Timothy P. Brigham

The Next GME Accreditation System — Rationale and Benefits

The American Council of Graduate Medical Education is moving from accrediting residency programs every 5 years to a new system for the annual evaluation of trends in measures of performance.

Physician and patient factors associated with ordering a colon evaluation after a positive fecal occult blood test

AbstractOBJECTIVE: Successful colorectal cancer screening relies in part on physicians ordering a complete diagnostic evaluation of the colon (CDE) with colonoscopy or barium enema plus sigmoidoscopy after a positive screening fecal occult blood test (FOBT). DESIGN: We surveyed primary care physicians about colorectal cancer screening practices, beliefs, and intentions. At least 1 physician responded in 318 of 413 (77%) primary care practices that were affiliated with a managed care organization offering a mailed FOBT program for patients aged ≥50 years. Of these 318 practices, 212 (67%) had 602 FOBT+ patients from August through November 1998. We studied 184 (87%) of these 212 practices with 490 FOBT+ patients after excluding those judged ineligible for a CDE or without demographic data. Three months after notification of the FOBT+ result, physicians were asked on audit forms if they had ordered CDEs for study patients. Patient- and physician-predictors of ordering CDEs were identified using logistic regression. MEASUREMENTS AND MAIN RESULTS: A CDE was ordered for only 69.5% of 490 FOBT+ patients. After adjustment, women were less likely to have had CDE initiated than men (adjusted odds, 0.66; confidence interval, 0.44 to 0.97). Physician survey responses indicating intermediate or high intention to evaluate a FOBT+ patient with a CDE were associated with nearly 2-fold greater adjusted odds of actually initiating a CDE in this circumstance versus physicians with a low intention. CONCLUSIONS: Primary care physicians often fail to order CDE for FOBT+ patients. A CDE was less likely to be ordered for women and was influenced by physician’s beliefs about CDEs.

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...

Rethinking CME: an imperative for academic medicine and faculty development.

To help address the clinical care gap, a working group discussed the future of faculty development in academic medicine, explored problems within the large, current enterprise devoted to continuing medical education (CME), and described four domains core to its revitalization and reformation. These domains are (1) preparing and supporting an engaged clinician-learner, (2) improving the quality of knowledge or evidence shared, (3) enhancing the means by which to disseminate and implement that knowledge and evidence, and (4) reforming the patient, health care, and regulatory systems in and for which the process of CME exists. Reshaping these domains requires the consideration of a more seamless, evidence-based, and patient-oriented continuum of medical education. Revitalizing CME also requires the full engagement of the academic medical community and its faculty. To achieve the goal of creating a new, more effective, seamless process of CME, the working group recommended an active faculty development process to develop strong clinician-learners, strong involvement of academic health center leaders, the development of an educational home for clinician-learners, and a meaningful national conversation on the subject of CME.

The accreditation system after the "next accreditation system"

The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties and its member boards introduced the six domains of physician competency in 1999. This initiated a national dialogue concerning the elements of competency of the physician, and incorporation of these elements into the framework of evaluation of residents and fellows, as well as the educational programs within which they are trained. The next step in this process will be the ACGMEs Next Accreditation System, which the authors describe in this commentary. Recognizing that there are already developments in the assessment of medical education that will influence future models of accreditation, the authors consider some of these innovations and discuss how they may shape the next accreditation system after the Next Accreditation System.

Interventions to address challenges associated with the transition from residency training to independent surgical practice

BACKGROUND Concerns regarding preparation of residents for independent surgical practice are widespread and support for junior surgeons entering practice is variable across institutions and practices. The American College of Surgeons (ACS) Division of Education partnered with the Accreditation Council for Graduate Medical Education (ACGME) to convene a National Invitational Conference to define key issues relating to the transition to practice and develop recommendations to address various challenges. OUTCOMES OF THE NATIONAL INVITATIONAL CONFERENCE Leaders from ACS, ACGME, certifying boards, residency review committees, program director organizations, and professional societies representing the breadth of surgical specialties, along with other key stakeholders, were invited to participate in the 1.5-day conference in July 2012. Key recommendations generated during the conference included the need to focus on the transition to practice within the context of the continuum of professional development; definition of specific levels of knowledge and skills expected of graduating surgery residents; development and adoption of competency-based methods for training, assessment, and advancement of residents; implementation of special interventions during the chief resident year to prepare residents for practice; robust evaluations of residents before graduation; intake assessments of junior surgeons during the onboarding processes; and effective mentorship for junior surgeons as they enter practice. Recommendations also highlighted major regulatory, legal, and financial issues. The key role of ACS and other national organizations in implementing the recommendations was underscored. CONCLUSION The recommendations from the conference should be of great help in addressing various challenges associated with the transition from surgery residency to independent practice.

Initial Validity Analysis of the Emergency Medicine Milestones.

OBJECTIVES The Accreditation Council for Graduate Medical Education (ACGME) Milestones describe behavioral markers for the progressive acquisition of competencies during residency. As a key component of the Next Accreditation System, all residents are evaluated for the acquisition of specialty-specific Milestones. The objective was to determine the validity and reliability of the emergency medicine (EM) Milestones. METHODS The ACGME and the American Board of Emergency Medicine performed this single-event observational study. The data included the initial EM Milestones performance ratings of all categorical EM residents submitted to the ACGME from October 31, 2013, to January 6, 2014. Mean performance ratings were determined for all 23 subcompetencies for every year of residency training. The internal consistency (reliability) of the Milestones was determined using a standardized Cronbachs alpha coefficient. Exploratory factor analysis was conducted to determine how the subcompetencies were interrelated. RESULTS EM Milestone performance ratings were obtained on 100% of EM residents (n = 5,805) from 162 residency programs. The mean performance ratings of the aggregate and individual subcompetency scores showed discrimination between residency years, and the factor structure further supported the validity of the EM Milestones. The reliability was α = 0.96 within each year of training. CONCLUSIONS The EM Milestones demonstrated validity and reliability as an assessment instrument for competency acquisition. EM residents can be assured that this evaluation process has demonstrated validity and reliability; faculty can be confident that the Milestones are psychometrically sound; and stakeholders can know that the Milestones are a nationally standardized, objective measure of specialty-specific competency acquisition.

Use of critical incidents to develop a rating form for resident evaluation of faculty teaching

Context  Monitoring the teaching effectiveness of attending physicians is important to enhancing the quality of graduate medical education.

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.

Assessing emergency medicine resident communication skills using videotaped patient encounters: gaps in inter-rater reliability

We report on a process for assessing the communication skills of emergency medicine residents that includes 1) a faculty development initiative; 2) videotaping of actual resident-patient encounters in the emergency department; and 3) creation of an observation instrument for evaluating communication behaviors. We tested this observation instrument for inter-rater reliability, finding moderate-to-high agreement for only 11 of 32 items. These related to personal introductions, conflict management, nonverbal communication, and overall performance. There was poor or no agreement for behaviors related to establishing rapport, gathering information, and contracting or informing. Challenges of assessing interpersonal skills of emergency medicine residents are discussed.