What’s NEXT in Residency Training: Fighting off the Tick Box Zombies

11 06 2012

This weekend, an interesting article on the curent state of UK residency training crossed my Twitter feed.   Due to restricted residency duty hours in the UK (yes they have a 48 hour work week for residents aka junior doctors), they fear they are graduating “incompetent doctors who are putting patients at risk.”

This debate is not just isolated to the other side of the Pond.  In fact, a recent reports in the New England Journal of Medicine documented that nearly half of residents are OPPOSED to restricted resident duty hours, with another paper in Academic Medicine showing that many internal medicine residents were concerned about limited educational opportunities with duty hours.  Finally, in a recent study that we did with the Association of Program Directors of Internal Medicine and the Association of Program Directors of Surgery published in Academic Medicine, program directors feared specific consequences of duty hours related to faculty morale, patient continuity and resident education.

While I could go on, the reason I started to write this post was NOT to rehash the duty hours debate!  Instead, I wanted to highlight a very specific concern that is mentioned in this UK story.  One of the chief complaints in the UK medical training system is that junior doctors were being passed on the basis of dreaded ‘tick-box forms’.  (You gotta love the Brits for colorful names to what we simply call evaluations).

So now at this point, I feel like I am watching 28 Days Later, where all of London was quarantined and zombies took over.   Will the Tick Box zombies come to the United States and take over our GME system?  Have they already?  I hope not…but let’s face it.  Everyone is wondering what comes NEXT with milestones and GME.

The “Next Accreditation System” or NAS (not to be confused with the rap artist) is about documenting the achievement of specific milestones related to specific “entrustable professional activity” or EPA.  An EPA is “simply the routine professional-life activities of physicians based on their specialty and subspecialty.”  For example, for internal medicine, one of the end of year EPAs is “Manage the care of patients on general internal medicine inpatient ward.”  In this way, EPAs are more granular than the 6 “core competencies” and should in theory be easier to observe and evaluate.  Lastly, for each EPA, there will be a “narrative” that programs can select to describe how competent the resident is in that area.

While program directors and others involved in GME are all learning the new “compet-english” that has been developed, many are also concerned about the burden of evaluation in a system that is already overburdened.  In other words, will the Tick Box zombies attack us stateside?   Well, some of this is up to how the residency educator community responds to the charge.  To prevent tick box zombie attack, program directors must resist the urge to create hundreds of milestone evaluations and add them to existing evaluations.   The key is not to reinvent the wheel but to modify existing evaluations to link them to milestones and EPAs. In some cases, old evaluations that were not helpful should be re-evaluated to see if they are necessary.  Moreover, to prevent tick box zombies from striking, it’s important to design and implement ‘good’ measures of resident performance.  A good measure would adhere to some of the same properties of optimal National Quality Forum quality measures: reliable, valid, linked to meaningful outcomes, feasible to collect, and distinguish between good and bad performance.  When good measures of residency performance do not always exist, there is an opportunity to work together to figure out what they are.   While this is definitely a work in progress, one nice thing is that no one is alone.  In Chicago, a citywide meeting of residency leaders of over 10 programs was held to share how best to do this and learn from each other.   After all, to truly make our NEXT step in GME, we must all work together to prevent the tick box zombie attack.

Vineet Arora MD  

Special hat tip to @keitharmitage for inspiring this post with his tweet : )


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Categories : residency training

The 5 F’s for Futuredocs and New Interns

26 06 2011

 

Yesterday, a tweet caught my attention from @JasonYoungMD who stated “My Five Foundations of Felling Fine: Food, Fitness, Friends & Family, Falling Asleep, Fulfillment.”  This seemed like the best advice I had heard for the newbie interns taking teaching hospitals by storm as well as the rising third year medical students who are about to be unleashed on the wards (if they haven’t already).  It also is a great starting point for program directors who are wondering how to ensure that their residents are “Fit for duty” according to the new ACGME rules.

 

  1. Food – While this is basic part of sustenance, finding food sometimes in the hospital can be challenging, especially at odd hours.  Fortunately, this has gotten better, but the choices may not be healthier.  In my own hospital, I’ve seen the front lobby transform from a small coffee kiosk (Java Coast which was celebrated when it arrived) to a full fledged Au Bon Pain (ABP as we affectionately refer to it).  While ABP was a welcome addition, it is easy to consume a lot of empty calories eating muffins or breakfast sandwiches!  To make matters worse, research from one of our very own sleep research gurus has shown that the more sleep deprived you are, the worse food choices you make!  Therefore, the thing you will reach for after a night shift is going to be the carbohydrate loaded Danish.  Residency programs must know this and usually have morning reports full of this type of food. So, consider how you will make healthy food choices – whether that be bringing your own food, or finding out where the healthy options are.  Lastly, don’t forget about the empty calories that come with beverages, especially coffee-related drinks.  For you Starbucks fans, there is an app for that – and I guarantee you may change your choices.
  2. Fitness – Like food, fitness can be hard to come by.  Interestingly, working in the hospital can actually be a way to get exercise.  For example, some studies demonstrate that residents walk as much as 6 miles on call!   However, its also just as easy to sit behind a computer and take a “mission control” approach to your call night where you are monitoring all your iPatients.  So, think about this and consider wearing a pedometer and most importantly getting into a routine.  When time is of the essence, find a way to work fitness into your day like taking the stairs in lieu of the elevator, or parking farther away.  If you join a gym, you have to make sure you go…and one easy way of doing this is to make sure your gym is on your way home from work and that is your first stop.  During residency, I actually switched to a gym that was directly on my route home that had a parking lot so I literally had no excuse and actually felt guilty while I drove by and did not stop there.  Others opted for 24hour gym craze that that could work for anyone’s schedule.  Lastly, exercising with a friend will likely lead to greater results than the solo work out.
  3. Friends & Family – Speaking of friends and family, this is the support system that gets interns through residency.  Fortunately, another omnipresent F can be helpful here – Facebook.   Busy interns or students can at least get reminders to electronically wish your friends happy birthday or log in on that random Monday off to reconnect with friends.   It’s also important to set appropriate expectations with your friends and family, for example when you are starting on a time intensive rotation that can be demanding.   Because of the intense nature of working in the hospital, some of you will form fast friendships with your co-interns and residents which can be helpful to get you through.  However, even your closest friends (including those at work) will ask you to choose between them and sleep- which can be very tough when you are running low on sleep.
  4. Falling asleep –So, speaking of sleep, my first question was where do I sleep?   Sounds silly I know, but I actually did not know where the call rooms were or did not have the call room key for my first call night ( I actually can’t remember which) so I ended up going to sleep for an hour in an unoccupied hospital bed.  So, this may not be possible today for 2 reasons: (1) interns are not likely sleeping when working the jam packed 16h shifts; and (2) hospital beds are nearly always filled! Still the challenge for today’s interns is getting sleep when working odd hours, especially if starting night shifts on night float or ‘night medicine’ as programs are evolving to include more night rotations.  If this means you have to invest in window treatments or wear an eyeshade at night, just do it.  There is nothing better than sleep for a resident and the more the better.  While your sleep at home may be limited regardless due to your other family obligations, its important to know your limits and set aside nights where you will recover.
  5. Fulfillment – Last but not least, its important to figure out how to keep yourself happy and fulfilled during your residency.  In some cases, that is a particular hobby or loved one that you need to stay in touch with.  In other cases, fulfillment is more complex.  It is not uncommon to have doubts about your future career as you stand by the fax waiting for outside hospital records, wait on the phone to schedule a follow up appointment for a discharged patient, or even transport a sick patient to get a needed test.  While many are working on ways to reduce the burden of this largely administrative work, interns and medical students are still straddled with a large amount of scut which can be demoralizing.  So, where do you find the fulfillment in your work? Well, you will find it when you least expect it – in the words of a patient who is eternally grateful.  In other cases, you will meet a mentor or role model who shares your passion and interest in medicine, whatever that may be, and can inspire you to keep you going. Whatever it is, find it and hang on to it for dear life during your darkest hours and it will pull you through.

I do need to add one more F to this fine list –  So provided that you are keeping up with the first 5 F’s, the best thing is that being in the hospital, learning medicine, and caring for patients is actually FUN!  So, don’t forget to pause and enjoy it…these tips will also serve you will in the FUTURE!

–Vineet Arora, MD

Other helpful posts to conquer any FEARS of starting on the wards:

What NOT to Wear on the Wards

How to Present to Your Attending


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Useless Charts & Fresh Eyes in Handoffs

28 03 2011

Last month, I was a speaker for AMSA on their patient safety webinar. This was the brainchild of Aliye Runyan, a fourth year medical student at University of Miami and her colleagues, to expand the patient safety taught to medical students.  They are not alone.  The IHI Open School also virally spreads patient safety training where traditional med schools failed.

My topic was handoffs – and they asked me to talk about it.  I wondered what could I tell mostly preclinical medical students, some of whom may not have even entered the clinical arena about handoffs.  Would what I say be over their head and irrelevant if they had no clinical context?  I was also hoping there were some fourth years on the call who could offer their experience doing handoffs as subinterns.

But, I forgot the importance of fresh eyes, a concept that is sometimes used to describe the one positive aspect of a handoff, that sometimes the best insights come from someone who is not well acquainted with the case.  I had a lot of fresh eyes (and mostly ears) on the call.  In the vibrant Q&A that followed (and continued via email), one of the things the medical students brought up asked me about something I said is sometimes bad in the signouts- TMI? or Too much information.  This often happens when the signout is used to help the primary team track the patient and it loses its function for the receiver.  In hospitals with electronic health records, TMI is often a symptom of “CoPaGA” syndrome, or Copy and Paste Gone Amock.

But, this led to the most interesting debate of the night- why has the medical chart become so useless that people feel they need to use the signout this way?  I was asked to think about this question again later in a meeting with our Epic staff who are working to create an automatic signout system for our residents – they really wanted to know why we needed a separate system.  Since our residents have iPads, why couldn’t they just look at the record?

I had to think about that one.  I said that the chart is a document that is an archive that is most helpful for those people that know the patient.  It is also one large medical bill.  And yes, Dr. Verghese makes excellent points about the iPatient, but the truth of the matter is that the medical record is not all that helpful when you don’t know a patient and you have to make a quick on-the-spot decision.  So, this is why we can’t ask busy residents to pause to look in the electronic health record to answer the clinical question of the moment when they don’t know the patient.  The information there is overwhelming.  Our chief resident had a better answer.  The night resident needs the Cliff notes to answer the question since they weren’t assigned (and don’t have time at that moment) to read the full text.

Of course, handoffs are more than just the written information.   A handoff also has to include a verbal interactive component.  As the implementation of shorter duty hours is looming, so too is a requirement that all residency programs make sure their residents are ‘competent in handoff communications.’   I was asked about this by Dr. Bob Wachter in an interview that was just released on AHRQ Web M&M last week (disclosure – I am on the editorial board).  Because programs are looking for a way to meet this requirement, I have racked quite a bit of frequent flyer miles visiting residency programs.  But, after I give a talk, I know that they may talk about it for a bit if I’m lucky. Once, I actually witnessed residents putting some of the principles I taught them into action shortly after I spoke at their resident report.  However, these moments are isolated and as you can guess, education by itself will not translate into practice change (we could talk to the handwashing people all day about that!).   So, like handwashing, a monitoring plan is also needed and yes, that is also part of the new requirement- that programs actively monitor resident handoffs.

So as we head into July 2011, here’s to more fresh eyes…

–Vineet Arora, MD


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