march 2009|Vol.2|no.1
From the Desk of the Associate Dean
The Latest on Graduate Medical Education at the School of Medicine
As the winter hopefully turns into spring we are getting ready to see the results of the Match and begin the cycle once again of readying for new interns. I know that everyone has put in long hours into the recruitment process to attract the best and the brightest. Many thanks to the program directors, coordinators, residents and faculty for their hard work and dedication to this annual ritual.
I am pleased to introduce to you the newest member of the graduate medical education office faculty, Ebony Thompson, MBA. Ebony just relocated from the University of Miami where she was the director of residency and fellowship operations of the ENT. She brings with her a wealth of experience and has hit the ground running. Her primary responsibilities will be working with and advising the residency coordinators, tracking duty hours and reimbursement from our hospital partners and taking over the affiliation process. With all of these tasks she is going to be extremely busy. Please visit her in her office in suite 504 of the 2040 building. She can be reached at 702-671-6437 or by email.
Other exciting news in GME includes family medicine in Las Vegas receiving five years in their reaccreditation. As mentioned in the last issue, child psychiatry in Reno received five years, but after receiving their accreditation letter, we found out that they had NO citations. Kudos to both Aron Rogers, DO (family medicine Las Vegas) and Erika Ryst, MD (child psychiatry Reno) on their achievements. As the year progresses, I am sure we will be hearing more from the ACGME requesting more site visits. We are also looking to expand some of the GME training programs. There will be more information on these exciting developments in future issues.
This March we will be launching a “Residents as Teachers (RATs)” program. This program will meet the accreditation requirements for both the LCME (accrediting body for medical schools) and the ACGME (part of the PIF submission). The launch will involve hands on workshops for residency program and clerkship directors which will be presented both in Las Vegas and in Reno. Our goal is to place a couple modules on the web for residents to work though followed by program specific workshops. Up until this time, the residency programs have specific expectations of the residents for teaching the students, but there have been very few sessions to impart the skills needed to accomplish the task. RATs is a national initiative. More on the RATs program as it evolves.
Construction has finally begun on the new collaborative simulation center based in Las Vegas. As you can see in the picture, demolition has been completed and actual structures are being built. The center is scheduled to open September 2009.
To prepare to use this facility, we have formed a curriculum integration taskforce with representatives from each of the clinical departments, students and residents. This taskforce has been charged with integrating simulation and standardized patient activities into all of the clerkships and residency programs. This is a tremendous resource that we need to use to enhance the educational experiences of our learners.
Residents have been actively involved in research. Many had the opportunity to present at regional meetings and some will have the chance to present at their national specialty meetings. Lists of participants and pictures can be found below. With all of this research activity, I am looking forward to the University of Nevada School of Medicine Resident Research Days – June 3 in Reno and June 5 in Las Vegas. I anticipate participation from all of our training programs.
Continuing on the research theme, James Kenyon, PhD, the principal investigator of the Nevada INBRE grant to enhance research structure in the state, has offered funding to pilot resident research blocks. A request for proposals was sent out in January with a due date at the end of February to all Las Vegas residents. Engaging residents in research will not only further the development of new knowledge but also will help them develop important skills necessary in their future academic careers. This pilot, labeled the resident core, will be an innovative aspect of the INBRE renewal application. We anticipate having a successful pilot which will become the resident core and expand into Reno in July 2010.
As always, I am interested in your feedback and/or suggestions.
Best,
m
Miriam Bar-on, M.D.
Associate Dean for Graduate Medical Education
Designated Institutional Official
From the ACGME
Building Bridges: Linking GME with Quality and Safety—an Institutional Perspective
Barbara Joyce, PhD
Background: Forming active partnerships between GME and institutional departments of quality and safety provide exciting and robust opportunities to meaningfully incorporate national and institutional quality and safety initiatives into resident training. In many institutions, departments of graduate medical education and departments of quality and safety operate independently of each other, with little interaction. Building bridges between these departments can enhance resident and physician training and improve patient care outcomes. Bridging the existing gap between GME and departments of quality and safety requires that we acknowledge and applaud each others’ strengths and search for ways to form active partnerships. This article describes “Building Bridges: Linking GME and Quality and Safety”, an institutional curriculum in Interpersonal and Communication Skills, designed to blend resident training with national and institutional quality and safety initiatives.
Many residency programs and institutional GME departments are actively partnering with their departments of quality and safety. These partnerships incorporate quality improvement projects and knowledge of the PDS A cycle into resident training as part of training in practice-based learning and improvement. In addition, many residency programs and institutions are working on improving transitions of care by developing standardized hand-off procedures, such as checklists or electronic hand-off forms. In systems-based practice, residency programs and institutions have improved and expanded morbidity and mortality conferences to include analysis of systems issues that led to the event, discussion of team communication issues that contributed to the event, and identification of the necessary system changes to prevent the unanticipated event or error from re-occurring. Hann et al.1 described an innovative process to link tiered clinical outcome data with resident evaluation and educational program improvement. Their approach encouraged program directors, faculty, and residents to become familiar with national, specialty-specific, and institutional quality outcome data, and to use this data in a meaningful way to drive educational change and evaluate resident performance.
Progress has been made incorporating quality and safety initiatives into Practice-based Learning and Improvement and Systems-based Practice curriculum. The competency domain of Interpersonal and Communication Skills remains an area where more focused and integrated work can be done. Rich opportunities exist to design institutional interpersonal and communication curriculum around national initiatives from many different quality and healthcare organizations. The joint commission identified communication problems among health care professionals providers, and between these professionals and patients and their families as a significant contributor to sentinel events.2 National Quality Forum recommended the use of “teachback” during informed consent as a method of improving clear communication between providers and patients or their families.3 Many organizations encourage hospitals and residency programs to adopt standardized hand-off techniques to reduce loss of critical patient information during transitions of care. Encouraging healthcare professionals to feel comfortable communicating up the chain of command is another example of a communication skill set that may reduce sentinel events. In the current climate of greater transparency in healthcare, many national organizations (Joint Commission, NQF) and healthcare systems are asking physicians to disclose errors and unanticipated events to patients and their families. Team training, crew resource management, and in situ simulation are also methods used in medical education to improve the communication between healthcare providers.
Linking GME and Quality and Safety: In designing our institutional curriculum we reviewed national I initiatives, our own institutional initiatives in quality and safety, as well as the ACGME accreditation requirements for interpersonal and communication skills. We blended these together to form our final curriculum.
The Henry Ford Institutional Curriculum Committee was composed of program directors, residents, medical educators, VP of Medical Education, as well as leaders from the Department of Quality and Safety, Service Excellence, Nursing Development, and our online university. We met over the course of two months to review and decide which topic areas linked best with national quality and safety initiatives and our system initiatives’ and discussed how we might capitalize on educational resources already developed by the Department of Quality and Safety. The group felt that the following six areas in communication skills warranted systematic educational training for all incoming first year residents in core residency programs: informed consent, disclosure of errors, teamwork (including a standardized method for hand-offs, communicating up the chain of command and crew resource management), delivering bad news, and delivering feedback to learners. Communication scripts (for example, specific trigger statements) and/or mnemonics were developed for each module and were designed to give the learner language to begin these difficult conversations.
An online module was created that provided foundational knowledge in each of the six topic areas. In these online modules, the communication “scripts” were described and residents were asked to view a video of a senior staff physician conducting an informed consent, disclosing an error, or delivering bad news to a patient. Videos in the teamwork modules included examples of hand-offs done well or challenges which might occur in communicating up the chain of command. In addition, each online module conveyed broader information related to national or system safety initiatives about why developing this particular skill set was important. For example, in the error disclosure module, residents reviewed material on their ethical obligation to disclosure error as well as reviewed summaries of national initiatives related to error disclosure. In the informed consent module, residents reviewed the importance of “teachback” and use of everyday language. This information formed part of an informed consent discussion as well as raised residents’ awareness of health literacy.
Residents were required to complete the online module prior to a small group discussion and an OSCE experience. A structured small group discussion designed to deepen residents’ understanding and application of the communication scripts and concepts was led by their program director or faculty champion. These small group discussions focused on helping residents and faculty discuss specialty-specific scenarios related to the above topics. The small group discussions also served to engage the learner in more deliberate learning around these communication skill sets.
After the small group discussion, residents completed three OS CEs related to the topic area. The OSCE scenarios were constructed from sentinel events that occurred at our hospital and were formative in nature. At the completion of this experience, residents completed a self assessment and rated their self efficacy for the specific communication skill sets. Standardized patients also completed an assessment of resident performance. Because OS CEs were videotaped, the resident’s faculty mentor was able to review all assessments, discuss with the resident their performance and opportunities for improvement. This also provided faculty with critical knowledge of their resident’s communication skills sets early in the resident’s first year. The institution also conducted faculty development for program directors and attending physicians. The focus of the faculty development sessions was to explain the initiative. An unintended consequence of this curriculum was that faculty gained skills in these specific communication skill sets by virtue of having to teach the topic.
Conclusions: “Building Bridges” was an institutional curriculum designed to teach important communication skill sets to all first year core residents that linked to national and institutional safety initiatives. The use of communication “scripts” helped residents learn the “beginning language” to initiate these difficult conversations. Partnering with our Department of Quality and Safety allowed us to use some already developed material, diffuse out institutional initiatives, and meet ACGME accreditation requirements for interpersonal and communication skills. A current research program is underway to analyze the effect of this training on resident self-assessment and resident performance on the OSCEs. We are also identifying patient outcome data that may indicate our training in these skill sets had an impact on patient care. Overall, residents, faculty and program directors reported they found this experience useful in expanding their communication skills.
This institutional curriculum is unique in blending national quality and safety initiatives into resident training in interpersonal and communication skills in a manner which provides residents with didactic and foundational knowledge in these six topic areas as well as assesses their ability to demonstrate specific communication skills. The faculty de-brief portion of this curriculum encourages residents’ to self reflect on their performance and to identify opportunities for improvement in their communication skills. The partnership that develops between HFHS Department of Medical Education and Department of Quality and Safety strengthens the institution’s ability to diffuse our safety initiatives to residents.
In a broader context, this curriculum highlights the need to consider communication skills training in these six topic areas as an important part of quality and safety training.
1 Hann C, Edwards F, Poole B, Godley M, Genuardi F, Zenni E. A Model to Use Clinical Outcomes in Medical Education. Acad Med, 2008; 83(6):574–580.
2 The Joint Commission. Health Care at the Crossroads: Strategies for Improving the Medical Liability System and Preventing Patient Injury-Executive Summary Accessed 11/08/08.
3 United States Department of Health and Human Services. 30 Safe Practices for Better Health Care. Accessed 11/08/08.
Best Practices
Fellowship Research Symposium: Sports Medicine, Child Psychiatry, Geriatrics
Carol Scott, MD, Program Director, Sports Medicine Fellowship–Reno
The Reno Fellowship Research Symposium was created July 2008 to enhance the Sports Medicine, Child Psychiatry and Geriatric fellows experience in research. This symposium consists of three fellowship programs, across specialties, working together to improve the research component of our fellowships.
We selected a research director, Dr. Andrew Pasternak who had completed a research fellowship at the University of Wisconsin. The research symposium is a required activity and occurs monthly for a one hour session. It is attended by the fellows and the program directors.
The initial meetings consisted of directed readings, didactic lectures and small group discussions of statistics and study design used in medical literature. More recent meetings have included speakers from the University of Nevada, Reno Center for Research Design and Analysis, the Center for Health Statistics and Informatics and the University of Nevada Institutional Review Board. Not only does this provide valuable information for the fellows, it allows networking with other university departments that may be helpful in future research design and implementation.
Fellows are encouraged to share research ideas and discuss how various topics in the symposium may apply to their own projects. Not only does this give fellows experience in research, it helps meet ACGME requirements and has provided a forum for program directors, as well as fellows, to interact and collaborate.
Future directions may include opportunities for joint research projects between departments. For additional information contact Carol Scott, MD, Erika Ryst, MD or Diane Chau, MD.
Residency Program Activities
Residents' Successful Research Endeavors
Internal Medicine
On Jan. 9 the Nevada Chapter of the American College of Physicians held their annual meeting in Las Vegas. Twenty of the internal medicine residents from both the Las Vegas and Reno programs participated in the research and clinical vignette competitions.
Each resident designed a poster and was given approximately ten minutes to present his/her case or study and answer questions from the two guest judges. Awards were given for research and clinical vignette categories. The first place award in each category was automatically accepted for the national ACP meeting this April in Philadelphia.
Awardees: Clinical Vignettes
- First place – Gastric Pneumatosis in a 46 y/o withou Vascular Disease – Beheshteh Nakhaee, MD; Reno
- Second place – Petrous Apicitis: A Presently Uncommon Complication of Middel Ear Infection, A Case Report and Review – Ali Abdul Jabbar, MD; Las Vegas
- Third place – Ovarian Teratoma Presents as Paraneoplastic Limbic Encephalitis – Katie Julian, MD and Vanessa Walker, MD; Reno
- Third place – Right Ventricular Septal Perforator Fistula Formation After Coronary Artery Bipass Grafting – Innocent Ezenwa, MD and Ashkan Bahin-Aein, MD; Reno
Awardees: Research
- First place - Effect of the Implementation of a Protocol Employing Vasopressor Restrictive and Fluid Liberal Strategies on the Survival in Sepsis - Saman Hayatdavoudi, MD; Reno
- Second place - Preservation of Fat-Free Mass in Overweight Patients Experiencing Significant Weight Loss - Khawaja Jahangir, MD; Reno
In addition to the first place awardees presenting at the national meeting, the other residents (who presented at NV-ACP had the opportunity to independently submit their cases for competitive selection to be presented at the national ACP meeting in April. The following residents had their abstracts selected and will attend the national competition.
- Recurrent Abdominal Pain and Diffuse Swelling in Patient with Lupus – Lia Cai, MD – IM Las Vegas
- PRES: The Reversible Syndrome – Aida Loudyi, MD – IM Las Vegas
- Myocarditis and Immunosupression – Ongoing Controversy – Nirmal T. Sunkara, MD – IM Las Vegas
- LGL Syndrome Mimicking Felty’s Syndrome – Hesham Mohammed, MD – IM Las Vegas
Pediatrics
This year four pediatric residents gave five presentations at the Western Society of Pediatric Research meeting in Carmel. In addition, one of these residents was also involved in three other projects which were presented at the meeting. The presentations are listed below.
- Weiner A, Gremse D, Patamasucon P. Management of liver abscess in the neonate.
- Obiageri Ekeh, Caroline Barangan. Double Portion: An Atypical Presentation of an MDA in an Adolescent Female.
- Kimberly D Dixon, Kira Molas-Torreblanca. Internuclear opthalmoplegia as a presentation of multiple sclerosis in a pre-pubescent female
- Juan C Collazos, Ruben J Acherman, Humberto Restrepo, Robert C Rollins, William J Castillo, Katrinka T Kip, William N Evans. Dextrocardia Diagnosed After One Month of Age Accompanied by Fewer Serious Cardiac Malformations.
- Juan C Collazos, Abraham Rothman, Alvaro Galindo, William N Evans, Humberto Restrepo. Balloon Dilation of Coarctation of the aorta in neonates weighing ≤ 2,500 Grams.
- William N Evans, Ruben J Acherman, Alvaro Galindo, Juan C Collazos, Humberto Restrepo. Treating Congenital Portosystemic Shunts in Newborns.
- Abraham Rothman, William N Evans, Ruben J Acherman, Gary A Mayman, Juan C Collazos, Humberto Restrepo. Balloon Dilation May Relieve Superior Vena Cava Obstruction Following Cavopulmonary Anastomosis.
- Katrinka T Kip, William N Evans, Abraham Rothman, Alvaro Galindo, Carlo M Zeidenweber, Juan C Collazos, Humberto Restrepo. The Value of Surveillance Cardiac Catherization Following Total Cavo-Pulmonary Connection Procedures.
Surgery
Acute care surgery fellow, Scott Cinelli, DO won the 2008 Nevada Chapter of the American College of Surgeons Committee on Trauma Resident Paper competition. This study will be presented as a poster at the Southwest Surgical Congress in March 2009. Further, Dr. Cinelli has taken his abstract to a manuscript and submitted it for publication.
- Scott M Cinelli DO, Michael J Casey MD, Deborah A Kuhls MD, Timothy D Browder MD, Jay E Coates DO, John J Fildes MD. Early Primary Closure of Open Abdominal Wounds Using the Abdominal Reapproximation Anchor (ABRA) System®.
Residents Successful in Obtaining Fellowships
Continuing the successful trend for residents pursuing fellowship after their primary residency, the following individuals have been accepted for advanced training:
- Yuri Reznik, MD – Family Medicine, Las Vegas – Hospitalist Medicine at Sutter Health in Sacramento, CA.
- Ray Tangredi, MD – Psychiatry, Las Vegas – Addiction Psychiatry at Oregon Health Sciences University in Portland, OR.
- Suneet Sidhu, MD – Internal Medicine, Las Vegas – Geriatrics at Kaiser Permanente California, in Fontana, CA.
- Obiageri Ekeh, MD – Pediatrics – Child Neurology at Albert Einstein School of Medicine in New York City, NY.
School of Medicine Fellowships Fill in the Match
Several of the School of Medicine fellowships participate in the NRMP match program. This year we were very successful in matching top ranked candidates for our programs.
- Sports Medicine–both the Reno and Las Vegas programs filled with top picks.
- Child Psychiatry–matched and filled both of their spots for the second year in a row.
- Surgical Critical Care–filled both of their positions with individuals who will continue following the critical care fellowship into the acute care surgery fellowship.
In the Spotlight
- Neila Shumaker, MD, the program director for the Hospice and Palliative Medicine fellowship in Reno received a VA Comprehensive End of Life Care grant for staffing and programming in Hospice and Palliative Care. This is a three year grant of $1 million dollars per year to support enhancing nurse staffing for a 10 bed identified hospice/palliative care unit within the skilled nursing facility at the VA. There is also funding for staff and program development for a palliative care consultation service, staff education, case finding and outreach. This grant will have great benefit to the fellowship.
- Chima Osuoha, MD, Las Vegas internal medicine resident, published a case report in gastrointestinal endoscopy – Double-balloon enteroscopy in the diagnosis and treatment of hemorrhage from small-bowel lymphangioma: a case report. In press.
- Greg Brown, MD, program director for the Las Vegas Psychiatry program will be presenting a talk on Psychiatric Assessment in the Urgent Care Setting at the annual meeting of the Urgent Care Association of America April 2009.
- Catherine McCarthy, MD, program director for the Reno family medicine obstetrics fellowship program presented a suture workshop and a lecture on osteoporosis at the Nevada Academy of Family Practice Winter CME conference in January 2009. In addition, she was also named the Nevada Business Journal’s 2008 “healthcare hero” in education.
- Kate Martin, MD, Las Vegas family medicine resident and Andra Prum, DO, Las Vegas family medicine clerkship director were invited to the Las Vegas Chapter of the American Heart Association Go Red meeting in February to discuss their research project on Las Vegas Women’s perception of cardiovascular disease before and after cholesterol measurement. This research project is funded by a grant from the AAFP Foundation with future funding from the Las Vegas AHA.
- Elissa Palmer, MD, program director for the Las Vegas family medicine obstetrics fellowship, met with the presidents and leadership of the family medicine organizations in South Carolina for a summit on the state of family medicine in her role as president of the Association of Family Medicine residency directors. In this role, Dr. Palmer also teaches in the year long national Institute of Program Director Development Fellowship with sessions in October, March and June.
In This Edition
From the Desk of the Associate Dean
The Latest on Graduate Medical Education at the School of Medicine
From the ACGME
Building Bridges: Linking GME with Quality and Safety—an Institutional Perspective
Best Practices
Fellowship Research Symposium: Sports Medicine, Child Psychiatry, Geriatrics
Resident Program Activities
Residents' Successful Research Endeavors
Residents Successful in Obtaining Fellowships
School of Medicine Fellowships Fill in the Match
In the Spotlight
Past Issues
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.