John G. Frohna

Teaching Primary Care in Community Health Centers: Addressing the Workforce Crisis for the Underserved

Universal coverage and multiple initiatives to improve health care delivery are crucial components of health care reform. However, the missing link has been a plan to rapidly address the primary care workforce crisis for the underserved. The authors propose a link between primary care graduate medical education and care for the underserved in community health centers, where expansion will be necessary for the anticipated increase in Medicaid and insured patients. This can be achieved by establishing primary care teaching health centers in expanded community health centers, which have established a patient-centered medical home practice environment. Residents would receive their final year of training in these centers, and then have the incentive of National Health Service Corps debt repayment if they subsequently practice in an underserved area. Primary care residents being trained in this setting would immediately increase the clinical capacity of community health centers and ultimately expand the primary care physician workforce. This proposal addresses the primary care physician workforce crisis and the associated key problems of limited access for the underserved and suboptimal primary care graduate medical education.

Putting the pediatrics milestones into practice: a consensus roadmap and resource analysis.

The Accreditation Council for Graduate Medical Education has partnered with member boards of the American Board of Medical Specialties to initiate the next steps in advancing competency-based assessment in residency programs. This initiative, known as the Milestone Project, is a paradigm shift from traditional assessment efforts and requires all pediatrics residency programs to report individual resident progression along a series of 4 to 5 developmental levels of performance, or milestones, for individual competencies every 6 months beginning in June 2014. The effort required to successfully make this shift is tremendous given the number of training programs, training institutions, and trainees. However, it holds great promise for achieving training outcomes that align with patient needs; developing a valid, reliable, and meaningful way to track residents’ development; and providing trainees with a roadmap for learning. Recognizing the resources needed to implement this new system, the authors, all residency program leaders, provide their consensus view of the components necessary for implementing and sustaining this effort, including resource estimates for completing this work. The authors have identified 4 domains: (1) Program Review and Development of Stakeholders and Participants, (2) Assessment Methods and Validation, (3) Data and Assessment System Development, and (4) Summative Assessment and Feedback. This work can serve as a starting point and framework for collaboration with program, department, and institutional leaders to identify and garner necessary resources and plan for local and national efforts that will ensure successful transition to milestones-based assessment.

The Quest Toward Unsupervised Practice: Promoting Autonomy, Not Independence

The ultimate goal of graduate medical education has often been described as supporting learners in the pursuit of independent practice. To achieve this goal, learners and supervisors attempt to balance autonomy vs supervision, defining autonomy as allowing a learner to make decisions in the absence of a supervisor, and supervision as ensuring that ultimate care decisions are in the control of a more experienced physician. These definitions are not only outmoded but perhaps were never correct. Instead, training must prepare learners for unsupervised practice, in which they interact with others (not act independently) and are afforded appropriate autonomy and levels of supervision during training. Indeed, this concept is now reflected in the educational competencies that have been developed by the Accreditation Council for Graduate Medical Education. It is not simply a matter of semantics. Overemphasis on independent practice as the goal beyond training threatens the openness of learners to seeking help when needed and misstates the goal they must strive to achieve. Without defining the intended goal— unsupervised practice—learners and supervisors risk losing focus on ensuring that learners make appropriate de

Internal medicine-pediatrics residency training: current program trends and outcomes.

Purpose. Combined internal medicine–pediatrics (med–peds) residency programs have existed since 1967. Due to the rapid growth in the number and size of programs during the 1990s, most current med–peds physicians completed their residency in the last ten years, making older studies of med–peds programs obsolete. The authors sought to determine completion rates of med–peds residency programs and describe the initial career plans for five cohorts of graduating residents from combined med–peds training programs. Method. Program directors of all U.S. med–peds residency programs were asked to complete a Web-based survey and base their responses on the records of cohorts of residents completing their programs from 1998 through 2002. To allow sufficient time to complete both the American Board of Pediatrics (ABP) and American Board of Internal Medicine (ABIM) certification examinations, certification status was requested only for the cohort completing training in 1998. Results. Responses were obtained from 92% (83/90) of the programs, reflecting 1,595 residents entering med–peds programs. Of these residents, 91% graduated from a med–peds program. Among the graduates, 82% were seeing both adults and children, 22% went on to subspecialty residencies, 21% began practice in rural or underserved areas, and 25% entered an academic position. ABIM and ABP pass rates for the 1998 cohort were 97% and 96%, respectively. Overall, 79% of the 1998 graduates are board certified in both specialties. Conclusions. Compared with previous studies, a greater proportion of residents who recently entered med–peds programs completed their dual training, and a larger percentage of graduates are seeing both adults and children. The proportion of residents entering subspecialty residencies has increased significantly, but the proportion of graduates in academic careers has remained stable.

Academic Medicine: A Key Partner in Strengthening the Primary Care Infrastructure Via Teaching Health Centers

In the United States, a worsening shortage of primary care physicians, along with structural deficiencies in their training, threaten the primary care system that is essential to ensuring access to high-quality, cost-effective health care. Community health centers (CHCs) are an underused resource that could facilitate rapid expansion of the primary care workforce and simultaneously prepare trainees for 21st-century practice. The Teaching Health Center Graduate Medical Education (THCGME) program, currently funded by the Affordable Care Act, uses CHCs as training sites for primary-care-focused graduate medical education (GME). The authors propose that the goals of the THCGME program could be amplified by fostering partnerships between CHCs and teaching hospitals (academic medical centers [AMCs]). AMCs would encourage their primary care residency programs to expand by establishing teaching health center (THC) tracks. Modifications to the current THCGME model, facilitated by formal CHC and academic medicine partnerships (CHAMPs), would address the primary care physician shortage, produce physicians prepared for 21st-century practice, expose trainees to interprofessional education in a multidisciplinary environment, and facilitate the rapid expansion of CHC capacity. To succeed, CHAMP THCs require a comprehensive consortium agreement designed to ensure equity between the community and academic partners; conforming with this agreement will provide the high-quality GME necessary to ensure residency accreditation. CHAMP THCs also require a federal mechanism to ensure stable, long-term funding. CHAMP THCs would develop in select CHCs that desire a partnership with AMCs and have capacity for providing a community-based setting for both GME and health services research.

The use of evidence-based medicine in pediatrics: past, present and future.

Purpose of review Evidence-based medicine is a process that seeks to integrate the best research evidence with clinical expertise and patient values in order to optimize clinical outcomes for our patients. This article will review the benefits of and barriers to the use of evidence-based medicine in pediatrics in the twenty-first century, discuss various implementation strategies and outline the resources that pediatricians could use to increase their knowledge and skills and apply them to their clinical practice. Recent findings Although physicians have generally welcomed evidence-based medicine, the benefits and limitations are often debated, and studies reveal that physicians feel that practicing evidence-based medicine could be difficult in a busy clinical practice because they lack the time, knowledge and resources. There have been many recent developments to help pediatricians overcome these barriers and to use best evidence in their practice. Summary Pediatricians must be able to use the evidence-based medicine process to identify, access, apply and integrate new knowledge into their practice to provide high-quality care for their patients. The resources discussed in this review will help pediatricians make clinical decisions about patient care that are based on the best, most current, valid, and relevant evidence available.

A validated search assessment tool: assessing practice-based learning and improvement in a residency program

OBJECTIVE The objective of this study was to validate an assessment instrument for MEDLINE search strategies at an academic medical center. METHOD Two approaches were used to investigate if the search assessment tool could capture performance differences in search strategy construction. First, data from an evaluation of MEDLINE searches from a pediatric residents longitudinal assessment were investigated. Second, a cross-section of search strategies from residents in one incoming class was compared with strategies of residents graduating a year later. MEDLINE search strategies formulated by faculty who had been identified as having search expertise were used as a gold standard comparison. Participants were presented with a clinical scenario and asked to identify the search question and conduct a MEDLINE search. Two librarians rated the blinded search strategies. RESULTS Search strategy scores were significantly higher for residents who received training than the comparison group with no training. There was no significant difference in search strategy scores between senior residents who received training and faculty experts. CONCLUSION The results provide evidence for the validity of the instrument to evaluate MEDLINE search strategies. This assessment tool can measure improvements in information-seeking skills and provide data to fulfill Accreditation Council for Graduate Medical Education competencies.

Standardized Checklist for Otoscopy Performance Evaluation: A Validation Study of a Tool to Assess Pediatric Otoscopy Skills

Introduction Acute otitis media (AOM) is the most frequently diagnosed pediatric illness in the United States and the most common indication for antibiotic prescription. Skill in pediatric otoscopy is essential to correctly identify children with AOM. However, studies have found diagnostic inconsistency and significant overdiagnosis among practitioners. Given the potential public and individual health consequences, there has been a call for improved education regarding the diagnostic certainty of AOM. Yet educational efforts continue to be limited, particularly in regard to competency assessment. The lack of a validated tool to assess otoscopy skill attainment objectively diminishes the instructors ability to provide useful feedback and direction to the learner. Methods We have undertaken an educational intervention with the goal of developing a validated Standardized Checklist for Otoscopy Performance Evaluation (SCOPE), building on key principles of the general pediatric ear exam. The SCOPE was developed with the input of process and content experts with attention to specific domains of validity. Results Our analysis provides important validity evidence for the SCOPE assessment tool. The instrument was piloted and successfully implemented with medical students and varying levels of residents in pediatrics and emergency medicine over a 5-year period in varied settings: urgent care, large and small pediatric clinics, and the emergency departments at two institutions. It has been used for both instruction and assessment purposes. Discussion Because the SCOPE can be used in teaching demonstration purposes, in formative and summative assessment settings, and across the continuum of learners, this instrument offers the potential for more educational efforts in the field of assessment in direct patient care. We anticipate that the SCOPE will foster an environment of efficient yet high-yield review and discussion of otoscopy and diagnostic competency.

Educational Innovations Project—Program Participation and Education Publications

AAIM is the largest academically focused specialty organization representing departments of internal medicine at medical schools and teaching hospitals in the United States and Canada. As a consortium of five organizations, AAIM represents department chairs and chiefs; clerkship, residency, and fellowship program directors; division chiefs; and academic and business administrators as well as other faculty and staff in departments of internal medicine and their divisions.

Developing Leaders in Pediatric Graduate Medical Education: The APPD LEAD Program

From the Department of Pediatrics, University of South Alabama College of Medicine, Mobile, Alabama (Dr Trimm); Department of Medical Education, Phoenix Children’s Hospital, Phoenix, Arizona (Dr Caputo); Department of Pediatrics, Weill Cornell Medical College, New York, New York (Dr Bostwick); Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (Dr Frohna); Department of Pediatrics and Communicable Diseases, University of Michigan Health System, Ann Arbor, Michigan (Dr Haftel); Division of Infectious Diseases, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia (Dr Waggoner-Fountain); and Department of Pediatrics, University of California, Davis, Sacramento, California (Dr Li) The authors declare that they have no conflict of interest. Address correspondence to Franklin Trimm,MD, Department of Pediatrics, 1700 Center St, University of South Alabama, USAChildren’s and Women’s Hospital, Mobile, AL 36604 (e-mail: rftrimm@health.southalabama.edu).