September 2009|Vol.2|no.3
From the Desk of the Associate Dean
The Latest on Graduate Medical Education at the School of Medicine
It seems like it was just a few days ago when I was writing about saying good bye to the graduating residents and preparing for the new group of interns and fellows. I am pleased to say that the new interns and fellows started in July with enthusiasm and probably a bit of anxiety. Over the past two months I have had the opportunity to personally work and interact with our new colleagues and must extend kudos to the program directors for their astuteness in trainee selection. At this time, my guess is that most of the initial anxiety has lessened and that the new trainees have figured out the multitude of systems with which they need to be familiar.
As we head towards fall, although hard to imagine with temperatures still way above 100 degrees, there are ACMGE site visits to prepare specifically for pediatrics and obstetrics/gynecology—both in the beginning of November. This summer, surgery had a site visit, as did emergency medicine—their first since becoming accredited. We now have to wait patiently for the review committees to make their decisions. A pleasant surprise occurred last week, when the ACGME internal medicine review committee lengthened the internal medicine Las Vegas cycle to five years, and also lengthened the geriatrics fellowship cycle to 3.5 years. Allegedly these increased cycle lengths was to decrease the burden on the review committees. Whatever reason the committee provided, two well-established programs got a bit of a reprieve from the ACGME.
This academic year we will have an institutional review—a site visit to determine how well the School of Medicine is managing their graduate medical education programs. Preparation for this visit has started and will involve the entire GME community. As we move forward in the process, I will be meeting with groups that include residents, fellows, program directors and members of the GMEC to answer the questions posed to us. It is our responsibility to demonstrate our compliance with the ACGME requirements.
As an institution, we do a great job training residents in their specific disciplines. We need to prove this to the ACGME. At the last visit, the institution was given six citations, all of which have basically been addressed. A summary of the citations follows:
- Two related to the training environment—lack of gender specific call rooms for OB and poor conference facilities for psychiatry in Las Vegas. Both issues have been addressed;
- Another citation focused on incompleteness of internal reviews and not following a strict process. New processes, forms and reports have been implemented, modified and re-implemented. All reports are uniform in format and have scheduled reporting dates;
- We were taken to task because at the last institutional review, the E-Value system was emphasized as a means for collecting evaluations. However, only global evaluations were being performed. At the present time, E-Value is still being used as the evaluation management platform. However, many of the evaluations have been customized for individual programs and for individual rotations within programs. Further, additional types of evaluations including 360 degree (self, peer, patient, ancillary staff), teaching and direct observation have been placed onto E-Value which serves as a central repository;
- The fifth citation dealt with the GME committee and its oversight of programs. We were cited for having only 2/17 programs with cycle lengths longer than three years. At this time, 8/17 programs have cycle lengths of greater than three years;
- The final citation had to do with interaction of the GMEC and the organized medical staffs of our affiliate hospitals. We have fixed this citation with having members of the GMEC also sit on medical executive committees of our affiliate hospitals, representatives from the hospitals sit on the GMEC and having frequent reports submitted to these hospital committees.
On September 1, the Clinical Simulation Center – Las Vegas (CSC – LV ) will open its doors to students and residents from the School of Medicine. Students from Nevada State College School of Nursing started their classes earlier and soon UNLV School of Nursing students will begin their classes. The collaborative nature of our center (three schools and two disciplines) is the first of its kind in the country. Further, our center is the largest west of the Mississippi. Each clinical department has been tasked with integrating simulation and/or standardized patients into their curricula. We hope to move interdisciplinary grand rounds to the center either in September or October. A grand opening has been scheduled for sometime in mid-October. Watch for announcements. A similar collaborative center (medicine and nursing) is planned for the new education building in Reno which is targeted to open in either 2011 or 2012.
One positive outcome of this newsletter has been the creation of a faculty development newsletter designed and developed by Carol Scott, M.D., program director for sports medicine in Reno, The Halftime Report. Based on the From the ACGME article below and the need to provide faculty development to her decentralized faculty, Dr. Scott decided a faculty development newsletter was the way to go. If you are interested in seeing her newsletter and want to follow her example, please contact her directly. This is a great way to address ACGME requirements, post relevant information about teaching and other program related news. Kudos to Dr. Scott!
It never ceases to amaze me the cyclic nature of GME. As we finish welcoming our new residents and getting them settled in their new roles, we begin—yet again, the process of recruitment of interns and fellows. Our calendar is determined by ERAS, NRMP, the match, intern orientation and resident graduation. There is comfort in the repetitiveness of the cycle as well as excitement in what unknowns it brings along the way.
Thanks for all you (residents, fellows, program directors, APDs, faculty, coordinators and staff) do at the School of Medicine to make GME great!
Best,
m
Miriam Bar-on, MD
Associate Dean for Graduate Medical Education and Designated Institutional Official
From the ACGME
Principled Approach to Error Disclosure Aligns with ACGME Competencies, Enhances Safety and Helps Institutions Improve
Julie A. Jacob
Manager of Corporate Communications, ACGME
Residents who make medical errors may be reluctant to disclose them for reasons including shame, fear of being sued and anxiety about losing their license. At the same time, it is important for residents — and other health care professionals — to disclose errors. Doing so helps individuals learn from the mistake, enables the hospital to adjust its processes to prevent or minimize the chances of this or a similar event re-occurring, provides accountability to patients harmed by errors and helps residents involved in the error to heal emotionally. This was the key message of a presentation entitled “Disclosure of Medical Error in the Context of Institutional ‘Just Culture’” at the 2009 ACGME Annual Educational Conference. Timothy McDonald, MD and David Mayer, MD, are the co-executive directors of the University of Illinois at Chicago (UI C) Institute for Patient Safety Excellence. Both are anesthesiologists in academic practice. Dr. McDonald also is the chief safety and risk officer and Dr. Mayer is the associate dean for curriculum at UI C College of Medicine.
A Principled Approach
The presenters discussed the principled approach to medical error disclosure used at the UI C Medical Center and UIC College of Medicine. They talked about how this approach embodies the ACGME core competencies and provided practical recommendations for how other teaching hospitals can develop a resident adverse event reporting program.
Drs. McDonald and Mayer compared developing a principled adverse event disclosure system to nurturing a crop. First, institutional leaders must “till the soil” by adopting an institution-wide disclosure policy and gaining staff support for the program. Second, the hospital must “plant the seeds” by establishing a step-by-step process for disclosing and investigating medical errors and also by educating and engaging resident physicians on the disclosure process. Finally, the hospital must “nurture the crop” by putting together a support team for residents who disclose errors and setting up a process for analyzing data and investigating the root cause of errors.
The speakers noted that, despite the many reasons why residents may be afraid to admit that they have made an error, a principled, standardized and fair policy for disclosing, investigating and making amends can increase the likelihood that residents will admit errors and contribute to hospital level improvements in patient safety procedures.
Error Disclosure and Investigation
The presentation outlined the process of disclosing and investigating medical errors, which entails 5 steps. They include reporting the error, investigating the error, improving the hospital’s processes to minimize the likelihood of the error happening again, communicating information about the error to the patient and staff members and providing an apology and remediation to patients harmed by an error or to their families.
Each step in the process is an opportunity for residents to learn and practice the 6 general competencies. For example, disclosing the error is an exercise in interpersonal and communication skills, professionalism and systems based practice.
Resident Support and Inclusion in the Processes to Address the Error
It is important to support residents who admit that they have made a mistake and to treat them fairly, the presenters said. Studies have shown that residents who make an error are at an increased risk of depression and are more likely to make another mistake. “Put together a support team that can be called on to give support when there is an adverse patient event,” said Dr. McDonald.
It also is important for residents to be part of the process of improving procedures to minimize the chances of that particular error happening again. For example, noted Dr. McDonald, after an incident in which an oxygen tank ran low while a patient was being transported to the hospital, residents developed a chart that allows health care team members to quickly and easily calculate how long a tank will provide oxygen.
Finally, making an apology to a patient who has been harmed is a valuable learning experience for residents, one that gives the resident a chance to practice interpersonal and communication skills, professionalism and practice-based learning and improvement. “It’s important for the resident to
understand the power of an apology,” said Dr. Mayer.
The bottom line is that hospitals have 2 choices when it comes to dealing with medical errors, said Dr. McDonald. “Hospitals can either talk about errors and learn from them, or continue to hide from them.”
RATS Debuts
A long time goal of the offices of graduate medical education and medical education has been to establish a “residents as teachers” program. Drs. Bar-on and Kimmel wrote a grant in early 2007 to get some of the UNR innovative teaching program money, but were unsuccessful. However, with the LCME self study, it became clear that this program was necessary. Subsequently, discussions were held at the graduate medical education committee (GMEC), and it was determined that we would develop an online set of modules that residents could work through as well as live presentations both in Las Vegas and in Reno. It was also emphasized to program directors that teaching residents to teach was an ACGME requirement and that RATs programs needed to be included into individual discipline didactic sessions. To both track resident participation and offer an incentive, a set of quizzes were developed and linked to each specific RATs module. Suzi Stempeck from IT services at the medical school designed a specific method of tracking residents who have completed the modules accompanied by their score. Residents who complete all of the modules with a score of 70% and greater will receive a certificate stating that they are Certified UNSOM Resident Teachers. The program debuted with faculty development workshops in March and April for program and clerkship directors. This debut was followed by a large group session in Las Vegas as part of intern/fellow orientation. Residents in Reno will attend sessions on September 16, 2009.
The program is comprised of seven modules and a link to the Clinical Teaching Perception Inventory developed by the Group on Resident Affairs of the AAMC. The modules include an introduction that addresses the purpose of RATs and adult learning as well as six other very focused presentations on key skills needed by residents to teach medical students and their junior colleagues. The goal is for these modules to solidify resident teaching skills from an academic, practical and fun perspective. The website may be accessed at www.medicine.nevada.edu/GME/rat.asp. Feedback is always welcome.
Best Practices
Annual Training Program Evaluation Checklist
Miriam Bar-on, MD
Associate Dean for Graduate Medical Education
The following form is from Cincinnati Children’s Hospital An Annual Training Program Evaluation Checklist and modified by the Office of Graduate Medical Education at the University of Nevada School of Medicine.
View form [PDF]
Hopefully this form will facilitate annual program reviews and provide program directors with concrete documentation of completion of this process. If you keep this form annually in your files (completed) you will score big with the ACGME-RC.
Programs are also encouraged to develop a program portfolio for assessment of program effectiveness. Examples of items that may be included in the portfolio:
- Resident evaluation aggregate scores (by level of training or across the program);
- In-training examination scores especially tracked over time;
- Board certification pass rates;
- Multi rater evaluations;
- Trends in School of Medicine annual survey;
- ACGME survey results
In the Spotlight
Welcome to Elizabeth Gutierrez who joins the internal medicine training program as a residency coordinator. Elizabeth, better known as Liz, previously served as the internal medicine student coordinator. The position was previously filled by Marsha Gallo who retired in June.
Welcome to Rich Baynosa, M.D. who is not only serving as a fellow in the micro-vascular hand fellowship program, but also was named associate program director for the plastic surgery program. Congratulations are also in order as Rich and his wife Jenny Baynosa, M.D. just became parents of a baby girl on July 27.
Congratulations to Sandy Wahi, M.D., MPH, internal medicine program director, who, along with her husband Argin Gururaj, M.D., welcome their third child, a little girl, born August 11. Big siblings are thrilled with the addition to their family.
Gregory Brown, M.D., program director for psychiatry in Las Vegas, is writing an invited paper (by the Urgent Care Association of America) on psychiatry in urgent care settings. This is a follow-up peer review article from his talk at this association’s national meeting earlier this year. Dr. Brown has also been asked to write a peer review article on Jung/Campbell/Spirituality for one of the academic psychiatry journals.
Congratulations to internal medicine residents Jimmy Diep, M.D. who matched at University of California Irvine School of Medicine for a cardiology fellowship, Fanny Chan, M.D. who matched at the University of Florida for a hematology-oncology fellowship, and Alireza Farabishahadel, M.D. who matched at Indiana University for an infectious disease fellowship. All fellowships will start July 1, 2010.
Congratulations to Aron Rogers, D.O. who received the Association of Family Medicine Residency Directors Bronze Level Award. This award is characterized by accomplishments in advocacy, training, tenure and performance including excellence in presentations as national meetings, scholarly publications and service. The award was presented at the annual program directors meeting on June 8.
Congratulations to Jake Kincheloe, M.D., chief resident in family medicine, was appointed to the board of the Nevada Academy of Family Medicine.
Presentations
Sreekanth Donepudi, M.D., fellow in geriatrics, had his abstract accepted for Nevada Public Health Association conference that will be held Sept. 21-22 in Reno at the Joe Crowley Student Union at the University of Nevada, Reno. His presentation is on colorectal cancer screening disparities in elder Nevadans.
Laura Boomer, M.D., third-year surgical resident, had her abstract “Disparities in Usage of Automotive Safety Restraints and Seat Belts by Latino Children” accepted for a poster presentation at the 2009 American Academy of Pediatrics National Conference and Exposition in Washington, D.C., Oct. 16-20.
Wright Jones, M.D., surgery chief resident, will give oral and poster presentations at the International Surgical Week in Adelaide, Australia from Sept. 6-10.
In This Edition
From the Desk of the Associate Dean
The Latest on Graduate Medical Education at the School of Medicine
From the ACGME
Best Practices
Annual Training Program Evaluation Checklist
In the Spotlight
Past Issues
March 2008
June 2008
September 2008
December 2008
March 2009
May 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.