Title:  Patient-centered and competency based education:

        Faculty Directions for Curriculum Use (consider this one of your

        "faculty development" activities).

 

Some (yes, there are alot more) of the key requirements of the ABIM and ACGME.

 

Summary: Teaching Rounds must occur for a minimum of 4.5 hours/week (separate from work rounds).  [At SBH, this should be 5 sessions/week.]

 

Teaching rounds must include time at the bedside for faculty to

demonstrate Hx and PE techniques as well as time at the bedside to

observe residents Hx and PE (the observation part can and should be part

of mini-CEXs).

 

There must be a written (or online) curriculum for each rotation, and

the curriculum must be reviewed by the faculty with the residents at

the beginning of each rotation.  Please direct residents to our

"OnLine Curriculum" and "OnLine References" for the IM rotation

at SixPotato.

 

Competency based education necessitates that for each rotation the

curriculum must include 1) what needs to be learned; 2) how

it is to be learned (including references); 3) documentation that the

material has or has not been learned (e.g., direct observation  of

residents, quizzes, etc.), 4)"formative" feedback mid-way through the

rotation to let residents know how they are doing, 5) "summative"

feedback by the end (not after) the rotation which goes into their

"permanent record".  [Feedback should be accompanied by encouragement

and direction.]

 

[When the ABIM visits us, in addition to everything else, they will

be looking carefully at the mid-rotation "formative" feedback. They

will also focus on how we remediate or otherwise handle "problem"

residents.]

 

On the inpatient General Internal Medicine rotations, what is learned,

taught, evaluated, must include the six general (core) competencies,

and there must be "faculty development" activities to make certain

faculty are up to date on the competencies. (Reading this counts.)

 

The ABIM and ACGME also require that residents evaluate the faculty for

our success, or lack thereof, at implementing the above.

 

The Six General Competencies (also called "Core" Competencies).

 

Regarding the six general competencies, there is a lot of material to

cover.  To make it easier for us to get this across, we are making

material available online to the residents in each of the six general

competencies, divided over the course of their 13 four week block

rotations.  When you are a teaching team attending, please read the

on line material assigned for that month (as well as the preceding months). 

Sometimes the material is different, depending on the residents’ level of

training. The online material can be counted toward "faculty development",

but there is also some material just for faculty to review.   Over the

course of a rotation, faculty should be able to have the residents discuss

most of the month's assigned material.  Not all material fits neatly into

one of the six general competencies.  If that comes up, use it as an

opportunity to discuss the overlap of some of the topics.  Dr. Hershey Bell

used a hexagon to outline how the six competencies can often cover the same

topic.  One element that is included as a part of each of the core competencies

is "patient-centeredness".  In other words, all six competencies are mastered

on behalf of the patient.

 

What Currently (and subject to change) we use the following key elements:

 

 

 

1.  Medical Knowledge:

    This also includes how the knowledge is utilized:  Clinical Reasoning

    and Clinical Judgment.  You should require that PGY-2/3 lookup

    information via Up-To-Date (or equivalent) and share when presenting

    some of the cases [See #5-EBM, below].  You should evaluate clinical

    reasoning and clinical judgment not only by what you observe on

    rounds, but also by performing chart reviews to look at Assessments

    and Plan from admission and progress notes of PGY-1 and PGY-2/3.

 

    [Note:  Residents are encouraged to add to their knowledge by

    utilizing 2-volume Harrisons, Harrison's On Line (available for

    free from Merck Medicus), The Medical Letter, MKSAP, peer

    reviewed journals, and Up-To-Date].

 

 2. Interpersonal and Communication Skills:.

    This is not exactly what you might think.  Actual history taking

    is supposed to be evaluated as part of Patient Care (see #3, next

    competency section); however, we sometimes fudge.  Interestingly,

    Interpersonal and Communication Skills is supposed to focus more on

    relationship building with patient, family, and communicating well

    with PCP, nurses, social workers, etc.   So the evaluation of this

    skill by teaching attending should focus on observing whether

    residents complete the Consult Request Forms, acknowledge Attending

    and Consult notes, communicate with the out-of-hospital SBH PCP, or

    communicate with not-on-our staff PCP, communicate with the family

    and keep them up to date. The Discharge Note to patients should be

    reviewed for evidence that it can be useful and understood by the

    patient and their families.  Patients, families, social workers are

    other key evaluators.

 

3.  Patient Care:

    This focuses on History-taking, Physical Examination and

    Procedural Skills. (For practical reasons, and to add to your

    general confusion, much of the History-taking reading material is

    placed in the section online  on Communication Skills).

    The teaching attending can best evaluate History-taking and

    Physical Examination Skills at the bedside and by performing

    mini-CEXs.  You should strive to perform at least one mini-CEX

    on each of the PGY-1 and 2 during the rotation.

    The history taking skills that we wish to see include:

    a.  Open-ended:  Let the patient talk, encourage the patient to

        talk.   Tons of references on this.  And based on our video

        taping of residents at Orientation, they need work on this.

    b.  Empathetic:  "That must have been very upsetting...."

        Dr. Tom Nasca, past-president of the RRC-IM has focused on this;

        you can review his articles. Also part of #4-Professionalism.

    c.  Culturally-sensitive:  Although this should be rather intuitive,

        the article by Green, Carillo, and Betancourt from the Annals

        nicely summarizes one aspect of this in the question:  "What

        do you think is going on....?"

    d.  Social-history that is useful for determining the System

        resources.   Yes, the SHx includes smoking, etc; however,

        what we also need to know is what pat. do/did for a living,

        who is at home with them, so we can figure out whether we

        will need to call VNS, have someone else available who can

        give them their insulin shots, etc.  Article by Cassel (current

        president of the ABIM with Dr. Olie Fein) in the Annals touches

        on this.  Ties into competency #6: SBP

    e.  In the ambulatory setting, we will need to make certain

        residents can counsel and instruct patients and provide

        "patient-centered" plans.  Patient-centered refers to care

        that takes patient preferences into account (e.g., do you

        prefer I-131 or methimazole; do you prefer brand or generic?)

    f.  Discharge Note to patient that is clear, concise, abbreviation

        free and error free (#5, below)  and incorporates scheduled

        utilization of system resources (VNS, Clinic- #6,below).

 

4.  Professionalism:

    Documents describing definition of a profession and professionalism

    are included as basic reading.  The ABIM has a long history of focus

    on professionalism, so their document "Project Professionalism" is

    particularly helpful for faculty.  The ABIM and others created

    the "Professionalism Charter" a few years ago, so this is a key

    document for residents.  Faculty should be aware of the concept

    of "hidden curriculum" which refers to telling residents

    not to accept bribes from pharmaceutical companies while winking and

    and taking the family on a drug company-sponsored trip to

    Hawaii.  Functioning as a pro-active Faculty Adviser would be a

    positive example of professionalism.  Other positive examples of

    professionalism would be:  Providing mid-rotation formative and end-

    of-rotation summative feedback; making certain that another faculty

    member is available to cover teaching rounds if you can't make it.

 

    Although there are many components of professionalism (altruism,

    compassion, integrity, respect, empathy...), the component we

    faculty can most easily evaluate is "accountability".  This

    includes accountability to provide continuity of care at

    discharge, accountability to show up for teaching rounds on time,

    accountability to keep attending informed of change in status

    of patients, accountability to sign out patients appropriately and

    to complete work before leaving, accountable to complete SBH

    practice guideline forms on CHF, etc [see #6-SBP, below].

 

    Another aspect of Professionalism that teaching attendings must

    discuss is physician or resident stress (this also includes

    fatigue, work hour regulations, impairment, depression,

    counseling.)   The symptoms of stress in residents have been

    increasing dramatically in past 2 years.  It is important that

    resources available to deal with stress be discussed at the

    beginning of each rotation:  meeting with teaching attending,

    faculty adviser, CMRs, program director, Ken Cohen).

 

5.  Practice-based learning and improvement (PBLI)

    Patient safety, quality of care and quality improvement

    are major areas of emphasis that JCAHO focuses on when

    they inspect our institution, and we have incorporated

    these topics, as well as Evidence-based medicine (EBM)

    as our main themes (currently) for PBLI.

 

    The EBM aspect of the online resources starts with simple

    search engines to gather evidence (Google, PubMed) and then

    progresses (OVID, Cochrane) and includes an excellent online

    course of Dr. Friedman on the concepts of EBM.

 

    You can observe the residents use of EBM by encouraging them

    (esp PGY-2 and 3) to bring in references from Up-To-Date,

    Medical Letter, and others, when they present cases to you.

    An important aspect of EBM is being mindful of when evidence

    generated from a relatively homogenous population may not

    apply to a specific patient.   Rounds are a good opportunity

    to emphasize that EBM is best used as a starting point, but

    EBM does not ignore the fact that patient preferences and clinical

    judgment may impact on the course of treatment.

 

    You can monitor for error reduction by reviewing the resident's

    Discharge Note to patient and reviewing the resident's prescriptions

    at discharge.

 

6.  Systems-based Practice (SBP)

    Key components of SBP include assessing which system resources

    patients may require (e.g. VNS, NH), understanding delivery systems

    (e.g.  managed care), and role of practice guidelines.

 

    As noted in section [#3] above on the Social History, residents need

    to develop skill in determining what "System Resources" are needed

    and available to care for patients, and then go about facilitating

    their appropriate use.  As emphasized by Drs. Cassel and Fein,

    [see #3-Patient Care] at the time of admission, the Social History is

    very important in anticipating which system resources patients are

    likely to require.   When new admissions are presented, or when

    charts are reviewed, faculty should take the opportunity to emphasize

    early discharge planning and the utility of the Social History

    in implementing this.

 

    SBP also includes an understanding of different forms of health care

    delivery (e.g., managed care).  The THCI (Tufts HealthCare Institute)

    has very good information on both managed care and PBLI), and there

    are several articles on various forms of insurance such as Medicare,

    Medicaid, and other systems with which physicians need to be

    familiar (OSHA, OIG, CMS,...).

 

 

    There are several sources for information regarding Practice

    Guidelines.  Residents should understand where physicians fit

    into the giant PDSA cycle of managed care and quality improvement:

 

    1.  EBM is used to generate Practice Guidelines

    2.  Managed Care plans promulgate the Practice Guidelines

    3.  NCQA monitors Managed Care Plans (such as PIH, HIP) for

        compliance with Practice Guidelines.

    4.  Managed Care plans provide "report cards" to physicians

        (and sometimes "incentives") based on "report cards"

 

    Current Practice Guidelines being monitored at SBH should be

    emphasized and monitored for resident compliance.

 

    Discharge Plans and Notes to patient which document system resources

    being scheduled (VNS, clinic) should be monitored by faculty.  #