Future of Graduate
Medical Education
Martin Olsen MD
Disclosure
Dr. Olsen is a consultant for Gaumard Scientific and a coholder of patent 7,866,983
Part 1
Areas of attention for the
ETSU Ob/Gyn residency
program
Initiatives for 2012-13
 Continue Research growth
 Enhance ultrasound curriculum
Next Site Visit
 Tentatively scheduled for October 2013
Current Required
Procedural Evaluation
The ACGME Outcomes Project
Evaluating Surgical Competency
In a New Model for Graduate Education
Dee E.Fenner, M.D.
CREOG TASK FORCE
Future Procedural Evaluation?
Page 2
Part 2
 The view from above
Which statement best describes your enthusiasm
for the topic of GME financing
?
 A) This discussion is likely to affect my life, so I am
excited to hear about it.
 B) If Dr. Olsen wants to talk about it, I’ll listen since I am
a respectful person
 C) Wake me when this is over
Transforming Graduate Medical Education to Improve Healthcare Value
NEJM 2011
Hackbarth G, Boccuti C
 Medicare spent $9.5 billion 2009
 Minimal accountability
 Medicare’s costs exceed actual costs by about $3.5
billion
 Some hospitals place excess into their general fund
Financing Graduate Medical Education—Mounting Pressure for Reform
NEJM 2012
Iglehart JK
 Obama administration plans to reduce Indirect Medicare
Payments by $9.7 billion over 10 years
 “IME adjustments significantly exceed actual added patient
care costs…”
 Advocates incentive programs that can be earned by
meeting performance standards
 7 Senators have asked Institute of Medicine to conduct
independent review of GME financing
 Recommendation- An outcomes based evaluation system…
new physicians measured for their competency
Plug the Leak: Align Public Spending with Public Need
Girard et al: J Grad Med Ed Sept 2012 293-95
 “..GME funding is no longer linked to prior public
service…has become principally a means to fulfill the
career aspirations of new doctors and the resource
needs of of individual hospitals…”
 “…unregulated market rewards an entrepreneurial
approach to physician training….”
 …we have a two year deadline before the health care
system will be inundated with 32 million or more newly
insured.”
Plug the Leak…
 “The only effective means of centrally guiding the
composition of the physician workforce is through
leveraging CMS funding…”
 “A strategically designed mandatory public health
service….”
 “…the time to act is now…”
 “… our national leaders must plug the chronic leak of
dollars into medical specialties we do not need…”
Faculty Financial Pressures
 Faculty are under increasing pressure to generate
revenue
 Faculty research suffers as a result of financial
pressures
 In many institutions, faculty work more hours than
residents
 Increased difficulty in faculty recruitment is likely
 Faculty have less time and rewards for teaching
Results? Predictions?
 At the hospital level, Graduate Medical Education will move
from a revenue generating activity to a revenue neutral
activity or even a financial loss
 Hospitals will pick up the tab for some specialty and
subspecialty education
 Increase in structured self learning activities by residents is
likely
 Faculty will spend less time with residents, hence a need will
exist to maximize the educational value of the time
expended
 An increased role for physician extenders/ education
extenders may occur
Criticisms of Current Teaching
methods
 Medical trainees regularly demonstrate that it is more
important that they never be wrong than it is that they
take chances and think creatively
 Educators may reward the student who parrots the safe
answer and punish the trainee who risks looking bad by
original thinking
Misch DA Andragogy and Medical Education-Are Medical
Students Internally Motivated to Learn Advan Health Sci Ed 7:153160 2002
Andragogy
 The art and science of adult education
 Malcolm Knowles is the father of Andragogy
 Controversial
 Unproven
 To it’s adherents, Adragogy principles approach the
level of dogma
Misch DA Andragogy and Medical Education-Are Medical Students
Internally Motivated to Learn Advan Health Sci Ed 7:153-160 2002
Knowles Concepts
 The need to learn
 The learner’s self concept
 Role of learner’s experience
 Readiness to learn
 Orientation to learning
 Motivation
More Self Directed Learning
 Just like attending physicians study for recertification
on their own time, residents study at home away from
the institution
 As work hours decrease, home time may increase
 Computerized self teaching and assessment
mechanisms may increase
 Time with attendings could decrease but be of more
intellectual value
What About Work Hours?
What are the Work Hours Restrictions for
Residents in the United Kingdom?
 A) 88 hours
 B) 78 hours
 C) 68 hours
 D) 58 hours
 E) 48 hours
What did US Neurosurgery
Residents say about Work
Hours Changes in 2011?
 A) Residents supported the changes and look forward
to additional future limitations
 B) Residents thought the changes were appropriate but
no further changes will be needed
 C) Residents did not answer a single question in favor
of the new duty hours limits
Duty Hour Reform through the Eyes of
Neurological Surgery Residents
J Grad Med Ed Dec 2012 p 415-16.
 Residents predicted decreased surgical volume and
increased medical errors because of suboptimal
handoffs.
 5% of residents had committed a medical error at the
end of a long shift
 8% had been in a life threatening event after a long
shift
 36% occasionally or frequently violated duty hours
A Thematic Review of Resident
Commentary on Duty Hours and
Supervision
Drolet, Soh, Shultz Fisher J Grad Med Ed Dec 2012 p 454-459
 Review of comments from a 2010 Survey- reported
NEJM
 874 of 2561 residents had free text comments
 Approximately 20% return rate
 2% of U.S. resident physicians
 95% of “overall impression” comments were negative
Resident Concerns
 16 hour duty limits for interns would negatively impact
education
 Limits would diminish preparation for more senior roles
later
 Decreased patient safety
 Decreased quality of care
 Scheduling issues
 Poorer resident quality of life*
Faculty Supervision
 Relatively undiscussed
 Text disagrees with table, but it seems that residents
are comfortable with increased supervision
“ Residents’ perceptions of the duty hours limits
offer important information for accreditors,
regulators, and leaders making decisions on
future refinements to the duty hours limits.”
Future Work Hours Changes?
 Nationally, Both Ob/Gyn and Surgery Educational
leaders are comfortable stating publically that today’s
residents are less prepared for practice than in the past
 Some information exists that Surgery may secede from
the ACGME
 There is no money to extend residency duration
 In the presenters opinion, it is unlikely that today’s
residents will experience additional restrictions during
their residency experience.
The Next Accreditation System– Rationale and Benefits
NEJM 2012
Nasca TJ, Philibert I, Brigham T, Flynn TC
 ACGME serves the public trust by enforcing standards
 Physicians are no longer independent actors but are
now leaders and participants in team oriented care
 A key element of NAS is measuring and reporting
outcomes
 Competencies should become less abstract and more
meaningful
NAS– Why?
 Create an entry point into the maintenance of
certification, licensing and lifelong learning
 Enhance the competence of future physicians in areas
that are relevant to a well performing, efficient and cost
effective healthcare system
NAS in a Nutshell
 Continuous Accreditation Model Annually submitted
data, other requested data
 Program trends
 Milestones as roadmap to competencies
 Scheduled program site visits replaced by 10 year self
studies
 Standards revised every 10 years • Frequent
institutional visits (CLER)
 Common and specialty program requirements
 Milestone data submitted on each resident twice
a year
 New Core Faculty surveys
 New scholarly activity input (no CVs)
 Site visit every 10 years
What is a Milestone?
 A marker that a resident has achieved goals and
objectives for his or her level
 Exact mechanisms still under development
CLER Visits
 Review institutional activities in the areas of safety, QI,
supervision, professional responsibilities
 Integration of residents into patient safety programs –
 Integration of residents into QI and efforts to reduce
disparities
 Establishment and implementation of supervision
policies
 Oversight of transitions of care
 Oversight of duty hours
Part 3Medical Simulation and GME
How long has Medical Simulation
been around?
 A) 20 years
 B) 50 years
 C) 100 years
 D) 500 years
 E) more than 1000 years
Resident Morale
 When a resident is in the Operating Room,
he or she knows that the care of the patient
takes priority over education.
 In the simulation lab, the resident knows that
education is the only priority.
Bath J, Lawrence P. Why we need open simulation to train surgeons
in an era of work hour restrictions. Vascular 2011;19:175-77.
 Less time in hospital will ultimately lead to less
competent surgeons
 A number of reports exist which demonstrate diminishing
operative exposure among residents
 Numbers of open cases are decreasing BUT the
complexity of the open cases conversely has increased
 Fundamentals of Laparoscopic Surgery (FLS)
certification is required before sitting for the American
Board of Surgery examination; the authors imply other
areas of surgical treatment should be treated similarly.
Is Surgical Simulation
Training Effective?
 Levine R, Kives S, Cathey G, Blinchevsky A, Acland R,
Thompson C. The use of lightly embalmed (fresh frozen)
cadavers for resident laparoscopic training. J Min Invas
Gynecol 2006;13:451-56.
 Banks EH, Chudnoff S, Karmin I, Wang C, Pardananis.
Does a surgical simulator improve resident operative
performance of laparoscopic tubal ligation? Am J Obstet
Gynecol 2007;197:e1-541.e5.
 Beyer L, De Troyer J, Mancini J, Bladou F, Berdah SV,
Karsenty G. Impact of laparoscopy simulator training on the
technical skills of future surgeons in the operating room: a
prospective study. Am J Surg 2011;202:265-72.
Types of Surgical Simulation
 Live animal models
 Animal tissue
 Cadaver
 Low fidelity task trainers
 Virtual reality
 NEW- Full body high fidelity surgical
simulator
What is Virtual Reality
Surgical Simulation?
Hysteroscopic polypectomy
Surgical
Chloe
A New Method to Assess
Competency and
Improve Patient Safety
Patient Safety Vision
A full body high fidelity surgical simulator can present in
the emergency environment with an unknown diagnosis.
After the diagnosis in made, the simulated patient can be
transported to the Operating Room where a procedure is
performed. Post-operative care can also be assessed.
Chloe in Baghdad
Abdominal Wall,
Abdominal Insert
Fascia is incised
Uterine Assembly 2 showing ectopic
pregnancy and dermoid cyst
© Gaumard Scientific Company, 2011. All rights reserved.
Surgical ChloeAbdominal Cavity
Let’s Run a Scenario
Pregnancy with Pelvic
Masses
Signs of Trouble
Insight to the Situation
Treatment Begins
Problem Solving
Debrief
Future of Medical Simulation?
 Medical School Education
 Likely RRC requirement
 Medical Liability Insurance?
 Board Certification?
 Licensure?
Questions
 Competency Based Goals and Objectives