Kevin Hinchey

The Internal Medicine Reporting Milestones and the Next Accreditation System

The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones Project to facilitate more synthetic and narrative-based assessments of educational outcomes. This commenta...

Implementing a resident research program to overcome barriers to resident research.

Internal medicine residents are required to participate in scholarly activity, but conducting original research during residency is challenging. Following a poor Match at Baystate Medical Center, the authors implemented a resident research program to overcome known barriers to resident research. The multifaceted program addressed the following barriers: lack of interest, lack of time, insufficient technical support, and paucity of mentors. The program consisted of evidence-based medicine training to stimulate residents’ interest in research and structural changes to support their conduct of research, including protected time for research during ambulatory blocks, a research assistant to help with tasks such as institutional review board applications and data entry, a research nurse to help with data collection, easily accessible biostatistical support, and a resident research director to provide mentorship. Following implementation in the fall of 2005, there was a steady rise in the number of resident presentations at national meetings, then in the number of resident publications. From 2001 to 2006, the department saw 3 resident publications. From 2006 to 2012, that number increased to 39 (P< .001). The department also saw more original research (29 publications) and resident first authors (12 publications) after program implementation. The percentage of residents accepted into fellowships rose from 33% before program implementation to 49% after (P = .04). This comprehensive resident research program, which focused on evidence-based medicine and was tailored to overcome specific barriers, led to a significant increase in the number of resident Medline publications and improved the reputation of the residency program.

Getting doctors to clean their hands: lead the followers

Background Despite ample evidence that hand hygiene (HH) can reduce nosocomial infections, physician compliance remains low. The authors hypothesised that attending physician role modelling and peer pressure among internal medicine teams would impact HH adherence. Methods Nine teams were covertly observed. Team member entry and exit order, and adherence to HH were recorded secretly. The mean HH percentage across encounters was estimated by compliance of the first person entering and exiting an encounter, and by the attending physicians HH compliance. Results 718 HH opportunities prior to contact and 744 opportunities after contact were observed. If the first person entering a patient encounter performed HH, the mean compliance of other team members was 64%, but was only 45% if the first person failed to perform HH (p=0.002). When the attending physician performed HH upon entering the patient encounter, the mean HH compliance was 66%, but only 42% if the attending physician did not perform HH (p<0.001). Similar results were seen on exiting the room. The effects of the first person were not driven solely by the attending physicians HH behaviour because the attending physician was first or second to enter 57% of the encounters and exit 44% of the encounters. Conclusions If the first person entering a patient room performs HH, then others were more likely to perform HH too, implying that peer pressure impacts team member HH compliance. The attending physicians behaviour also influenced team members regardless of whether the attending physician was the first to enter or exit an encounter, implying that role modelling impacts the HH behaviour of learners. These findings should be used when designing HH improvement programmes targeting physicians.

Internal medicine milestones.

William Iobst, MD, is Vice President of Academic Affairs, American Board of Internal Medicine; Eve Aagaard, MD, is Associate Professor of Medicine, University of Colorado School of Medicine; Hasan Bazari, MD, is Program Director, Internal Medicine Residency Program, Massachusetts General Hospital, and Associate Professor of Medicine, Harvard Medical School; Timothy Brigham, MDiv, PhD, is Chief of Staff and Senior Vice President, Department of Education, Accreditation Council for Graduate Medical Education; Roger W. Bush, MD, is Attending Physician, Virginia Mason Medical Center; Kelly Caverzagie, MD, is Assistant Professor of Medicine and Associate Vice Chair for Quality and Physician Competence, Department of Internal Medicine, University of Nebraska Medical Center; Davoren Chick, MD, is Clinical Assistant Professor of Medicine, Department of Internal Medicine, University of Michigan Medical School; Michael Green, MD, is Professor of Medicine, Yale University School of Medicine; Kevin Hinchey, MD, is Associate Professor, Tufts University School of Medicine, and Chief Academic Officer, Baystate Medical Center; Eric Holmboe, MD, is Chief Medical Officer, American Board of Internal Medicine; Sarah Hood, MS, is Director of Academic Affairs, American Board of Internal Medicine; Gregory Kane, MD, is Professor of Medicine, Interim Chairman of the Department of Medicine, Jefferson Medical College; Lynne Kirk, MD, is Professor of Internal Medicine, University of Texas Southwestern Medical Center; Lauren Meade, MD, is Assistant Professor of Medicine, Tufts University School of Medicine, and Associate Program Director for Internal Medicine, Baystate Medical Center, and Chair of Educational Research Outcomes Collaborative–Internal Medicine; Cynthia Smith, MD, is Senior Medical Associate for Content Development, American College of Physicians, and Adjunct Associate Professor, Perelman School of Medicine; and Susan Swing, PhD, is Vice President, Outcome Assessment, Accreditation Council for Graduate Medical Education.

From theory to actual practice: Creation and application of milestones in an internal medicine residency program, 2004–2010

Background: In the USA, the Accreditation Council of Graduate Medical Education, Educational Innovations Project is a partner in reshaping residency training to meet increasingly complex systems of health care delivery. Aim: We describe the creation and implementation of milestones as a vehicle for translating educational theory into practice in preparing residents to provide safe, autonomous patient care. Method: Six program faculty leaders, all with advanced medical education training, met in an iterative process of developing, implementing, and modifying milestones until a final set were vetted. Results: We first formed the profile of a Master Internist. We then translated it into milestone language and implemented its integration across the program. Thirty-seven milestones were applied in all settings and rotations to reach explicit educational outcomes. We created three types of milestones: Progressive, build one on top of the other to mastery; additive, adding multiple behaviors together to culminate in mastery; and descriptive, using a proscribe set of complex, predetermined steps toward mastery. Conclusions: Using milestones, our program has enhanced an educational model into explicit, end of training goals. Milestone implementation has yielded positive results toward competency-based training and others may adapt our strategies in a similar effort.

Integrating quality improvement and residency education: insights from the AIAMC National Initiative about the roles of the designated institutional official and program director.

Active engagement of both the designated institutional official (DIO) and the program director (PD) is essential to implement any change in graduate medical education (GME). Strategies that are established by the Accreditation Council for Graduate Medical Education or other entities are, in the end, effective only as implemented at the individual program level. The interpretation of national standards or guidelines, and the specific adaptation to the vagaries of individual institutions and programs, can lead to significant variability in implementation and potentially in outcomes. Variability occurs between programs within the same institution and between some specialty programs at different institutions. The National Initiative, sponsored by the Alliance of Independent Academic Medical Centers, was launched in 2007 to demonstrate the effectiveness of GME as a key driver to improve quality, patient safety, and cost-effectiveness of care. This report addresses (1) the key roles of both the DIO and the PD in achieving the goals of the National Initiative, (2) the challenges these goals presented to each role, and (3) some of the tactics drawn from the experiences of the National Initiative in overcoming those challenges. The experience of the National Initiative underscored the synergies of the DIO and PD roles to improve patient care while simultaneously fulfilling their critical responsibilities as institutional and program leaders in GME with even greater effectiveness.

I can do patient care on my own: autonomy and the manager role.

Purpose An internal medicine (IM) residency program redesigned its second year, the Manager Year, to restore balance among autonomy, supervision, and clinical competence. This study examined the response of residents and some supervising attendings to this innovation. Method In this qualitative study—part of a total program evaluation—two authors gathered data from 36 second-year resident-managers, 3 third-year residents, and 8 attendings through semistructured interviews between spring 2005 and spring 2007. All resident-managers in 2005–2006 and all but one in 2006–2007 were interviewed. From verbatim transcripts, two of the authors coded the responses into themes; then all four reviewed and revised these themes. Results Coding revealed that second-year residents associated four qualities with their experience as managers: ownership of patients, accountability to others, competence in patient management skills, and personal satisfaction. They described the manager role as being as being “on your own.” They were accountable to fellow managers, attendings, and nursing staff at a different level from that of an intern. Without an intern to teach, they learned critical management skills to complete their work. They became adult learners around their own patient cases. Conclusions Successful preparation of physicians for independent practice requires a careful balance between autonomy and supervision, increasing the former during the training program sequence. For resident-managers, the assignment as principle caregiver occurs at the interface between the two. Managers identify themselves as a great deal more autonomous while still valuing attending supervision and input from co-managers to meet responsibilities.

AM last page: Applying Knowles' Andragogy to resident teaching

3. Knowles MS. Andragogy in Action: Applying Modern Principles of Adult Education. San Francisco, Calif: Jossey Bass; 1984. 2. Knowles MS, Holton EF, Swanson RA. The Adult Learner: The Definitive Classic in Adult Education and Human Resource Development. 6th ed. Boston, Mass: Elsevier; 2005. Adult Learning Theory Developing teaching skills in residents is a critical component of medical education because residents spend up to 20% of their time teaching junior learners.1 They often rely on the traditional pedagogical approaches that they observed during their years of formal schooling, but these often do not translate well with their adult learners.

Development of a checklist for documenting team and collaborative behaviors during multidisciplinary bedside rounds

OBJECTIVE: The objective of this study was to develop a reliable and valid checklist for documenting team and collaborative behaviors occurring during multidisciplinary bedside rounds. BACKGROUND: Teamwork and collaboration are important for providing high-quality patient care, yet there are no objective means of evaluating the occurrence of team and collaborative behaviors during bedside rounds. METHODS: A checklist was developed and tested on 3 general medical units. Items on the checklist were derived from the literature and our medical center’s patient-family–centered values. RESULTS: The final version of the checklist was determined to be reliable, valid, and easy to use in the clinical setting. CONCLUSION: Clinicians, administrators, and investigators are encouraged to use and/or modify this checklist for use in their setting. Further research identifying instruments to objectively measure teamwork and collaboration is needed.

Sources of Satisfaction: A Second Administration of the Program Director Satisfaction Survey

Q T D m m c t s j C c n the past decade, the short half-life of leaders in cademic medicine has been an important issue, but esidency program directors have been of particular nterest because of their roles in developing and mainaining a high-quality academic environment, ensuring ontinuous cycles of program and process improveent, and monitoring the development and well-being f physicians-in-training from the time of recruitment o graduation. Program directors have short job duraions and high burnout associated with administrative hassles,” long work hours, dissatisfaction with promoion opportunities, and concerns about resources. In 1996, 34% of internal medicine program directors eported some degree of “burnout,” defined as “the loss f enjoyment or enthusiasm for a job, so that an indiidual is no longer able to devote emotional energy to ts accomplishment.” Among this group of 262 proram directors, a 3-year cohort study demonstrated a 9% turnover and mean job duration of 2.4 years. urnover was highly associated with overall job satisaction. Program director characteristics that were inependently predictive of job turnover included low atisfaction with colleague relationships, high percentges of administrative work time, perceptions of the job