The ACGME's Updated Accreditation System for GME

So the ACGME today just announced a major restructuring to the process of how residency and fellowship training programs are reviewed.    It is called the NAS (Next Accreditation System).  Take home points  from the article, published today online in the New England Journal of Medicine:

1.      Measurement and reporting of outcomes occur through the milestones  (this “grounds the competencies and makes them meaningful”)

2.      Programs submit milestone data on residents every 6 months.

3.      Sponsoring institutions will be responsible for the quality and safety of the environment for learning and patient care.

4.      Programs can be formally reviewed with a “site visit” every 10 years (this is VERY similar to the ACCME, which accredits CME programs, with the “self-study” process).

5.      The accreditation system focuses less on problem identification and more on success of programs in addressing them (this is quality improvement in its purest form, in my opinion).

My personal opinion: I am VERY glad that the ACGME mentioned self-regulation in the article.  If the medical education profession did not regulate itself, then others who likely have no business evaluating medical education would be regulating it.  Kudos to the ACGME, for listening to program directors that the administrative “burden” was overshadowing the education of trainees, which I feel is the reason most program directors chose to do what they do.

I believe that it is wonderful that the ACGME took on this ambitious NAS endeavor.  I look forward to what the next steps will be.  What are your thoughts?

What Is Med-Peds?

Most people understand the specialty of pediatrics: the care of children.  The advocacy group for pediatricians is the AAP, or the American Academy of Pediatrics.  Fewer understand the specialty of internal medicine (“medicine” for short), which is the care of adults.  The specialty society for this group is called the ACP, or American College of Physicians.

I am both of these.  I am both a pediatrician AND an internal medicine doctor (called an “internist”).  The name of the “specialty” given to what I do is called “Med-Peds”.

Med-Peds training is relatively unique, in that it incorporates half of its time (2 years) in internal medicine and the other half (2 years) in pediatrics.  After this training, doctors are eligible to go into practice in internal medicine, OR in pediatrics, OR in both (this last is ideal).  They can also choose more subspecialty training in internal medicine, OR in pediatrics, OR in both.  This flexibility in career options is quite attractive to those who choose our field.

Med-Peds is considered a primary care field.  Obviously, family medicine is a primary care field, as is pediatrics and internal medicine.  But in all of these options, trainees can choose further training.  This article (focus on Table 1) highlights the percentages of each which go into primary care.  Many forget that Med-Peds is a great option for those interested in primary care.  Others consider Med-Peds a great choice for those in medical school who can’t decide what they want to do.  Whether one chooses Med-Peds for any of these options is not critical: they chose it for their own reason, and that is what matters most.

What I have the privilege of doing within Med-Peds is being an educator.  At Indiana University School of Medicine, I oversee a Med-Peds residency program (the largest one in the country), and love the opportunity to train future physicians, no matter what their interests.  Niches within Med-Peds include transitional care (caring for patients as they transition from being a child to being an adult) and global health.  However, it is important to realize that Med-Peds alone as a specialty cannot be solely responsible for transitioning every child with a chronic condition to adulthood, and that other physicians need to be comfortable in thinking about this transition.  One of my Indiana University colleagues and mentors, Dr. Mary Ciccarelli, was involved in writing a document about transitional care, which was recently published, and has been passionate about furthering the concept of transitional care.

Explaining Med-Peds to physicians not familiar with it is difficult enough explaining it to patients is even harder (hence the reason for this post).  Med-Peds is not necessarily an “alternative” to family medicine (for the record, I do not “bash” family medicine as a specialty); the training is very different, yet many in both end up practicing similarly, in a primary care arena.

If you are a medical student, I encourage you to think about Med-Peds as a specialty.  If you are a patient, I encourage you to consider a Med-Peds doctor as your primary care physician.  Here are some quick facts about Med-Peds:

The training is four years total: two in pediatrics and two in internal medicine.

The training allows opportunity to pursue further training in either pediatrics, or internal medicine, or both.

A wonderful organization which promotes Med-Peds is called NMPRA (National Med-Peds Residents’ Association).  This website provides the best explanation of Med-Peds that I have seen.

A wonderful organization which promotes the education of Med-Peds trainees is called MPPDA (Medicine-Pediatrics Program Directors’ Association).  I was honored to serve as the president of this organization from 2010-2011.

Med-Peds is the only “combined” residency which is accredited by the Accreditation Council for Graduate Medical Education (ACGME).

There are currently 77 residency programs in Med-Peds accepting residents in the National Residency Match Program (the “Match”).  We would like to see Med-Peds grow as a field and have more accredited programs.

A blogger who has the same Med-Peds training as myself (and completed his training just as I was beginning mine at Indiana) is Dr. Rob Lamberts.  Here is his current website.

The Med-Peds Section of the American Academy of Pediatrics is the second largest section in the entire Academy.

I would love to hear your comments about the field of Med-Peds.  It is a wonderful specialty, and I am honored to call myself a Med-Peds doctor!

Social Media in Academic Medicine

The inspiration for this post came from a Twitter chat on the theme of Social Media in Academic Medicine on the “meded” chat, on Thursday 2-16-2012

Social media is definitely integrated into today’s culture. So many young people are using social media. In addition, a quicly growing demographic in social media is actually those in their 40s-50s. Despite this impressive growth, social media has not, in my opinion, made its way into mainstream academic medicine yet. Certainly papers have been written on the topic of social media in medical schools, but much of the focus has been on professionalism around using social media, and less on what positives social media can bring to medicine.

With regards to social media in academia, however, the growth is slow. Promotion of faculty in academia on the strength of a portfolio focusing on social media is currently probably not that common. But should it become more common in the future? Will physicians who choose to be engaged in social media for purposes of promoting medical education or medicine consider this as their main “scholarship”? And what about the physician who chooses to blog on medical topics (which can provide quality information on the internet to counteract some questionable medical material that currently exists)? Is that something to put on a dossier? Surely it can attract an audience, and can provide useful information to patients and those interested in health.

Finally, as we talk about the hidden curriculum in medicine often, how should the academic physician who is “laughed at” or “taunted” for tweeting or blogging react when she hears: “You are wasting your time with that social media stuff.” (you can probably ascertain that indeed I have heard this quote more than once)

I have my opinions, and would love to hear yours. I will leave you with a few articles on Social Media in the academic arena.

Professors like social media more than other educational technology

How higher education uses social media

Social Media Footprint for Academics

A doctor's reputation vs a hospital's responsibility: Social Media

Quality Improvement in Medicine and Medical Education

There are fads in medicine (e.g., “Vitamin E can prevent heart disease”, which we now know to NOT be the case), and then there are things that here to stay. The movement of quality improvement (QI) is definitely in the latter category. The importance of quality improvement in medicine cannot be overemphasized, yet there are some who question the utility of QI. There are others who have bought into why quality improvement is critical towards improving patient care. A new arena within medicine of “implementation science”, where putting guidelines into actual practice constitutes success, is emerging. This has even transcended maintenance of certification. Part 4 of the process involves doing a specific quality improvement project aimed at improving one’s performance with regards to patient care. All of the medical specialties in the ABMS have such a requirement. Quality improvement is also embedded into the CME world as well, with Performance Improvement CME, or PI-CME, coming of age as an important aspect of what physicians do. So how does a clinician go about doing quality improvement? My suggestion is to think about something that doesn’t go as smoothly as one would like (in the CME world, this is known as a “practice gap”, which drives why it is important for physicians to continually be educated). Whether it be ordering necessary tests in diabetic patients (e.g., urine for microalbumin, LDL cholesterol levels) or improving throughput in the office, quality improvement principles can guide an approach toward improving “something” (whatever the something may be). Within medical education, quality improvement curricula are now no longer innovative: they are REQUIRED. Residency programs are required to teach quality improvement to trainees, although the ideal way to teach it is not known. The literature in this arena is clearly growing, however, which is exciting, and it is common now at academic medical centers for residents to provide excellent ideas for improvement projects. So why is there push back to looking at improving how one practices? In other words, what can the organizations which lead the QI movement do to achieve front-line clinician buy-in to the importance of the science of improvement? After all, the ultimate outcome is improved patient care outcomes, and who would not support that?

Teaching on Disclosure of Medical Errors

I’ve been a teaching physician for a bit over 10 years now.  One of the great things about teaching learners about medicine is that in doing so, I myself learn something every day.  There are so many things to learn in medicine.  Sure, a lot is “medical content”, but there are so many other things.  How to “connect” with a patient, how to interact with other health care professionals, how to improve adherence: all of these are some of the “softer” sides of medicine—but just as important as the newest drug for managing a particular disease.

Since 2003, I have been privileged to teach quality improvement principles to residents.  While what we were doing was “innovative” in 2003, now it is no longer innovative: it is REQUIRED.  Teaching what I call "the science of improvement" is very exciting to me, and demonstrates how advances in medicine move forward. 

One area within quality improvement that is particularly exciting to teach about is Disclosure of Medical Errors.  What this means is that we realize that errors occur, and rather than hiding them, we (the medical community) should tell patients about these errors.  Literature is now actually supporting the fact that when errors are disclosed, patients/families are LESS likely to be sue physicians, not more likely.

While this is fascinating information to me, the real impetus should not be about getting sued versus avoiding a lawsuit: it should be about doing the right thing for patients.  It has been fascinating to read the literature on this topic, and how it has “pushed the envelope” towards doing the right thing for patients which ultimately improve patient care.  Authors such as Tom Gallagher and Wendy Levinson (from the University of Washington, and the University of Toronto, respectively) have written on this topic for years, and have really advanced the field.

While reading some posts on Twitter today, Mike Moore, a medical student in the Seattle area posted a link to this outstanding TED talk on Disclosing Errors by Dr. Brian Goldman.  Wow.  This is absolutely worth watching, and should be required for medical students and residents (as well as teaching and practicing physicians).

So how should medical schools teach about Disclosure of Medical Errors?  If it isn't happening, it is time to do so.  If it has been integrated, kudos are in order: it is an important tenet of quality improvement to make the care that we provide for patients better—and isn’t that why we are all here anyway?

Social Media and Stages of Change

I am a physician educator, and have been for over 10 years.  I have been involved in teaching residents (GME, or Graduate Medical Education) for 10 years now, and have recently added to that the opportunity to work and learn in the CME (Continuing Medical Education) world.  Both of these areas carefully study ways to best teach medicine and medical concepts to learners.

One concept important for any physician to learn is something called “Stages of Change”.  One key tenet of this model is that people progress through different stages in the journey to change.  Sometimes, it takes a long time to complete this progression. 

The first stage is Precontemplation, in which one has not yet fully acknowledged that a change for a problem behavior is necessary.  In Contemplation, the second stage, acknowledgement has occurred, but the person is not yet ready for the behavior change.  In the next stage, Preparation, the person is ready for the change.  The next stage, Action, involves changing the behavior.  The Maintenance stage is one in which the behavior remains changed.  Sometimes another stage is Relapse, in which the person reverts back to the undesired behavior.

Two classic examples used to teach this in medical school are quitting smoking, or starting an exercise regimen.  However, one can apply the principles of the Stages of Change Model to other areas. 

Obviously, one very hot topic nowadays is physician involvement in social media.  Many physicians are jumping on the bandwagon.  Others, however, are “holding out” for various reasons (many of which include some reference to lack of time).  Personally, I was actually in this second category until May, 2011. 

In May of 2011, my wife mentioned that I should join Twitter.  That turned out to be the beginning of a new era in how I do what I do.  I joined one weekend, and have never looked back.  Now, I have actually been a heavy user of Twitter during medical conference meetings (apparently, I was the highest volume tweeter at the AAMC meeting in November, 2011, and also came back from the ACEHP meeting this past weekend as a high volume tweeter as well.  I’ve joined a few others (LinkedIn, Google+, Doximity, and others), and have learned so much in the process.

One of my plans is to become involved in the scholarly work around the use of social media by physicians, to ultimately help patients.  I had a great opportunity to meet with others at the ACEHP meeting in Orlando about this topic, and think that it will definitely be lots of fun to study this area.

So what does that mean for me?  I went from the Precontemplative stage to the Action stage relatively quickly, regarding my own personal use of social media.  I use it to learn, to teach, and to advocate (Reference 1).  I personally feel it has made me more efficient, not less.  Plus, it has been a lot of fun, and I have met (virtually, and a few in real life) many new people I would otherwise not have had the opportunity to meet.

So where do you fit in to the Stages of Change Model with regards to using Social Media?  Are you still dead set on not joining Social Media (Precontemplative)?  Have you considered joining social media (Contemplative)?  Are you planning on taking the plunge (Preparation)?  Have you joined (Action), but then gave it up (Relapse)? 

Reference 1.  McGowan B. Technology and Medical Education.  Presented at ACEHP PreConference Workshop on January 21, 2012.  Found at: http://www.slideshare.net/cmeadvocate/acehp12-preconference-emerging-technology-and-medical-education 

Reference 2. Sherman L. Sitting next to me during Reference 1, saying “Do you realize that you bypassed some stages of change?” on January 21, 2012.

Social media policies within medical schools

I have been in multiple discussions in various venues about social media in medical schools recently.  It appears to me as if every conversation ends up focusing on professionalism (or more specifically, unprofessionalism and what students should NOT do).  The conversation then turns to “a policy is necessary so that trainees/students understand what  isn’t ok”.  About a month ago, I wrote this blog here, which touched on this topic. 

While I agree that a policy or a guideline (the IU School of Medicine calls it a guideline) is important, and professionalism should of course be mentioned, I always tend to notice almost no discussion of what good can come from social media in medical education.

Is it that people are scared?  Is it that people are worried about doing something that will come back and haunt them?  Can medical schools be sued over comments made by students or faculty in social media circles?

I am particularly proud of the IU School of Medicine’s social media guideline here (shout-out to my colleague Gabe Bosslet for his direction and leadership in crafting this document). 

My personal opinion is that of course people need to be smart and not post patient information, or anything that might link with a direct patient, in a social media context.  But we sure are missing what great potential is out there.  What about disseminating helpful health information to patients?  What about the opportunity to dispel rumors, false information, and “snake oil cures”?  What about the potential for maintaining quality public health information (on vaccines, for example) for all to see or read?

Below are some interesting posts on the topic of Social Media policies, specifically with regard to health care.  Please let me know your thoughts on this subject, and how we can leverage the good from social media with the concern over unprofessional online behavior.

Social media policy gone wrong

Medical school social media policies

A publication on Social Media policies in US medical schools

Social Media guides

Western Australia Social Media policy