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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.

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Residency Redesign in Internal Medicine

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  1. Residency Redesign in Internal Medicine American College of Physicians (ACP) Society of General Internal Medicine (SGIM) Association of Program Directors in Internal Medicine (APDIM)

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. American College of PhysiciansOverall 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

  7. ACPConcerns • 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

  8. ACP RecommendationsUndergraduate • Use premedical education to decompress 1st year • Flexible 3rd year with well-functioning practice environments • Enthusiastic role models • Late 3rd-4th year • Revisit pathophysiology, mechanisms of disease • Understand translation of knowledge into practice • Improve analytic, interpretive skills, preparing for life-long learning • 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

  9. ACP RecommendationsGME • 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) • 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

  10. ACP RecommendationsGME (cont’d) • Enhance ambulatory training • Increase ambulatory time • Eliminate dysfunctional clinics • Create block ambulatory time (no inpatient) • Utilize team care (including ambulatory/inpatient teams) • 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

  11. ACP RecommendationsGME (cont’d) • 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

  12. Society of General Internal MedicineConcerns • 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.

  13. SGIMConcerns • 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.

  14. SGIMConcerns • 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.

  15. SGIMConcerns • 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.

  16. SGIMRecommendations • Patient-centered care taught by example of high-quality interdisciplinary care • Better inpatient-ambulatory balance • Explicit teaching re health disparities, including teaching in social sciences • Define “core” knowledge, skills, attitudes • 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.

  17. SGIMRecommendations • Better resident evaluation, a moral and ethical responsibility • Redesign clinical work, educational processes around interdisciplinary teams • Better supervision by faculty • 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.

  18. SGIMRecommendations • Specific preparation for life-long learning • Reforms in undergraduate and continuing medical education as well • 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.

  19. Association of Program Directors in Internal MedicineConcerns • 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.

  20. APDIMConcerns 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.

  21. APDIMConcerns 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.

  22. APDIMConcerns 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

  23. APDIMConcerns 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.

  24. APDIMConcerns 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.

  25. APDIMConcerns 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.

  26. APDIMRisks/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.

  27. APDIMRecommendations • 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

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