clinical Assessment
(CCA)
Comprehensive Clinical Assessment 1991-Present
• A high-stakes examination for University of Michigan Medical Students
• Fourth Year students must pass the CCA in order to Graduate
• 10-15 stations over ~4-5 hours• ~150 M4 students per year• Summative Evaluation• Standards have been set for Pass/Fail• Remediation for failures
Rochester AB. et.al.. Academic Radiology. 5(3):169-72, 1998
Summary of Station Comparison:CCA & POA
POA- GME
• Formative
• Informed Consent & Policy
• Pain Assessment
• Socio-Cultural Communication
• Evidence Based Medicine
• Images
CCA-UGME
• Summative
• History & Physical Diagnosis
• Geriatrics
• Socio-Cultural Communication
• Evidence Based Medicine
• Images
Institutional Implications for GME & UGME
• Training the Faculty in the Teaching Skills of competency assessment– Medical School Objectives Project (MSOP)– Accreditation Council of Graduate Medical Education
• Reimbursement of faculty time and effort• Payment for both assessments – Medical
School vs. Hospital– Is the medical school or the hospital responsible for ‘educational
cost’?
• Trainee awareness of “competency gap” between the expectations of medical School and residency
POA Demographics 2002-2004
Gender
Male 54%
Race
White / Non-Hispanic Underrepresented Minorities
Other
70.1%
6.5%
23.4%
Medical Schools
Public
International
62%
1.5%
United States Medical Licensing Examination (USMLE)
Step 1
Step 2231
233
The University of Michigan Health System Plan for Competency Based Resident Education
• Joint Hire faculty member with the Department of Medical Education
• Centralized OSCE – Post-Graduate Orientation Assessment (POA)
This is based on the system already in place for Undergraduate Medical Education at UMHS.
The Department of Medical EducationChairman: Larry Gruppen, PhD
• One of ~5 departments of medical education at LCME accredited medical schools
• The department had focused on CME and UGME in the past with assessment and research expertise
• The office of Graduate Medical Education and the Department of Medical Education
– Joint Hire – Job Description
• 50% appointment GME office, 50% appointment Dept. of Med. Ed.• Aid Residency programs with curriculum development, core competency
assessment• Use this work as a vehicle of scholarly pursuit
– The department has a long history of UGME – now will develop its expertise in GME