measuring outcomes for residency graduates steven l. frick, md chairman, dept. of orthopaedic...
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Measuring Outcomes for Residency Graduates
Steven L. Frick, MD
Chairman, Dept. of Orthopaedic Surgery
Director of Medical Education, Nemours Children’s Hospital
Professor and Assistant Dean
University of Central Florida College of Medicine
Orlando, Florida
No financial disclosures.
AAOS Program Committee
POSNA Curriculum Committee
POSNA Residents Review
POSNA Treasurer, Board of Directors
JRGOS Board of Directors
ABOS QWTF
ACGME Milestones Project Workgroup
Macy Foundation Report 2011The Content and Format of Graduate Medical EducationRecommendation III-A: The length of GME should be determined by an individual’s readiness for independent practice- demonstrated by fulfillment of nationally endorsed, specialty-specific standards- rather than tied to a GME program of fixed duration.
Role for CORD
Optimistic versus Pessimistic “an opportunity in every difficulty”
versus “ a difficulty in every opportunity”
Evidence Based Medicine
Integrating individual clinical expertise with the best external
clinical evidence
Outcome
A final product or end result
A. Flexner - 1910
Medicine can be learned but not taught
Active participation required
Need dedicated educators and students
“get comfortable with uncertainty”
Role of professional education
Provide practitioners the intellectual tools to assess information critically, stay abreast of changing knowledge, adapt to continuous change, and reflect on the larger role and responsibilities of the profession in society.
From Time to Heal by Kenneth Ludmerer
“Is there a core body of knowledge and skills that
the finishing resident should possess prior to
starting practice or fellowship?”
- Richard Gross, MD
Need curriculum
and
competency assessment
William Halsted:Residency Training systemIntroduced in 1889 at Johns
Hopkins based on: a fixed period of time for training, structured educational content, actual experience with patients, escalating responsibility for
patient care during training, and a period of supervised practice after formal training.
Remains the cornerstone of surgical training in North America more than a century later
Competency Based Education
Defined by the outcome of the educational process, not the content
Develop weighted curriculum to teach and assess (Farmer, Gross, Wadey)
Assessing competence focuses on what the learner is able to do
Miller’s model of competence
Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine (Supplement) 1990; 65: S63-S7.
Prof
essio
nal a
uthe
ntici
ty
Read, Listen Knows
Shows how
Knows how
Does
Performance or “hands on”
Live Demo; Multimedia
Becoming Expert
“The 10,000 Hour Rule”
About 10 years- dedicated practice
Bill Joy- UNIX, Sun Microsystems; Mozart; The Beatles; Bobby Fischer;Bill Gates
Model of complete clinical careModel of complete clinical care
Engage
Empathize
Educate
EnlistFix It
Find It
Opening
Closing
Culturally Competent Care
The ability to understand and work with patients whose beliefs, values, and histories are significantly different from our own.
• Quality of Outcomes
• Patient-Physician Relationship
• Malpractice Claims
CCC Education
Team Harmon
y & Quality of Work
Life
Error Prevention
Medical/Surgical Team Concerns
Cultural Competence in Health Care
Courtesy of A. White, III, MD
Defining / Teaching/ Modeling Professionalism most important
Drs. Cruess body of workHidden curriculum
Social ContractIndividual Awareness
Surgery- tripartite body of knowledgeFrank Wilson, MD
Preoperative - evaluation, indications, planning
Intraoperative - technical execution Postoperative - immobilization, weight-
bearing, PT All 3 necessary for success
Ortho Surgical Education
Interns - pre and post operative care, framework of ortho fundamentals, closed management of fxs
PGY 2/3 - basic decision-making and psychomotor skills
PGY 4/5 - independent decision-making, subspecialty skills, integrate knowledge
Our Educational philosophy at CMC Not training Stimulus - Reaction vs
Stimulus - Thought - Reaction Create one-on-one master-apprentice
situations Graduated responsibility ALWAYS supervised in highest risk activities
(OR) Have to spend enough time with them to
know
Charlotte Competency Stages
Stage I - do not know anything cannot do anything, and know it
Stage II – know and can do a lot, but do not recognize what you do not know and cannot do DANGER
Stage III – know and can do a great deal, but realize there is much you do not know
“The beginning of a mountaineer’s career, when energy and enthusiasm outpace experience and judgment, is said to be the most dangerous part.”
Photo by Guillaume Dargaud
Setting Standards
Job of Chair and RPD to set standards of excellence
Graduates of program should meet these standards in all core competencies
Assessing competency
Complete 5 years of orthopaedic surgery program under watchful eye of PD
12 months PGY1 / internship, 48 months orthopaedic surgery
Evaluations and comment by faculty, peer evaluations, portfolio (presentations, courses, outcomes instruments), OITE, operative experience log
Consensus of PD and faculty
ABOS
I believe this individual is capable of the competent independent practice of orthopaedic surgery.
Steven L. Frick, MD
Residency Program Director
An Expert- Knows
Knows WHAT to do Knows HOW to do it Knows WHEN to do it (and when not
to) Knows WHY to do it Knows WHEN to ask for help Knows WHAT we don’t know
Is it possible/desirable to define and measure
competency and then
graduate a resident before 5 years?
A Competency-Based Curriculumin Orthopaedic Surgery:
From Idea to Implementation
Markku Nousiainen, MS, MD, MEd, FRCS(C)
Sunnybrook Health Sciences Centre
University of Toronto
Current challenges in residency training
reduction in work hours
reduced time spent in OR
teaching surgical skills
reduction in wait times
improvement in patient safety
reduced training opportunities for residents
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Competency-based education
“Training process that results in proven competency in the acquisition & application of skills & knowledge to medical practice that is not simply dependent on the student’s length of training & clinical experiences”
Problems
Toronto experience- 5 years, now all in for first time
Still no defined “curriculum” More resource intensive than
traditional pathway = costs more Current environment of GME= very
dependent on Medicare funding Some predict reduction in Medicare
GME funding under PPACA 2010
How much of residency education is experiential?
Can we list / define everything you need to learn?
Can we transfer knowledge gained from experience without making residents have
the experience?
Duty hours 2003
First ortho class with 80 hour work week- double failure rate on part I ABOS certification exam
Similar result 2011 exam takers Why? Does this exam measure competency? Who do you want – 90%ile or 30%ile?
GME-Decade of Accountability
To patients by residents, faculty Patient safety, Resident safety- RPD To residents by faculty, institution Societal demands for assurance of
competency Safe, Effective, Patient centered,
Timely, Efficient, Equitable (IOM) Increased requirements by oversight
organizations – RPD time Professional, ethical behavior
demanded
NAS- Next Accreditation System
Coming to Ortho July 2013 No more site visits, PIFs every 5
years Annual “Biopsy” of 4 things
– Institutional report – Annual survey of residents and faculty– Case logs– Milestones (q 6 mos reports from
Competency Committee)
Self report every 10 years
Ortho Milestones- 18cover PC and MK
All have 5 levels
By graduation resident should be level 4 (competent) in all
For peds- septic arthritis and SC humerus fracture
Surrogates for knowledge in other areas
NASwww.acgme-nas.org
Institutional reviews (q 18 mos) Milestones reports (q 6 mos)- form a
competency committee Operative experience database Resident annual survey Faculty annual survey (new) ORTHO JULY 1, 2013
Future of Orthopaedic Residency Education
Change is coming Need to protect experience, in addition
to more rigorous evaluation / oversight More evaluations / structured
experiences Remember importance of graduated
independence Milestones will be modified as we go NAS is on the way- BE AN OPTIMIST!