March 2008|vol.1|No.1
From the Desk of the Associate Dean
GMEmail, what I hope will be a quarterly newsletter, will update the School of Medicine community on the latest in graduate medical education. It’s my vision that the newsletter will:
• Highlight resident and faculty achievements;
• Present best practices in graduate medical education;
• Focus on training initiatives and residency programs, and;
• Provide updates from the Accreditation Council for Graduate Medical Education (ACGME).
I want to reflect on what’s transpired over the past 16 months since I accepted the position of associate dean. I began my role, so to speak, a day early with an institutional review that was successful thanks to the efforts of the GME community and the school’s leadership. With three years until the next visit, we’re in a position to qualify for innovations sponsored by ACGME. At the same time, we’re poised to make improvements and aim for a five-year cycle. Probably the biggest area for improvement is in the oversight of current programs. One of the institutional citations noted that the majority of our programs are on short cycles for review. It’s my hope that with dedicated program directors and committed faculty we will overcome this citation. The internal review process, in which many of you have participated (we did 11 of them this year), is a chance to assess where programs stand in requirements both common and institution specific. By taking the internal review process seriously, we will have the opportunity to work on areas needing improvement and demonstrate worthiness during the accreditation process.
To meet the needs of Nevada’s population, it’s critical that we expand our GME programs. Many of us have participated in a statewide initiative to work with the Nevada Hospital Association to do just that. Further, in Las Vegas, a new Veterans’ Administration Hospital will open in 2011. This is a tremendous chance to expand our training in a collaborative manner. Planning is now underway. The school however also recognizes the need for expansion and we have submitted plans for a rural family medicine residency, a medical oncology fellowship, and a cardiology fellowship. These plans are in various stages in the ACGME process. We are optimistic that several will come to fruition.
Last March, we had an excellent match and now seeing the results in our intern class across the disciplines. These individuals are busy preparing to become second years, as program directors are reflecting on this year’s applicants while they prepare, submit and certify their match lists. In another six weeks, we will know the results.
To further the school’s research mission, we re-established Resident Research Day in Las Vegas. I was prepared to have enough papers to squeak by in an afternoon but was absolutely delighted with a response of 47 abstracts to the call for submissions. As a result, we had both a poster session featuring clinical vignettes and a platform session for presentations of basic science and clinical studies. Based on the success of the day, we are expanding Resident Research Day to Reno on April 23. For its inaugural year, we have ten submissions to date. Resident Research Day will be held in Las Vegas on June 12 and a call for submissions will occur in the next few weeks.
There have been faculty development sessions for program and associate program directors, as well as, key faculty and clerkship directors. The first session featured a workshop on “Building a Competency Based Curriculum” and the sessions this year were three hour sessions on “Evaluation of Residents.” Additional sessions will be presented for residents on becoming teachers. These sessions will be done through individual departments and training programs.
Last year we held the first chief resident retreat. This daylong retreat brought the chief residents from all the programs, both Las Vegas and Reno, together in Las Vegas. Topics covered during the sessions included planning to be chief, dealing with conflict and issue recognition. The next chief resident retreat is scheduled for April 24, 2008 in Las Vegas. A needs assessment will be sent out to the chief residents to determine what will be presented during the session. Leadership development is always the underlying theme and topics presented will address perceived needs.
As you can see it has been a busy year. As we move forward, I hope that this newsletter will facilitate communication between the GME office, the residents, program directors and the medical school. Please provide me with feedback about GME News as well as information that can be shared with everyone.
Miriam Bar-on, M.D.
Associate Dean for Graduate Medical Education
Designated Institutional Official
GME Notes
Nine Red Flags in Accreditation Site Visits and Reviews
As many of our programs are having site visits resulting in significant numbers of resident and faculty involvement, I thought that the following article is important and encourage everyone to read it. The following are excerpts from the ACGME e-Bulletin, Feb. 2008, Nine Red Flags in Accreditation Site Visits and Reviews, Barbara Bush, Ph.D., William Robertson, M.D., Ingrid Philibert, MHA, MBA.
The nine red flags outlined in this article were compiled from the observations of several members of the ACGME field staff with many years of experience, and were informally validated by a number of RRC and former RRC members. Red flags are attributes of programs that are discernible during site visits. This summary offers insight into these attributes, which may raise site visitor and RRC reviewer questions about program quality and compliance with aspects of the program and institutional requirements. One use of this information is for an internal assessment or self-study with the goal of program improvement. The ninth red flag relates to preparation for the accreditation review, and may be particularly useful to a program preparing for its site visit.
The attributes are germane to both residency and fellowship programs, and the term “residents” refers to both residents and fellows. The ordering of the nine “red flags” is random and does not reflect any particular importance of the items.
Red Flag 1: Lack of Program Leadership This red flag relates to indications that the program director and key faculty fail to advocate for residents on important education and patient care matters. Signs include insufficient attention or lack of response to concerns residents have raised about aspects of the program and insufficient efforts to correct problems identified by the residents. These deficits may also show up as a failure to address problems with rotations at participating institutions or as insufficient follow-up by the sponsoring institution to problems or concerns requiring institutional interventions. Such issues may contribute to a failure to address areas of prior non-compliance, and may result in repeat citations on a successive review. In the process of preparing for site visits, insufficient leadership may become apparent as a program’s reliance on communication and preparation managed solely by the program coordinator or another staff member, rather than direct involvement of the program director. On the day of the visit the program director may rely entirely on an associate to answer all questions from the site visitor.
Red Flag 2: Lack of Program Infrastructure for Teaching and Evaluation Insufficient clinical or didactic curriculum, including formal didactics, conferences and lectures, or
deficiencies in the systems for evaluating residents, faculty and the program may have a negative impact on the residents’ educational environment.
Red Flag 3: Lack of Appropriate Volume and Variety of Patients Lack of appropriate patient populations to ensure an appropriate depth and breadth of clinical education is characterized by insufficient volume or balance of patients (diagnoses, clinical problems, acuity and demographics), disputes with other disciplines that affect the number and type of patients available to a particular program, or too many residents, fellows and other learners competing for the same patient populations.
Red Flag 4: Problems with Resident Recruitment and/or Retention Reduced ability of a program to recruit or retain residents may be due to geographic location, program or institutional reputation, reduced interest in the specialty, or program-level problems that induce residents to leave prior to graduation. Signs of this difficulty are evident from unfilled resident positions or a high resident turn-over. As a result, poorly qualified residents may require intensive remedial teaching and evaluation, creating an added burden on the program director and faculty. Problems with resident recruitment may also contribute to a poor record for graduates in sitting for and passing their board examination.
Red Flag 5: Lack of Dedicated Teachers This red flag involves the faculty’s unwillingness or inability to devote the added time required for effective teaching (at the bedside and in the operating room, or during conferences, rounds and other didactic activities). On some occasions, this problem may be evident in low numbers of board-certified faculty or a key faculty component that is not adequate to teach the number of residents in the program. Causes may include problems with faculty recruitment, high faculty turnover or faculty attrition. Lack of effective faculty teaching also may manifest as too much or too little supervision, or the faculty’s not turning over cases or giving hands-on responsibility to residents, not allowing sufficient autonomy for decision-making with appropriate oversight, not offering progressive responsibility and not providing meaningful evaluation and feedback to the residents. During the site visit, residents may report over-reliance on fellows to teach, or competition between residents and fellows for attending physicians’ teaching time.
Red Flag 6: Lack of Meaningful Didactics (Rounds, Conferences and Lectures) A didactic component that does not cover the essential body of knowledge (basic science and clinical) of the specialty, frequent cancellation of conferences, lack of sufficient faculty attendance at or participation in conferences, and an over-reliance on residents or fellows to organize and present at conferences reflect insufficiencies in the program’s organized curriculum.
Red Flag 7: Lack of Financial and Human Resources A lack of financial and human resources at the program or institutional level may be apparent in inadequate or outdated facilities, or excessive clinical demands on faculty, including the program director. Other ways in which this may become apparent include insufficient support services for patient care that affect residents and faculty, or excessive service needs, with residents needing to "cover" too many hospitals. Issues with adequate support of the program also may show as inadequate numbers administrative and ancillary staff for the size of the program, or a lack of adequate institutional support or funding for the program.
Red Flag 8: Service has a Higher Priority than Education Evidence of undue reliance on residents to provide service includes clinical services that cannot run without the presence of residents, frequent instances of residents being pulled from one rotation to cover another service, and duty hour violations affecting a significant percentage of the residents in the program. Another example is a resident’s being required to provide coverage or cross-coverage on inpatient units during their ambulatory, subspecialty or research rotations.
Red Flag 9: Lack of Preparation for the Accreditation Process In the ongoing management of the program, deficiencies may present themselves as inadequate attention to selected requirements. In the preparation for the accreditation site visit, one sign of this may be a poorly prepared program information form (PIF). Examples include PIFs with obvious errors, inconsistencies or failure to follow the instructions; missing documents; or a PIF that arrives after the specified date, which is set to allow the site visitor adequate time to review the documents.
On the day of the visit, a program leader who does not understand or argues about the standards
may be evidence of inadequate attention to the accreditation process. Knowledge deficits related to the accreditation standards, or lack of “buy-in” for all or selected accreditation requirements (institutional, program and common requirements, including the competencies and duty hours) on the part of program leaders and faculty may contribute to this.
Other potential red flags were considered, but ultimately rejected because they related to program elements important only in selected specialties and subspecialties. Two deserve specific mention: 1) lack of faculty and/or resident scholarship; and 2) excessive focus on research at the program level that may prevent faculty from providing clinical and didactic instruction to their residents.
Residents Successfully Present at State and Regional Meetings
INTERNAL MEDICINE
Jan. 26 was the Nevada Chapter of the American College of Physicians (ACP) annual meeting in Las Vegas. Residents from the Las Vegas and Reno internal medicine programs presented clinical vignettes and research papers in the resident competition.
Recipients of first place awards have the opportunity to present at the national ACP meeting. The winners were:
Clinical Vignettes
o First Place: Tatyana Reznik, From Encephalitis to Fractures (Reno)
o Second Place: Robery Dalrymple, Apical Balloning Syndrome Triggered by Psychosis (Reno)
o Third Place: Jyothi Rotti, Not All Bone Loss is Osteoporosis (Las Vegas)
Research Papers
o First Place: Naveen Gande, Jennifer Lising, Cuong Nguyen, Routine HIV screening in outpatient settings: Is it feasible and acceptable? (Las Vegas)
o Second Place: Venkatesh Lakshminarayanan, What is MACE? Analysis of MACE Consistency in Hydroxymethylglutaryl-CoA Reductase Inhibitor (Statin) Trials (Reno)
PEDIATRICS
At the annual Western Society for Pediatric Research meeting in Carmel, six pediatric residents presented. This meeting is coupled with the American Federation for Medical Research and encourages residents and faculty to share their studies:
• Recurrent vomiting and diarrhea as a presentation of dysmenorrheal. K.A. Molas-Torreblanca and C.J. Barangan
• A randomized controlled dose response study of lansoprazole oral disintegrating tablets in suspension for treatment of gastro-esophageal reflux disease in children. L. Orendain and D.A. Gremse
• Mysteries of shock: S. Kamat and L. Shah
• Serostatus of infants born to human immunodeficiency virus positive mothers in southern Nevada: outcome of an enhanced maternal-child intervention program 2005-2007. E. Ezeanoule, S. Kapella, K. Ezeanoule, I. Jack, J.L. Noonan
• Spectrum of primary immunodeficiencies in southern Nevada. E. Ezeanoule, I. Jack, S. McKnight, S. Kapella and K. Ezeanoule.
• Delayed diagnosis and treatment of perinatally acquired human immunodeficiency virus. E. Ezeanoule, K.A. Ezeanoule, L. Orendanin
• Feasibility and acceptability of routine human immunodeficiency screening: experience in an urban outpatient setting. E. Ezeanoule, O. Ekeh, A. Palacoc, D. Hemrajani, K. Kornswad, N. Gande, A. Norman, J. Lising, S. Satya, C. Nguyen, E. Ellis, J. Butt, A. Greenberg. R. Reich.
In the Spotlight
Special Distinctions
Caroline Barangan, M.D., associate program director for pediatrics, and Cynthia Schenauer, M.D., hospitalist director for pediatrics, will present a workshop on professionalism at the Association of Pediatric Program Directors annual meeting in Honolulu in May. This workshop was selected competitively from a large selection of submitted abstracts.
The American Psychiatric Association and its Committee on Graduate Education selected Gregory Brown, M.D., program director for Las Vegas psychiatry, to receive the Annual Irma Bland Award for Excellence in Teaching Residents.
Gregory Brown, M.D., program director for Las Vegas psychiatry, and residents Tina Goodson, M.D. and Bradley Goodson, M.D. will present “Mind Mapping Software in Resident Training” as part of a larger session on innovative use of technology in teaching residents. The presentation was selected competitively and will be presented at the Association of Directors Psychiatry Residency Training annual meeting in New Orleans in March.
Michael Epter, D.O., program director of emergency medicine, received the Young Educator Award from the American Academy of Emergency Medicine.
Jack Lazerson, M.D. was named director of the pediatrics residency program.
The American Academy of Child and Adolescent Psychiatry asked child psychiatry program director, Erika Ryst, M.D., and founder Henry Watanabe, M.D. to write an article about the program in Reno. This is the first new fellowship in child and adolescent psychiatry in the country in many years and the first in Nevada.
Sandhya Wahi-Gururaj, M.D. joined the internal medicine residency program in Las Vegas.
In This Edition
From the Desk of the Associate Dean
GME Notes
Nine Red Flags in Accreditation Site Visits and Reviews
Residents Successfully Present at State and Regional Meetings
In the Spotlight
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.