Susan Guralnick

Domain of Competence: Systems-Based Practice

From the Office of Graduate Medical Education and Student Affairs, and Department of Pediatrics, Winthrop University Hospital, Mineola, NY (Dr Guralnick); Perelman School of Medicine, University of Pennsylvania, and Children’s Hospital of Philadelphia, Philadelphia, Pa (Dr Ludwig); and Association of American Medical Colleges, Washington, DC (Dr Englander) The views expressed in this report are those of the authors and do not necessarily represent those of the Accreditation Council for Graduate Medical Education, the American Board of Pediatrics, the Association of Pediatric Program Directors, or the Academic Pediatric Association. The authors declare that they have no conflict of interest. Publication of this article was supported by the American Board of Pediatrics Foundation and the Association of Pediatric Program Directors. Address correspondence to Susan Guralnick, MD, 222 Station Plaza N Suite 510, Mineola, NY 11501 (e-mail: sguralnick@winthrop.org).

The pediatrics milestones: a continuous quality improvement project is launched-now the hard work begins!

From the Association of American Medical Colleges, Washington, DC (Dr Englander); Department of Pediatrics, Dayton Children’s Medical Center and the Wright State University Boonshoft School of Medicine, Dayton, Ohio (Dr Burke); Winthrop University Hospital, Winthrop, NY (Dr Guralnick); Departments of Pediatrics and Internal Medicine, University of Minnesota Amplatz Children’s Hospital and the University of Minnesota School of Medicine, Minneapolis, MN (Dr Benson); Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Drs Hicks and Ludwig); Department of Pediatrics, Boston Children’s Hospital/Boston Medical Center and Boston University School of Medicine, Boston, Mass (Dr Schumacher); Dartmouth Institute for Health Policy and Clinical Practice Center for Leadership and Improvement, Hanover, NH (Ms Johnson); and American Board of Pediatrics, Chapel Hill, NC (Dr Carraccio) Address correspondence to Robert Englander, MD, MPH, Association of American Medical Colleges, 2450 N Street NW, Washington, DC 20037 (e-mail: renglander@aamc.org).

Resident work duty hour requirements: medical educators' perspectives.

From the Association of Pediatric Program Directors (Drs Burke, Rushton, Guralnick, Hicks); Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, Ohio (Dr Burke); Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Ind (Dr Rushton); Winthrop University Hospital, Mineola, NY (Dr Guralnick); and The Children’s Hospital of Philadelphia, Department of Pediatrics, the University of Pennsylvania School of Medicine, Philadelphia, Pa (Dr Hicks) Address correspondence to Ann E. Burke, MD, Dayton Children’s Medical Center, Medical Education Department, One Children’s Plaza, Dayton, Ohio 45419 (e-mail: Ann.burke@wright.edu).

Domain of Competence: Patient Care

From the Boston Combined Residency Program in Pediatrics, Pediatric Emergency Medicine, Boston Medical Center, Boston, Mass (Dr Schumacher); Association of American Medical Colleges, Washington, DC (Dr Englander); Department of Clinical Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (Dr Hicks); Competency-Based Assessment, American Board of Pediatrics, Chapel Hill, NC (Dr Carraccio); and Office of Graduate Medical Education and Student Affairs, and Department of Pediatrics, Winthrop University Hospital, Mineola, NY (Dr Guralnick) The views expressed in this report are those of the authors and do not necessarily represent those of the Accreditation Council for Graduate Medical Education, the American Board of Pediatrics, the Association of Pediatric Program Directors, or the Academic Pediatric Association. The authors declare that they have no conflict of interest. Publication of this article was supported by the American Board of Pediatrics Foundation and the Association of Pediatric Program Directors. Address correspondence to Daniel J. Schumacher, MD, MEd, One Boston Medical Center Place, Boston, MA 02118 (e-mail: daniel. schumacher@bmc.org).

The ACGME Self-Study-An Opportunity, Not a Burden.

In 2013, the Accreditation Council for Graduate Medical Education (ACGME) implemented the Next Accreditation System.1 A major goal of the new system is for program accreditation to become a continuous process of quality improvement. Accredited residency and fellowship programs report specified data annually to the ACGME. These data are then reviewed by the specialty review committees for compliance with each specialtys requirements. The newest component of this process is the self-study. The self-study is a new and evolving approach to residency and fellowship accreditation. Although a self-study has been used by many educational accreditors, it has not been used in graduate medical education. The ACGME now requires programs, as a part of their 10-year review cycle, to perform a self-study.2,3 Why is this a challenge for programs? This is a new process and tested models are lacking. The approach used by the Liaison Committee for Medical Education is time-consuming and not truly applicable to a graduate medical education program, as it is a much smaller unit of analysis compared to a medical school. To date, there are no templates or sample documents available, nor have any seminars or workshops been presented by representatives from programs that have done this successfully. Programs need to “start from scratch,” and this is not an easy task. Additionally, the more time programs spend on developing a new process, the less time they may have to actually perform the self-study. The purpose of this article is to provide an example of a successful self-study process, along with a sample timeline and self-study materials. This will hopefully guide other programs through the process, and decrease the time spent on developing a new self-study process. Ultimately, this should allow more time to be spent on the performance of a rich and informative self-study.

Competent for Unsupervised Practice: Use of Pediatric Residency Training Milestones to Assess Readiness.

Purpose To describe clinical skills progression during pediatric residency using the distribution of pediatric milestone assessments by subcompetency and year of training and to determine reasonable milestone expectations at time of graduation. Method Multi-institutional cohort study of the milestones reported to the Accreditation Council for Graduate Medical Education for all 21 pediatric subcompetencies. Most subcompetencies were measured using five milestone levels (1 = novice, 2 = advanced beginner, 3 = competent, 4 = proficient, 5 = master); 3 subcompetencies had only four levels defined. Results Milestone assessments for 2,030 pediatric residents in 47 programs during academic year 2013–2014 were obtained. There was significant variation in end-of-year milestone ratings for residents within each level of training, which decreased as training level increased. Most (78.9%; 434/550) graduating third-year pediatric residents received a milestone rating of ≥ 3 in all 21 subcompetencies; fewer (21.1%; 116/550) received a rating of ≥ 4 in all subcompetencies. Across all training levels, professionalism and interpersonal communication skills were rated highest; quality improvement was rated lowest. Conclusions Trainees entered residency with a wide range of skills. As they advanced, skill variability within a training level decreased. Most graduating pediatric residents were still advancing on the milestone continuum toward proficiency and mastery, and an expectation of milestone ratings ≥ 4 in all categories upon graduation is unrealistic; milestone ratings ≥ 3 upon graduation may be more realistic. Understanding current pediatric residents’ and graduates’ skills can help to identify key areas that should be specifically targeted during training.

The Association of Pediatric Program Directors' strategic plan: an opportunity for transformational change.

I n late February 2010, the leadership of the Association of Pediatric Program Directors (APPD) assembled key representatives of the pediatric undergraduate medical education and graduate medical education community to develop a new APPD strategic plan, a road map that could potentially transform pediatric medical education. This collaborative process included past and present leaders of APPD and current leaders of the Academic Pediatric Association (APA); the dialogue served to inform our understanding of history, where we are now, and consider what we might want to explore. It is unusual for strategic planning to take place in the presence of others outside an organization, but within the same field. However, the APPD board felt that the inclusion of all key stakeholders was critical to our deliberations and would allow us to learn and grow from the valuable contributions of many current and past leaders in pediatric medical education. In addition to the APPD leaders and representatives, others present for the 2-day proceedings were Gail McGuinness, APPD member and executive vice president of the American Board of Pediatrics (ABP); Janet Serwint, president elect of the APA and an associate program director; Ted Sectish, a past president of the APPD and director of the Federation of Pediatric Organizations; Jerry Woodhead, president elect of the Council on Medical Student Education in Pediatrics; Jim Bale, incoming chair of the Council of Pediatric Subspecialties; Carol Carraccio, director of the Initiative for Innovation in Pediatric Education (IIPE) and the Milestones Project; and Hilary Haftel, director of the Longitudinal Educational Assessment Research Network

View from the Association of Pediatric Program Directors (APPD)

S everal years ago the Association of Pediatric Program Directors (APPD) added an objective to its Strategic Plan. This new objective involved developing a relationship with a journal that would allow us to have a published voice in the academic community. Today, we are thrilled to publish our first page in Academic Pediatrics. This relationship affords the APPD the opportunity to communicate important issues in residency and fellowship education and training to the academic community at large. The Association of Pediatric Program Directors was formed twenty-four years ago, as program directors realized the incredible benefits of networking, sharing, and working together to advance the quality of residency training. The first year we had fewer than 150 members. Today our membership is now over 2000 strong, and includes program directors, associate program directors, Internal Medicine-Pediatrics program directors, program coordinators, department chairs, subspecialty fellowship directors and coordinators, other medical education specialists, and chief residents. At our 2006 strategic planning meeting we defined our current Mission, Vision and Values. They are as follows: Mission: The Association of Pediatric Program Directors is committed to excellence in pediatric graduate medical education to ensure the health and well-being of children. Vision: Exemplary Pediatric Education Values: Innovation Collaboration Communication Scholarship The key areas of focus for our strategic plan include: Lead, Collaborate and Advocate Foster Professional Development Promote Innovation and Best Practices in Educational Programming We have been working as an organization, and collaboratively with other organizations, to achieve these goals.

Identifying Gaps in the Performance of Pediatric Trainees Who Receive Marginal/Unsatisfactory Ratings.

Purpose To perform a derivation study to determine in which subcompetencies marginal/unsatisfactory pediatric residents had the greatest deficits compared with their satisfactorily performing peers and which subcompetencies best discriminated between marginal/unsatisfactory and satisfactorily performing residents. Method Multi-institutional cohort study of all 21 milestones (rated on four or five levels) reported to the Accreditation Council for Graduate Medical Education, and global marginal/unsatisfactory versus satisfactory performance reported to the American Board of Pediatrics. Data were gathered in 2013–2014. For each level of training (postgraduate year [PGY] 1, 2, and 3), mean differences between milestone levels of residents with marginal/unsatisfactory and satisfactory performance adjusted for clustering by program and C-statistics (area under receiver operating characteristic curve) were calculated. A Bonferroni-corrected significance threshold of .0007963 was used to account for multiple comparisons. Results Milestone and overall performance evaluations for 1,704 pediatric residents in 41 programs were obtained. For PGY1s, two subcompetencies had almost a one-point difference in milestone levels between marginal/unsatisfactory and satisfactory trainees and outstanding discrimination (≥ 0.90): organize/prioritize (0.93; C-statistic: 0.91) and transfer of care (0.97; C-statistic: 0.90). The largest difference between marginal/unsatisfactory and satisfactory PGY2s was trustworthiness (0.78). The largest differences between marginal/unsatisfactory and satisfactory PGY3s were ethical behavior (1.17), incorporating feedback (1.03), and professionalization (0.96). For PGY2s and PGY3s, no subcompetencies had outstanding discrimination. Conclusions Marginal/unsatisfactory pediatric residents had different subcompetency gaps at different training levels. While PGY1s may have global deficits, senior residents may have different performance deficiencies requiring individualized counseling and targeted performance improvement plans.

Economic Tough Times: Solutions Found in the Medical Education Continuum

This is a challenging time for all. The country’s economic status is dire, and no one remains untouched. Health care education dollars were already tight. With hospitals and medical schools dealing with massive economic losses, funds for education are disappearing rapidly. Now, more than ever, medical educators need to look at how we spend these funds. Roberts and DeWitt, 1 at a recent workshop, suggested that we can increase the size of the medical education ‘‘pie’’ by pooling resources and capitalizing on the synergy that comes from sharing human resources. In many centers of medical education, medical students, residents, fellows, and practicing physicians are trained in parallel and often competitive environments. One domain’s victory results in fewer resources for the others. However, there are economic advantages and efficiencies in the sharing of resources across the continuum of medical education. Sharing faculty, faculty development programs, space, educational modules, learning technology, simulation centers, standardized patient curricula, evaluation tools, and more will enable medical schools, residency programs, fellowship programs, and continuing medical education to survive and even thrive. Best practices can be shared. Valid and generalizable assessment methods can be developed. Ultimately we can enhance the preparation of physicians to meet our true goal—high-quality health care for all. It is clear that education is a longitudinal process, with learners achieving advancing levels along a continuum well described by the model of skills acquisition of Dreyfus and Dreyfus. 2 Many organizations, in the United States and internationally, have begun to focus on medical education as a continuum. In 1994, Robert G. Petersdorf wrote in the Journal of the Royal Society of Medicine: