Eric J. Warm

The Ambulatory Long-Block: An Accreditation Council for Graduate Medical Education (ACGME) Educational Innovations Project (EIP)

IntroductionHistorical bias toward service-oriented inpatient graduate medical education experiences has hindered both resident education and care of patients in the ambulatory setting.AimDescribe and evaluate a residency redesign intended to improve the ambulatory experience for residents and patients.SettingCategorical Internal Medicine resident ambulatory practice at the University of Cincinnati Academic Health Center.Program DescriptionWe created a year-long continuous ambulatory group-practice experience separated from traditional inpatient responsibilities called the long block as an Accreditation Council for Graduate Medical Education Educational Innovations Project. The practice adopted the Chronic Care Model and residents received extensive instruction in quality improvement and interprofessional teams.Program EvaluationThe long block was associated with significant increases in resident and patient satisfaction as well as improvement in multiple quality process and outcome measures. Continuity and no-show rates also improved.DiscussionAn ambulatory long block can be associated with improvements in resident and patient satisfaction, quality measures, and no-show rates. Future research should be done to determine effects of the long block on education and patient care in the long term, and elucidate which aspects of the long block most contribute to improvement.

There is no "i" in teamwork in the patient-centered medical home: defining teamwork competencies for academic practice.

Evidence suggests that teamwork is essential for safe, reliable practice. Creating health care teams able to function effectively in patient-centered medical homes (PCMHs), practices that organize care around the patient and demonstrate achievement of defined quality care standards, remains challenging. Preparing trainees for practice in interprofessional teams is particularly challenging in academic health centers where health professions curricula are largely siloed. Here, the authors review a well-delineated set of teamwork competencies that are important for high-functioning teams and suggest how these competencies might be useful for interprofessional team training and achievement of PCMH standards. The five competencies are (1) team leadership, the ability to coordinate team members’ activities, ensure appropriate task distribution, evaluate effectiveness, and inspire high-level performance, (2) mutual performance monitoring, the ability to develop a shared understanding among team members regarding intentions, roles, and responsibilities so as to accurately monitor one another’s performance for collective success, (3) backup behavior, the ability to anticipate the needs of other team members and shift responsibilities during times of variable workload, (4) adaptability, the capability of team members to adjust their strategy for completing tasks on the basis of feedback from the work environment, and (5) team orientation, the tendency to prioritize team goals over individual goals, encourage alternative perspectives, and show respect and regard for each team member. Relating each competency to a vignette from an academic primary care clinic, the authors describe potential strategies for improving teamwork learning and applying the teamwork competences to academic PCMH practices.

Entrustment and Mapping of Observable Practice Activities for Resident Assessment

ABSTRACTEntrustable Professional Activities (EPAs) and the Next Accreditation System reporting milestones reduce general competencies into smaller evaluable parts. However, some EPAs and reporting milestones may be too broad to use as direct assessment tools. We describe our internal medicine residency curriculum and assessment system, which uses entrustment and mapping of observable practice activities (OPAs) for resident assessment. We created discrete OPAs for each resident rotation and learning experience. In combination, these serve as curricular foundation and tools for assessment. OPA performance is measured via a 5-point entrustment scale, and mapped to milestones and EPAs. Entrustment ratings of OPAs provide an opportunity for immediate structured feedback of specific clinical skills, and mapping OPAs to milestones and EPAs can be used for longitudinal assessment, promotion decisions, and reporting. Direct assessment and demonstration of progressive entrustment of trainee skill over time are important goals for all training programs. Systems that use OPAs mapped to milestones and EPAs provide the opportunity for achieving both, but require validation.

Diabetes and the Chronic Care Model: A Review

There is a significant gap between evidence-based diabetes care and actual care delivery. The Chronic Care Model (CCM) was developed to bridge this gap and translate scientific knowledge directly to the care of patients. The CCM is a primary care based framework that identifies the essential elements of high quality chronic disease care. It includes attention to self-management support, delivery system design, decision support, information technology, community linkages, and the health care organization as a whole. This review will describe these elements and provide evidence for their use in improving diabetes care. Evidence for the CCM as a whole will also be presented.

The Quality and Safety Educators Academy Fulfilling an Unmet Need for Faculty Development

Educating physician trainees in the principles of quality improvement (QI) and patient safety (PS) is a national imperative. Few faculty are trained in these disciplines, and few teaching institutions have the resources and infrastructure to develop faculty as instructors of these skills. The authors designed a 3-day, in-person academy to provide medical educators with the knowledge and tools to integrate QI and PS concepts into their training programs. The curriculum provided instruction in quality and safety, curriculum development and assessment, change management, and professional development while fostering peer networking, mentorship, and professional development. This article describes the characteristics, experiences, and needs of a cross-sectional group of faculty interested in acquiring skills to help them succeed as quality and safety educators. It also describes the guiding principles, curriculum blueprint, program evaluation, and lessons learned from this experience which could be applied to future faculty development programs in quality and safety education.

Interval Examination: The Ambulatory Long Block

H ow can you tell when a system is broken? Six years ago, I did not ask questions like this. The Accreditation Council for Graduate Medical Education (ACGME) had accredited our residency at the University of Cincinnati for multiple 5-year cycles, we recruited well to our city, and our residents knew how to take care of sick patients. All was well. We hardly noticed that patient satisfaction scores in the clinic were consistently low and that residents rated their ambulatory education at the bottom of the residency experience. What did you expect in a clinic? Was it ever any different? How can you tell when a system is broken? One way is to only ask questions that validate instead of evaluate. Fortunately for us, Marilyn Gaston, local hero and former director of the Bureau of Primary Health Care, came to town.

End-of-Life Graduate Education Curriculum Project

IN 1997, THE AMERICAN BOARD OF INTERNAL MEDICINE (ABIM) added “End-of-Life Care” to its educational requirements for post-graduate education. To assist residency programs develop the infrastructure to support this new change, a pilot project was begun in 1998 for 30 residency programs, supported by a grant from the Robert Wood Johnson Foundation with technical assistance from ABIM. This project has been continued with a goal of recruiting an additional 60 primary care residencies (Internal and Family Medicine) each year for 3 years. Project components included the following steps:

Medical specialty boards can help measure graduate medical education outcomes.

U.S. graduate medical education (GME) training institutions are under increasing scrutiny to measure program outcomes as a demonstration of accountability for the sizeable funding they receive from the federal government. The Accreditation Council for Graduate Medical Education (ACGME) is a potential agent of measuring GME accountability but has no interaction with physicians after residency training is completed. American Board of Medical Specialty (ABMS) member boards interact with physicians throughout their careers through maintenance of certification (MOC) and are a potential source of valuable data on physician competency and quality of care, both of which could be used to measure GME accountability.The authors propose that ABMS boards and the ACGME deepen their existing relationship to better assess residency training outcomes. ABMS boards have a wealth of data on physicians collected as a by-product of MOC and business operations. Further, many ABMS boards collect practice demographics and scope-of-practice information through MOC enrollment surveys or recertification examination questionnaires. These data are potentially valuable in helping residencies know what their graduates are doing in practice. Part 4 of MOC generally involves assessment of the quality of care delivered in practice, and ABMS boards could share these deidentified data with the ACGME and residency programs to provide direct feedback on the practice outcomes of graduates.ABMS member boards and the ACGME should broaden their long-standing relationship to further develop shared roles and data-sharing mechanisms to better inform residencies and the public about GME training outcomes.

Beyond a Curricular Design of Convenience: Replacing the Noon Conference With an Academic Half Day in Three Internal Medicine Residency Programs

Several residency programs have created an academic half day (AHD) for the delivery of core curriculum, and some program Web sites provide narrative descriptions of individual AHD curricula; nonetheless, little published literature on the AHD format exists. This article details three distinctive internal medicine residency programs (Cambridge Health Alliance, University of Cincinnati, and New York Presbyterian/Weill Cornell Medical College) whose leaders replaced the traditional noon conference curriculum with an AHD. Although each program’s AHD developed independently of the other two, retrospective comparative review reveals instructive similarities and differences that may be useful to other residency directors. In this article, the authors describe the distinct approaches to the AHD at the three institutions through a framework of six core principles: (1) protect time and space to facilitate learning, (2) nurture active learning in residents, (3) choose and sequence curricular content deliberately, (4) develop faculty, (5) encourage resident preparation and accountability for learning, and (6) employ a continuous improvement approach to curriculum development and evaluation. The authors chronicle curricular adaptations at each institution over the first three years of experience. Preliminary outcome data, presented in the article, suggests that the transition from the traditional noon conference to an AHD may increase conference attendance, improve resident and faculty satisfaction with the curriculum, and improve resident performance on the In Training Examination.

Erratum to: A Multiple Choice Testing Program Coupled with a Year-long Elective Experience is Associated with Improved Performance on the Internal Medicine In-Training Examination

Background The Internal Medicine In-Training Exam (IM-ITE) assesses the content knowledge of internal medicine trainees. Many programs use the IM-ITE to counsel residents, to create individual remediation plans, and to make fundamental programmatic and curricular modifications.