DOIM Training Program: An Update 2008
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    DOIM Training Program: An Update 2008 DOIM Training Program: An Update 2008 Presentation Transcript

    • VCU Department of Internal Medicine Training Program An Update - 2008 Stephanie Ann Call, MD MSPH Training Program Director June 2008
    • Educational update
      • Education re-design project
      • Accreditation update
      • Update on 2007-08 initiatives
      • Program demographics update
      • Program evaluation by housestaff
      • Program evaluation by faculty
      • 2008-09 plans
    • Education re-design
      • New accreditation requirement changes
        • July 2009
        • Less restrictive
        • Allow flexibility and innovation
      • Current dissatisfaction and confidence in training structure
        • Are we training internists effectively in 2008?
    • Education re-design
      • One-year project
      • Working groups, focused on specific issues – summer 2008
        • “Outside the box” thinking
        • Focused on core values, concepts, goals
      • Integration of ideas into final curriculum and training structure – fall/winter 2008
      • Initiation of new curriculum July 2009
    • Academic year 07-08 Accreditation updates
      • Internal Review
        • Core program – fall 2007
        • Most specialties – fall 2007
        • In general, positive reviews
      • External Reviews
        • Cardiology programs – June 2008
        • Hematology/oncology – June 2008
      • New accreditations submission
        • Palliative care – June 2008
      • ACGME resident surveys
        • Winter 2007-08 – copy in handout
    • Update on new initiatives 2007-08
    • Initiatives – 2007-08
      • Pathways
        • All pgy2 residents entered pathway in July 2007 – generalist, specialist, hospitalist
        • Pathway curricula and advising initiated
        • Details of pathways available on ERIC
          • 1-2 months focused experience per pgy2/3 year
          • Focus area advisor, assures mentor established
          • Monthly pathway meetings
    • Initiatives 2007-08
      • Pathways
        • Generalists – Dr. Bennett Lee
          • Continuity experience in community – Port and Al Rogers – very positive feedback from practice and residents!
          • Pilot – Senior level faculty practice month
          • Monthly generalist educational seminars
        • Hospitalists – Dr. Alan Dow
          • Hospitalist experience
          • Performance improvement training
          • Monthly seminars
        • Specialists – Dr. Christian Barrett
          • Focus on mentoring, mentor lunches
          • Research months – very successful
          • Fellowship application advising
    • Initiatives 2007-08
      • New rotations
        • Palliative care
          • Curriculum developed
          • Two-week required rotation pgy 3
          • Evaluations
        • Peri-operative consultation
          • Curriculum developed
          • Incorporated into medicine consult rotation pgy2
          • Evaluations
        • CDU experience
          • Build into MAR experience
          • Mixed reviews
        • Geriatrics consultation service closed
    • Initiatives 2007-08
      • ACC clinic improvements
        • Restructure of leadership team
          • Multidisciplinary leadership team – led by Stephanie Call
          • Involves residents on team – clinic ops
        • Resident clinic task force
        • Major medical records improvements
          • Dr. Peter Boling and Zee Dabney
        • EMR
          • Electronic prescriptions, med lists
          • Moving to notes
        • Scheduling improvements
        • Patient flow improvement efforts underway
    • Initiatives 2007-08
      • Resident Performance Improvement Activity
        • Dr. Bennett Lee, Dr. Andrew Poklepovic, Shelley Burns
        • Focused in outpatient setting
        • Resident-performed review of over 600 charts from ACC clinic
        • Evaluation of data
        • Development of PIM project proposals
        • Formal presentations
        • Selection and implementation of project
        • Evaluation and report
    • Initiatives 2007-08
      • Standardized patient assessments
        • Dr. Bennett Lee
        • Core clinical skills focus
        • All categorical pgy1 residents – Nov 2007
        • Structured feedback
      • Simulation-based orientation
        • Dr. Alan Dow
        • Will be expanding in 2008-09
    • Initiatives 2007-08
      • Medical technology training
        • Medical technology Mondays
        • Stephanie Call, Maia Lavallee
          • In collaboration with library and SOM staff
        • All categorical pgy 1 residents
        • Curriculum
          • The well-formed clinical question
          • Effective literature searching – medline
          • Other databases and electronic resources
          • Powerpoint skills and presentation
        • Includes assignments and final presentation
        • Presented at national AAMC meeting spring, 2008
    • Initiatives 2007-08
      • Work hours – Dr. Jeff Kushinka
        • Improved tracking and reporting
          • Required on all inpatient rotations
          • Electronic reporting – New Innovations
        • Identification of problem areas
        • Focus improvement projects
          • MRICU - update
          • Inpatient wards
    • Initiatives 2007-08
      • Introduction to clinical research lecture series
        • Majority of faculty lecturers from DOIM
        • 10-part series, text by Hulley
        • Over 100 attendees summer 07
        • Request by school and GME to repeat this year
        • Thursdays, MSB, noon July-August
    • Initiatives 2007-08
      • Reflective writings
        • Initiated in pgy1 class of 07-08
        • Three writing assignments
          • Logged electronically into portfolio on New Innovations
          • Purpose – foster sense of self-reflection as component of professional development for physician
        • 90% completion by interns
    • US Medical School Graduates Percent of entering interns graduating from US medical schools Office of Educational Affairs
    • US Medical Schools Represented Office of Educational Affairs Number of medical schools
    • Mean USMLE Scores for Entering Interns Excludes preliminary interns Office of Educational Affairs
    • ABIM Certifying Examination Pass Rate Percent
    • Subspecialty ABIM Certifying Examination Pass Rate Percent
    • Housestaff scholarly activities
      • Details on ERIC website and program website, publication disseminated
      • > 110 publications, presentations 07-08
        • Includes national and international presentations
        • > 10 manuscripts
        • Several investigator awards, presentation awards
    • Housestaff End-of-Year Program Evaluation
    • Best things about residency program (housestaff survey)
      • People, comraderie – faculty, fellows, housestaff
      • Resident-centered
      • Pathology, patient population, clinical experience
      • Clinical training and preparation
      • Supportive environment, friendly
      • Strong commitment to teaching
      • Resident concerns are dealt with openly, effectively, open to change, responsive
    • Program Leadership Annual Housestaff Survey, Office of Educational Affairs
    • PD/CMRs – 2007-08 *Rated 1-5, 1-not at all effective 3-adequate 5-very effective 4.4 Serving as resident advocate 4.5 4.6 Visibility 4.4 4.5 Availability/accessibility 3.8 4.3 Responsiveness to resident concerns 4.0 4.5 Administrative role 4.1 4.6 Clinician/clinical role model 4.2 4.6 Teaching 4.1 4.6 Overall leadership CMRs PD
    • Conferences Annual Housestaff Survey, Office of Educational Affairs
    • Conferences 3.97 3.54 3.73 4.28 3.98 3.93 Mean 2007 3.78 3.40 3.60 4.03 3.91 3.74 Mean 2006 3.92 3.65 4.09 4.52 N/A 4.23 Mean 2008 More time to voice opinions and concerns, would like follow-up Housestaff meetings Dry topics, little applicability or usefulness GME Better with Aurora and Suri facilitating, still a bit argumentative EM/IM Like faculty panels, great topics for discussion, make me think M&M Physical diagnosis rounds Has become a great conference, would like more clinical expert faculty Journal club Key Comments Conference
    • Ward Medicine Annual Housestaff Survey, Office of Educational Affairs
    • Inpatient services Annual Housestaff Survey, Office of Educational Affairs 3.84 3.96 4.00 Heme/onc 3.65 3.80 3.69 VA wards 3.81 4.47 4.08 MCVH wards Balance – Education-Service (5-excellent) Quality of Clinical Experience (5-excellent) Quality of Education/Teaching (5-excellent)
    • Inpatient ward services – general themes
      • Positive
        • Excellent patient exposure, case diversity
        • Many comments on excellent teaching faculty, skilled clinical supervisors
          • A few attendings identified as not teaching or not effective in inpatient setting
        • VA – good learning environment, much improved, great patient population, great support from Frank Fulco
        • Great autonomy at the VA
        • Excellent teaching and great support staff on heme/onc
    • Inpatient ward services – general themes
      • Constructive/concerns (note significantly fewer!)
        • A few attendings identified as not teaching, otherwise no comments on this
        • Frustration with all systems – resident performance of “social work” duties
        • MCVH-specific comments
          • Load and acuity are detrimental to teaching efforts
        • Heme-onc-specific comments
          • Too many patients
          • Routine chemo, other non-teaching admissions – consider admit to non-teaching service
        • VA-specific comments
          • Too few patients
          • Dissatisfaction with nursing and ancillary services
    • Critical Care Annual Housestaff Survey, Office of Educational Affairs
    • ICU services Annual Housestaff Survey, Office of Educational Affairs 4.14 4.09 4.26 VA ICU/CCU 4.64 4.79 4.87 MCVH MRICU 3.73 3.91 3.77 MCVH CCU Balance – Education-Service (5-excellent) Quality of Clinical Experience (5-excellent) Quality of Education/Teaching (5-excellent)
    • Primary Care Clinic Annual Housestaff Survey, Office of Educational Affairs
    • Continuity clinic – general themes
      • MCVH ACC clinic
        • Efficiency and organization issues are major concern
        • Scheduling issues – pervasive complaint
        • Lack of support and teamwork from nursing
        • Paperwork and systems problems
        • Lack of time
        • Need for EMR
        • Lack of teaching
        • Lack of communication with consultants
        • Lack of social work support in clinic
      • VA primary care – all positive!
        • Well-run system
        • Excellent precepting
        • Great staff
    • Housestaff Rating of Rotations Scale: 1–5 (1 = poor, 5 = excellent) 4.0 3.3 3.3 3.5 3.8 4.7 3.8 3.9 3.6 4.3 2007 4.0 3.2 3.7 3.6 3.8 4.7 3.9 3.5 3.3 4.1 2006 2.9 2.7 3.7 3.4 4.0 4.8 3.5 3.7 3.5 4.5 2005 4.2 3.4 4.0 3.3 4.2 4.9 3.9 4.0 3.7 4.2 2008 3.6 3.5 3.6 3.6 4.2 4.8 3.3 4.0 3.9 4.4 2004 3.2 2.9 4.0 4.8 2.6 3.9 3.7 4.1 2003 3.3 3.5 3.4 VA PCC 3.1 3.7 3.5 MCVH PCC 3.5 3.8 3.9 VA ER 3.1 3.3 3.2 MCVH ER 3.9 4.0 3.9 VA ICU 4.8 4.9 4.9 MCVH MRICU 3.5 3.5 3.3 MCVH CICU 4.0 4.0 4.2 Hem/Onc ward 3.7 3.7 3.1 VA wards 4.2 4.3 4.2 MCVH wards 2002 2001 2000
    • Housestaff Rating of Rotations Scale: 1–5 (1 = poor, 5 = excellent) 4.1 4.2 3.6 4.2 3.7 3.2 3.1 2007 3.9 PGY2 ambulatory specialty block 4.1 4.1 3.5 3.6 3.1 3.3 2006 See next slide 4.6 4.1 3.8 3.4 N/A 2007 Consultative services Student health PGY3 urgent Intern ambulatory block MAR Geriatric consults
    • Consultative services
      • Evaluated individually 2007-08
        • Education/teaching
        • Quality of clinical experience
        • Balance education/service
        • Overall
      • Consistent numerical scores > 4.0
        • Exceptions - GI/hepatology, Peri-operative
      • Individual data to be posted to web and sent to Division Chairs
    • What do our clinical faculty do effectively?
      • Allow autonomy, yet still provide effective supervision
      • Provide excellent patient care
      • Respect time, round efficiently
      • Teach
      • Maintain morale
      • Maintain approachability and availability
      • Role model good physician-patient interactions
      • Lead
      • Support the housestaff
      • Express interest in, enthusiasm for, and respect for the residents
    • What would the housestaff like to see more from clinical faculty?
      • More evidence-based clinical decision-making and teaching
      • Less conflicting time demands on faculty while on teaching services – inpatient and outpatient
      • More teaching, more efficient teaching in clinic
      • Greater focus on teaching the fundamentals, physical examination
      • More feedback
      • More consistent structure to ward rounds
      • More support with consulting team interactions
      • More teaching on inpatient wards and consults - lighter days
      • Higher standards, expectations of students, interns, residents
      • More bedside teaching
    • Suggestions for change – training program
      • Increased focus on ambulatory training
      • Improve clinic
      • Move conferences to once/week
      • Increase opportunities for housestaff to express opinions
      • Re-work pull system so less abused
      • More training in leading a team
      • Reduce number of evaluations
      • Remove clinic from inpatient months
      • Remove Q3 call from VA ICU rotation
      • Preliminary medicine schedule improvements
    • DOIM Faculty Member Program Evaluation 2007-08
    • Faculty ratings – strongly agree (> 4)
      • VCU IM residents
        • Demonstrate commitment to excellence
        • Model professional behavior
        • Routinely incorporate EBM
        • See an appropriate volume and variety of patients
        • Do not frequently exceed work hour limitations
        • Are adequately supervised
        • Have adequate instruction and supervision in procedural skills
        • Are well-prepared for primary care practice
        • Are well-prepared for entry into fellowship training
    • Faculty ratings less than strongly agree ( average rating 3-4)
      • Residents have adequate opportunities for clinical research
      • Resident primary care clinics are appropriate and effective ambulatory care triaining sites
    • Faculty ratings of program Mean rating (5- strongly agree) Question 3.6 Most resident faculty have adequate time for resident teaching 4.3 Most resident faculty are effective clinical teachers 4.5 Most resident faculty have adequate knowledge and clinical skills 4.2 VAMC provides adequate resources 4.4 MCVH provides adequate resources 4.2 VCU DOIM provides adequate support for residency training
    • Faculty comments - themes
      • Strengths
        • Faculty
        • Patients, diversity of clinical experience
        • Tradition of excellence
        • Commitment to excellence in patient care
        • Commitment to education
        • Program leadership
        • Resident work ethic
        • Camaraderie among residents and faculty
        • Quality of recruits
        • Constant program improvements and initiatives
    • Faculty comments - themes
      • Improvements
        • Many clinic and ambulatory training improvement suggestions – thank you!
        • Less interruptions to consult services by pulling residents away
        • More emphasis on humanitarian aspects of medicine in curriculum
        • Consideration of alterative inpatient team structures due to work hours
        • More outpatient subspecialty exposure
        • More formal mentoring
        • Continued procedural training
        • Patient load too light
        • Less focus on throughput, more on quality of care
        • Consideration of all-hospitalist ward attendings
    • 2008-2009 Initiatives
    • 2008-09 Initiatives
      • Conference restructure
        • 2-3 hour lecture block, Tuesdays 3-6pm
        • Expect residents to round and be present until 3pm on clinical services
        • Video-conferenced to VA if unable to duplicate
        • Podcasts
        • Incorporation of more active learning styles
          • TBL, small group discussions, audience-response systems
        • No more noon conferences
          • Except intern conference Mondays, Grand Rounds, occasional Wed EM-IM
    • 2008-09 Initiatives
      • Work hours
        • MRICU restructure
          • Two-week intermittent blocks over two months
          • Additional staff to assist with 30-hour violations
          • Other changes as previously outlined
        • Consideration of removal of all overnight call on wards with 7-day night float system
    • 2008-09 Initiatives
      • Continuity of housestaff on services
        • Removal of bridge system for wards
        • Removal of extra clinics while on consult and elective services
          • Exceptions – Womens Health, Med Peds, Generalist residents who have two ½-day clinics per week
    • 2008-09 Initiatives
      • ACC clinic
        • New practice partner model
        • Electronic notes, fully electronic medical record
        • Continued systems improvement efforts
        • Re-structure of faculty staffing models and expectations
    • 2008-09 Initiatives
      • New rotations
        • Geriatric medicine ambulatory experience
        • Neurology ambulatory experience
        • Restructure of ACSB pgy2 experience
        • Restructure of ambulatory block pgy1
        • VA cardiology service
    • 2008-09 Initiatives
      • Introduction to clinical research lecture series to be repeated
      • Continued work on pathways
      • Continued work on PIM projects
      • Extension of simulation-based orientation
      • Increased simulation training for procedures
      • Standardized patient assessments
      • Chart-recall project – night float rotations