Residency Redesign in Internal Medicine

1
Residency Redesign in Internal Medicine

• American College of Physicians (ACP)
• Society of General Internal Medicine (SGIM)
• Association of Program Directors in Internal
  Medicine (APDIM)

2
Common Themes

• Interest in Internal Medicine, especially General
  Internal Medicine has declined, in part because
  training differs from practice.
• Increase ambulatory training.
• Quality of ambulatory clinics must improve.
• Consider block outpatient (and inpatient) time.
• Develop core curriculum, with reasonable
  expectations for achievement.

3
Common Themes (contd)

• High-quality training must be linked to
  high-quality, patient-centered care.
• Emphasis on EBM, quality improvement, patient
  safety, cultural sensitivity, health disparities,
  professionalism, life-long learning
• Close resident supervision with graded
  independence
• Better assessment of resident competency
• Residents must have experience and training in
  multidisciplinary team care.

4
Common Themes (contd)

• Maintain three-year residency with flexibility to
  innovate.
• ACP and APDIM propose two years core training,
  with third year tailored to individual career
  goals.
• SGIM suggests reconsideration of meaning of Board
  certification.
• Assign residents on the basis of educational
  needs, acknowledging risks.

5
Common Themes (contd)

• Faculty teaching should be monitored, assessed
  and rewarded.
• Faculty development essential
• Promotion and rewards for educators
• GME funding needs to be unlinked from
  hospital-based care.
• ACP and SGIM suggest revision of medical school
  curriculum.

6
American College of PhysiciansOverall Goals

• High quality, relevant experience with satisfied
  trainees
• Effective education to facilitate acquisition of
  necessary competencies
• Acquisition of the abilities needed to remain
  current and to understand and adapt to changing
  circumstances of healthcare

Weinberger SE, Smith LG, Collier, VU. Redesigning
training for Internal Medicine. Ann Intern Med.
2006144927-932
7
ACPConcerns

• Interest in general Internal Medicine careers
  down (54 to 27 from 1998 to 2003), possibly
  from
• Stress during residency
• Inadequate ambulatory experiences
• Unenthusiastic senior resident and faculty role
  models

Weinberger SE, Smith LG, Collier, VU. Redesigning
training for Internal Medicine. Ann Intern Med.
2006144927-932
8
ACP RecommendationsUndergraduate

1. Use premedical education to decompress 1st year
2. Flexible 3rd year with well-functioning practice
   environments
3. Enthusiastic role models
4. Late 3rd-4th year
5. Revisit pathophysiology, mechanisms of disease
6. Understand translation of knowledge into practice
7. Improve analytic, interpretive skills, preparing
   for life-long learning
8. At least one high-intensity clinical experience

Weinberger SE, Smith LG, Collier, VU. Redesigning
training for Internal Medicine. Ann Intern Med.
2006144927-932
9
ACP RecommendationsGME

• Structure of residency
• Retain 3 year duration
• 2 years of core training
• 1 year customized (future generalist hospital
  and/or ambulatory emphasis future subspecialist
  complementary experiences)
• Integrate education and service, limiting patient
  load per resident

Weinberger SE, Smith LG, Collier, VU. Redesigning
training for Internal Medicine. Ann Intern Med.
2006144927-932
10
ACP RecommendationsGME (contd)

• Enhance ambulatory training
• Increase ambulatory time
• Eliminate dysfunctional clinics
• Create block ambulatory time (no inpatient)
• Utilize team care (including ambulatory/inpatient
  teams)
• Develop core teachers with specific education
  competencies, reward them

Weinberger SE, Smith LG, Collier, VU. Redesigning
training for Internal Medicine. Ann Intern Med.
2006144927-932
11
ACP RecommendationsGME (contd)

• Stress professionalism
• Patient-centered, culturally sensitive,
  evidence-based care
• Patient partnerships
• Lifelong learning
• Self-evaluation, self-reflection
• Social activism on behalf of patients

Weinberger SE, Smith LG, Collier, VU. Redesigning
training for Internal Medicine. Ann Intern Med.
2006144927-932
12
Society of General Internal MedicineConcerns

• Ambulatory training seldom adequate
• Inadequate infrastructure for longitudinal care
• Case mix disproportionately complex
• Time insufficient to develop continuity skills
• Variable quantity, quality of block rotations
• Vacations taken during block
• Ambulatory residents are back up if emergency
  absence elsewhere

Holmboe ES, Bowen JL, Green M et al. Reforming
Internal Medicine Training J Gen Intern Med 2005
2011651172.
13
SGIMConcerns

• Changed inpatient setting
• Patients sicker, LOS shorter with residents time
  taken with non-clinical tasks
• Multidisciplinary teams have replaced
  physician-centric model
• Work hour rules promote fragmentation
• Error research implicates poor supervision,
  evaluation, teaching

Holmboe ES, Bowen JL, Green M et al. Reforming
Internal Medicine Training J Gen Intern Med 2005
2011651172.
14
SGIMConcerns

• Problematic curriculum
• No consensus as to core curriculum
• Little study of best educational
  setting/experience for acquisition of specific
  elements
• No definition of minimal competency to be
  achieved in each content area

Holmboe ES, Bowen JL, Green M et al. Reforming
Internal Medicine Training J Gen Intern Med 2005
2011651172.
15
SGIMConcerns

• Little specific instruction re health disparities
  and cultural competency
• Little specific instruction re life-long learning
• GME financing does not match training needs,
  educational settings

Holmboe ES, Bowen JL, Green M et al. Reforming
Internal Medicine Training J Gen Intern Med 2005
2011651172.
16
SGIMRecommendations

1. Patient-centered care taught by example of
   high-quality interdisciplinary care
2. Better inpatient-ambulatory balance
3. Explicit teaching re health disparities,
   including teaching in social sciences
4. Define core knowledge, skills, attitudes
5. Greater flexibility in certification and in
   pathways to specialization

Holmboe ES, Bowen JL, Green M et al. Reforming
Internal Medicine Training J Gen Intern Med 2005
2011651172.
17
SGIMRecommendations

1. Better resident evaluation, a moral and ethical
   responsibility
2. Redesign clinical work, educational processes
   around interdisciplinary teams
3. Better supervision by faculty
4. Link GME funding to training environments that
   lead to satisfactory patient outcomes

Holmboe ES, Bowen JL, Green M et al. Reforming
Internal Medicine Training J Gen Intern Med 2005
2011651172.
18
SGIMRecommendations

1. Specific preparation for life-long learning
2. Reforms in undergraduate and continuing medical
   education as well
3. Collaboration to foster education research and
   disseminate best practices

Holmboe ES, Bowen JL, Green M et al. Reforming
Internal Medicine Training J Gen Intern Med 2005
2011651172.
19
Association of Program Directors in Internal
MedicineConcerns

• Education not patient-centered, linked to patient
  safety
• Residents not exposed to career options
• Interest in IM, especially GIM, is down
• Core principles for redesign
• Link high-quality education and patient care
• Redesign must be comprehensive

Fitzgibbons JP, Bordley DR, Berkowitz LR et al.
Redesigning resident education in Internal
Medicine a position paper from the Association
of Program Directors in Internal Medicine Ann
Intern Med. 2006144920-926.
20
APDIMConcerns and Solutions

• Educational environment
• Too much inpatient emphasis
• Sick inpatients not followed as outpatients
• Outpatient clinics often chaotic
• Poor outpatient care drives all but the sickest
  away, distorting outpatient learning experience

Fitzgibbons JP, Bordley DR, Berkowitz LR et al.
Redesigning resident education in Internal
Medicine a position paper from the Association
of Program Directors in Internal Medicine Ann
Intern Med. 2006144920-926.
21
APDIMConcerns and Solutions

• Educational Environment Solutions
• Assign residents based on educational need
• Continually evaluate effectiveness of education
• Emphasize on EBM and team approach to quality and
  safety
• Use carefully graded supervision

Fitzgibbons JP, Bordley DR, Berkowitz LR et al.
Redesigning resident education in Internal
Medicine a position paper from the Association
of Program Directors in Internal Medicine Ann
Intern Med. 2006144920-926.
22
APDIMConcerns and Solutions

• Inappropriate inpatient rotations
• Insure diversity of diagnoses, time for
  reflection
• Provide team leadership experiences
• Use hospitalists
• Ineffective ambulatory experiences
• Provide continuity of care with team
• Explore use of community-based practices
• Provide ambulatory block rotations (no inpatient)
• Teach QI principles in ambulatory setting

23
APDIMConcerns and Solutions

• Restrictive Program Requirements
• Allow for innovation, e.g., IM-RRCs Educational
  Innovations Project
• Outdated curriculum
• Develop core curriculum

Fitzgibbons JP, Bordley DR, Berkowitz LR et al.
Redesigning resident education in Internal
Medicine a position paper from the Association
of Program Directors in Internal Medicine Ann
Intern Med. 2006144920-926.
24
APDIMConcerns and Solutions

• Outdated curriculum (contd)
• Maintain 3-year duration
• Year 1 Balanced experience in ambulatory,
  inpatient, general, subspecialty
• Year 2 Supervisory experiences and increased
  independence
• Year 3 Tailored to career goals. Focus on team
  leadership skills and provision of safe,
  efficient, cost-effective care

Fitzgibbons JP, Bordley DR, Berkowitz LR et al.
Redesigning resident education in Internal
Medicine a position paper from the Association
of Program Directors in Internal Medicine Ann
Intern Med. 2006144920-926.
25
APDIMConcerns and Solutions

• Faculty issues
• Monitor and assess faculty teaching
• Provide for faculty development
• Change promotion and reward system
• GME funding
• Transparent allocation to match to educational
  needs
• Evaluate competence of teaching hospitals

Fitzgibbons JP, Bordley DR, Berkowitz LR et al.
Redesigning resident education in Internal
Medicine a position paper from the Association
of Program Directors in Internal Medicine Ann
Intern Med. 2006144920-926.
26
APDIMRisks/Obstacles

• Student life-style, compensation issues
• Dysfunctional health care system
• Expense of competency-based advancement of
  residents
• Residents not vital to hospital operation may
  become observers and expendable.
• Ideal training environment may not prepare for
  later experiences.

Fitzgibbons JP, Bordley DR, Berkowitz LR et al.
Redesigning resident education in Internal
Medicine a position paper from the Association
of Program Directors in Internal Medicine Ann
Intern Med. 2006144920-926.
27
APDIMRecommendations

• Immediate
• Year 3 experience with multidisciplinary team
  leadership, instruction in systems-based
  practice, clinical quality improvement and
  patient safety
• Short term (1-2 years)
• Define core knowledge, skills, attitudes
• Individualize Year 3
• Institute faculty development programs
• Experiment with new approaches, e.g. EIP
• Long-term (3-5 years)
• Change faculty promotion and reward systems
• Change GME funding