May 2009|Vol.2|no.2
From the Desk of the Associate Dean
The Latest on Graduate Medical Education at the School of Medicine
It is the beginning of June and time for both reflection and anticipation. Everyone is busy getting ready to send off graduating residents into the “real world” and to welcome new interns who will discover the realities of being a resident. Let’s take a moment to reflect on our accomplishments.
- For the first time in GME history, multiple programs have received the maximum five year accreditation cycles and some without any citations.
- Six residents received Arnold P. Gold foundation teaching awards and were also inducted into the Gold Humanism Honor Society.
- The Nevada INBRE program sponsored a competitive request for research proposals and three residents were funded for a three month block to complete their projects.
- There will be representation of all of the residency programs at resident research day in Las Vegas, and in Reno representation of 2/3 residency programs and 3/5 fellowships.
- Reno internal medicine residents won 5/6 awards presented at the Nevada American College of Physicians meeting with the winning clinical vignette going on to the national competition and winning there.
- The third annual chief resident retreat was held and the incoming chiefs learned about communicating in a leadership position based on their own temperament and those of others
- Residents continue to perform scholarly activities and submit their work to regional and national meetings for presentation. Presentations were in such venues as Carmel, Phoenix, Maui, New Orleans, Philadelphia, Hong Kong, and San Juan.
- Residents also continue to publish their scholarly activities in discipline specific journals, demonstrating to the ACGME review committees that they are involved in scholarship and research.
- Residents matched at outstanding fellowships in record number, a testament to their hard work and the quality of our training programs.
- The RATs or residents as teachers program was launched in March with a workshop for program directors and clerkship directors. Individual modules are being placed on the GME website for residents to study. Short assessments will follow each module. Once a resident has completed all of the modules, he/she will receive a certificate stating that he/she is a certified UNSOM resident teacher. As part of the intern orientation in Las Vegas all incoming residents and fellows will participate in a RATs workshop.
- The collaborative simulation center in Las Vegas is well on its way to be completed. This 31,000 square foot center will be integrated into the curricula for all programs. Presently we are identifying funding sources to help increase the equipment available for learning and to establish a standardized patient program. The center is scheduled to open September 1. With several smart classrooms including one sized for 80 persons, we also anticipate moving such events as interdisciplinary grand rounds, psychiatry grand rounds and various other conferences to this venue.
- Internal medicine and emergency medicine collaborated for their first ever combined grand rounds. Based on the success of the first program, we anticipate having these sessions on a quarterly basis. Personally, I hope that this collaboration will inspire others to collaborate for other joint educational opportunities both in Las Vegas and in Reno.
- The GME office has both a new coordinator and an administrative assistant. Both individuals have been working hard to expand the services offered by the GME office and hopefully centralizing some of the GME functions to eliminate duplication of efforts.
Since I am in the reflecting mood, it is only fair to address some of our challenges. Of course I would be remiss in not touching upon the economy. The challenging economic times have affected the medical school and our hospital partners. With that said, I think that everyone’s support of GME activities has been remarkably strong. There is a huge physician shortage in Nevada, both in primary care and in other specialties/subspecialties. To remedy the situation, we need to expand GME to offer more residency programs and fellowships. It is to my personal goal as we move forward to assist in developing such programs. We must keep our students and resident graduates in Nevada. To begin to move forward, we have to expand our partnership pool to such institutions as the Las Vegas VA and St. Mary’s in Reno.
As we move forward, I will keep you posted. There is maybe some good news on the horizon with respect to increasing GME. A bill sponsored by our own Harry Reid is in the Senate to increase GME residency positions by 15 percent. Of course it maybe a while until we get there, but let’s be optimistic. Nevada would qualify for many more positions because of various criteria established in this bill. We may need to get you to write to your congressmen and senators voicing your support for this federal legislation.
I would also like to see some more integration of some of the training aspects between the Las Vegas and Reno training programs. With the opening of the new simulation center, we will have smart classrooms that can PICTEL up to Reno. Possible joint conferences such as Interdisciplinary Grand Rounds and IM/EM Grand Rounds would not only integrate training, but have the residents get to know each other.
Anticipation is always a good feeling. With the new interns and fellows arriving to our programs, their excitement will be catching. They bring new ideas with them which we can incorporate to strengthen our programs. Further this is a time for change. Beginning with the new academic year, new program requirements will be in place for our two largest programs, internal medicine, both in Las Vegas and Reno. The respective program directors have been revamping curricula to meet the new requirements. Probably the biggest challenge has been the change to the new “caps” put on admissions and numbers of patients that residents can follow or have on a team. The engagement of our hospital partners has been interesting, but they seem to understand the new requirements.
Good luck to our graduating residents/fellows please keep in touch and share your achievements. Welcome to our incoming interns/fellows. The GME office has an open door policy and we look forward to meeting all of you.
Best,
m
Miriam Bar-on, M.D.
Associate Dean for Graduate Medical Education
Designated Institutional Official
From the ACGME
One Small Step for Faculty Development
Jack Contessa, PhD
Surgical Educator in the Department of Surgery
Hospital of Saint Raphael, New Haven, CT.
The Hospital of Saint Raphael (HSR ) is a full-service community teaching hospital located in downtown New Haven, Connecticut. The hospital has accredited residency programs in general surgery, internal medicine, transitional year, oral and maxillofacial surgery, and radiology, along with fellowships in nephrology, gerontology and cardiovascular diseases. The general surgery residency program at the institution has approximately 35 faculty members that work with and supervise the program’s 24 surgical residents. Nearly one-third are employed by the hospital and about two-thirds are private practice surgeons located in New Haven and surrounding communities. A majority also have surgical privileges at the other hospital in the city — Yale–New Haven.
By its very nature, the domain of surgery often requires surgeons to be tethered to the OR for hours at a time. Added to that is the variability of community physicians’ schedules. Collectively, these factors make it challenging to create an educational forum where the majority of faculty can gather and be apprised of the numerous and substantive changes in residency training requirements that have taken place recently.
To overcome this challenge, we opted to pursue a “distance learning” electronic communication strategy as one of several strategies to enhance communication and ongoing education. Out of this, a bulletin for faculty of the general surgery residency program entitled “The Cutting Edge” was born. We explained in our inaugural issue that the goal was to present as succinctly as possible items important to success of the residency program and the faculty involved in it. We created the Bulletin as a single page, reader-friendly document, keeping in mind the premium of faculty time and the desire not to overburden them with yet another piece of paper to read.
We decided to publish the Bulletin bi-monthly and make the lead headline story of each issue one of the ACGME competencies. For the first year at least, this seemed to make the most sense — six competencies, six issues per year. For the secondary story headline, we described practical teaching techniques (an item generated by our faculty needs assessment). We selected the software Microsoft® Office Publisher to create the Bulletin since it has a number of colorful, engaging and easy to use templates and, like other Microsoft® Office Products, has a similar look and feel that flattens out the learning curve for novice users. The specific layout we chose is titled Watermark, and is configured for a lead story headline (ACGME Competencies) and a secondary story headline (teaching tips and other items of note).
In the spring of 2008 we launched our inaugural issue of “The Cutting Edge.” Using our residency management software, we sent copies electronically to all faculty members, including site directors who oversee residents’ extramural rotations. Because not everyone has Microsoft® Office Publisher, the Bulletin is also converted to a PDF document and faculty receives both formats. To maximize visibility, we also placed copies at Grand Rounds presentations, in the physicians’ lounge, and mailed copies to their offices.
Almost immediately we received feedback about the high quality and value of the Bulletin. One of the initial techniques we presented was the concept of “wait time,” the time that an instructor pauses following a question he or she asks. Feedback indicated faculty were willing to experiment with this notion, which demonstrates positive learning outcomes when instructors “wait” at least three seconds after asking a question before calling on a resident to answer.
It’s still early in our initiative, and to date we have published only four issues of “The Cutting Edge” with the remaining two issues due in November and January. Before the first year’s cycle is complete, we plan to solicit faculty feedback to assess the impact of this publication and also to request ideas for a theatre for next year’s Bulletin.
We recognize that this initial effort is just a “stake in the ground” and one small step toward developing a comprehensive solution to a challenging problem. However, we believe that we can build on this small success and use it to shape a more inclusive and meaningful faculty development program.
Editor’s Note: Faculty development has become one of the common program requirements in two specific areas – the first – for evaluation of resident performance especially if the methods have changed or new methods have been added. The second – for teaching skills, knowing about the competencies and knowing about the educational program/curriculum of the residency program. Programs across the country are getting citations for not having faculty development plans and programs in place. Departmental or program specific newsletters with teaching tips etc. may be a great way to reach adjunct and/or community faculty. If you need assistance, please don’t hesitate to contact me by email.
Best Practices
Standardizing Remediation
Miriam Bar-on, MD
Associate Dean for Graduate Medical Education
Developing remediation plans for residents is something that all program directors face. It is challenging. One potential method of dealing with remediation is to standardize the process in which remediation is not only addressed, but also how plans are developed. The process basically includes four basic steps:
- identification and characterization (academic versus professionalism) of the lapse
- meeting with the resident to discuss the lapse
- counseling and educating on expected performance
- development of a specific remediation plan
A simple framework to develop the remediation plan applies to both types of remediation. In identifying the lapse or the reason for remediation in terms of competencies will assist in developing the plan. The establishment of goals for the remediation taking into consideration specific competencies is very helpful. Once these two steps have been completed, the next step is determining if resident education is necessary as part of the plan. This step will provide fundamental information for the resident as background or even as a specific objective (next step) in beginning the remediation process. For example, a resident who has professionalism issues with incomplete medical records may need to read statutes on the importance of medical records, the hospital policy regarding medical records completion and the JCAHO medical records policies as part of his/her remediation.
The “meat” of the remediation plan is the design of SMART objectives. SMART is an acronym for objectives that are: Specific, Measurable, Achievable, Realistic and Time. On the remediation plan form which can be found below, specific descriptors for each of the categories are attached. As the remediation planning progresses, monitoring is critical. Giving a resident a remediation plan without monitoring his/her progress essentially can set the resident up for failure. As educators, it is our responsibility to ensure that remediation plans can be successful. The final aspect of remediation plan design is defining what will happen to the resident for either not completing the remediation plan as designed or having a relapse. These conditions must be specified in the initial remediation plan so that the resident is clear regarding potential consequences of not taking remediation seriously.
Request remediation plan worksheet.
Residency Program Activities
Lectures and Physicals
Family Medicine, Las Vegas organized and presented two more Advanced Life Support in Obstetrics courses to over 40 physicians, nurse widwives, paramedics and health care professionals in Reno and Las Vegas. Two of the instructors were Amanda Casey, MD from the Reno family medicine program and Kate Martin, MD from the Las Vegas program.
Pediatrics and Family Medicine, Las Vegas residents have given Tar Wars anti-tobacco presentations to fourth and fifth-grade students in Las Vegas.
Family Medicine, Las Vegas residents and faculty have been busy performing over 600 high school pre-participation sports physicals at six local high schools.
In the Spotlight
Fellowships
Two fourth-year surgery residents matched in plastic surgery fellowships. Ben Cousins, MD will attend the University of Miami for a two-year program and Wright Jones, MD will attend Emory University for a three-year program.
Honors
Praveen Jayakumar, MD, a second-year internal medicine Las Vegas resident, was awarded a scholarship for the 18th Annual Mayo Internal Medicine Review Course, July 18-23 in Rochester, Minnesota. The internal medicine board review course received a large number of applications for the program and the selection process was difficult. However, the course’s leadership felt that Dr. Jayakumar represents the type of trainee for which this program was designed. Sandhya Wahi, MD nominated Dr. Jayakumar.
Six residents, Kate Martin, MD, Wright Jones, MD and Randy St. Hill, MD from Las Vegas and Katie Julian, MD, Jonathan McCaleb, MD and Saman Hayatdavoudi, MD from Reno, were awarded resident teaching awards at the March 27th Clinicians’ Ceremony. The residents were nominated by students from the class of 2010 for excellence and humanism in teaching. In addition the residents were inducted into the Gold Humanism Honor Society.
Richard Baynosa, MD, a graduating plastic surgery resident, received the Outstanding Resident Teaching Award, Las Vegas and Amber Hayes, MD, second-year family medicine resident, received the Outstanding Resident Teaching Award, Reno from the Class of 2009. The awards were presented at the dean’s dinner the evening prior to hooding.
Congratulations to family medicine, Reno program director, Richard Williams, MD who was promoted to associate professor.
Alicia Pilarski, DO, second-year emergency medicine resident, was elected vice president of the American Academy of Emergency Medicine Resident Student Association. Dr Pilarski has been active in this association for some time and engaged her fellow resident Sandra Thomasian, MD, an intern in the emergency medicine program, in the organization as well. Dr. Thomasian was elected member-at-large of the American Academy of Emergency Medicine Resident Student Association.
Congratulations to David Rankey, MD, second-year emergency medicine resident, resident division winner, and JD McCourt, MD, core emergency medicine faculty, faculty division winner of clinical pathologic case conference competition, Council of Residency Director's in Emergency Medicine. They will present their respective cases in the national finals in October at the American College of Emergency Physicians.
Emergency medicine program director Michael Epter, DO was appointed sub-committee chair of the CORD remediation taskforce in the competency of interpersonal skills and an oral examiner for the American Board of Emergency Medicine. Congratulations.
Randy St. Hill, MD, fourth-year surgery resident, was nominated by the surgery department and accepted to attend SAGES Advanced Minimally Invasive GERD/Bariatric Surgery, a laparoscopic foregut surgery course in Norwalk, Connecticut.
Presentations
Beheshteh Nakhaee, MD, a third-year internal medicine, Reno resident, was awarded one of the ten top prizes for her poster presentation titled, "First Case Report of Methamphetamine-Induced Gastric Pneumatosis in a 46 YO Without Known Vascular Disease," at the national meeting of the American College of Physicians in Philadelphia in April. Posters were separated into ten groups with one judge each. Dr. Nakhaee won the $500 prize for her group. This poster also was awarded first prize in the Nevada Chapter American College of Physicians meeting in January.
Surgery resident Laura Boomer, MD had two abstracts accepted and presented: "Health Disparities in Solid Organ Tumors of Latino Children", L.A. Boomer, MD, J.J. Freeman, MD, J.R. Gosche, MD, PhD, A Feliz, MD at the 42nd Annual Meeting of Pacific Association of Pediatric Surgery, Hong Kong, Platform presentation on May 13; and "Cholangiocyte Apoptosis is an Early Event During Induced Metamorphosis in the Sea Lampre, Petromyzon marinus L", L.A. Boomer MD, S.A. Bellister MD, L.L. Stephenson BS, MT(ASCP), S.A. Hillyard PhD, J.D. Khoury, MD, J.H. Youson, PhD, J.R. Gosche, MD, PhD, at the American Pediatric Surgical Association’s 40th Annual Meeting, Fajardo, Puerto Rico Poster presentation on May 28.
Ryan Young, MD, third-year OB/GYN resident, won the annual Joseph A. Rojas, MD Resident Research Paper Day in May with his presentation on the use of “Cytotec in the Post Date Pregnancy for Outpatient Induction of Labor.”
Wright Jones, MD, fourth-year surgery resident, gave a poster presentation on “Diverticulitis and Spigelian Hernia: A Bizarre Association” at the 29th Annual Surgical Infection Society Meeting in Chicago in May.
Sports medicine fellow Farhan Malik, MD presented a poster titled, "Silverman Triatholon: Injury Data 2005-2008" at the American Medical Society for Sports Medicine in April in Tampa, Florida.
The emergency medicine residency program leadership, program director Michael Epter, DO, associate program director Ross Berkeley, MD and research director David Slattery, MD, presented their study "BLINK: Faculty first-impressions of emergency medicine residency applicants are not accurate as a poster" at the annual Society of Academic Emergency Medicine in May in New Orleans. Their abstract was published in Academic Emergency Medicine 2009; 4: S55-56.
Also presenting at the annual Society of Academic Emergency Medicine was third-year emergency medicine resident Marc Burdick, DO. He presented a poster on burn resuscitation, his resident research project.
Sports medicine fellowship director Michael D. Milligan, MD is scheduled to give the platform presentation "Pre-Injury, Post-Injury and Post-Surgery Hip and Knee Kinematics of a Place Kicker Suffering ACL Tear" at the National Athletic Trainers Association annual national meeting in San Antonio on June 19.
Randy St. Hill, MD gave a talk at the Association of Surgical Technology meeting titled “Surgical Education: From Halsted to Virtual Reality, A Paradigm Shift” on May 28 at their national annual conference at Ceasar's Palace in Las Vegas.
Publications
Emergency medicine associate program director Ross Berkeley, MD and colleagues published a paper on the CLEAR Registry. The citation is: The Balls A, LoVecchio F, Stapczynski SJ, Mulrow M, Levine B, Berkeley R, et al. CLEAR: Central Line Emergency Access Registry. The CLEAR project protocol methods paper. American Journal of Emergency Medicine 2009; 27: 119-122.
Laura Boomer, MD and Wright Jones, MD, surgery residents, will have their manuscript, "Optimal Fluid Resuscitation: Timing and Composition of Intravenous Fluids" published this month. Laura Boomer, Wright Jones, Brett Davis, Shelley Williams, and Annabel Barber. SURGICAL INFECTIONS Volume 10, Number 3, June 2009.
Farhan Malik, MD published the article “Steroids in Combat Sports: Adverse Affects on Health” at the Nevada Athletic Commission website.
In This Edition
From the Desk of the Associate Dean
The Latest on Graduate Medical Education at the School of Medicine
From the ACGME
One Small Step for Faculty Development
Best Practices
Resident Program Activities
In the Spotlight
Past Issues
March 2008
June 2008
September 2008
December 2008
March 2009
GMEmail is a service of the Office of Health Science Communication, University of Nevada School of Medicine. Miriam Bar-on, M.D., Editor, Office of Graduate Medical Education. Copyright 2008 University of Nevada School of Medicine.