Michael Picchioni

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.

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.

The clinic is my woodshed: a new paradigm for learning and refining communication skills

Jazz cats use the term ‘woodshedding’ to denote a period of intense practice during which they aim to take their playing up a few notches. Developing expertise, whether we are speaking musically or talking about communicating with patients, requires a lifelong commitment to such practice. For physicians, the woodshed is not a practice room or an isolated space. No: clinical environments are the woodsheds; they are the only places in which one can hone communication skills. The idea of ‘shedding’ in the setting of routine practice challenges prevailing notions about communication skills training and has implications for how such skills should be learned, nurtured and assessed. In this essay, we use stories of woodshedding from jazz music history to discuss concepts related to deliberative practice, formal education and learning communities.