DECEMBER 2008|Vol.1|no.4
From the Desk of the Associate Dean
The Latest on Graduate Medical Education at the School of Medicine
Wow how time flies! It seems like we just welcomed the new interns and now they are almost 50% done their intern year. Reports from program directors indicates that they are by in large doing well. Now the holidays are upon us, we have a new president and the economy is walking a tight rope. World events have not stopped life in the GME world. We had a very busy year that has yielded some very nice successes.
As you recall, this spring and early summer was packed with lots of ACGME site visits. The program directors and their faculty/staff worked extremely hard to submit their Program Information Forms and gather the necessary information for these visits. Residents also played an integral role in the programs’ outcomes. I am delighted to share with you the outstanding results.
In Las Vegas
- Internal Medicine 4 years (first time ever)
- Plastic Surgery 5 years (NO citations)
- Sports Medicine 5 years
In Reno
- Psychiatry 2 years
- Child Psychiatry 5 years
- Geriatrics 3 years (NO citations)
- Internal Medicine Decision pending additional data
Las Vegas family medicine and surgical critical care had reviews in October and their results are pending. Emergency medicine will participate in a mock site visit to gain experience and begin to prepare the program for their official site visit that will occur sometime in 2009. Other programs anticipating site visits in 2009 include general surgery, pediatrics and obstetrics/gynecology.
At the last count, the School of Medicine has 11 residency programs between Las Vegas (8) and Reno (3). In addition, there are three and four accredited fellowships in Las Vegas and Reno respectively.
University of Nevada School of Medicine Graduate Medical Education
Accredited Programs including Fellowships, Las Vegas
Residency Programs
Emergency Medicine
Family Medicine
Internal Medicine
Obstetrics and Gynecology
Pediatrics
Plastic Surgery
Psychiatry
Surgery
Fellowship Programs
Medical Oncology
Sports Medicine
Surgical Critical Care
Non-Accredited Programs (Fellowships)
Family Medicine–Obstetrics
Acute Care Surgery
Microvascular Hand
Accredited Programs including Fellowships, Reno
Residency Programs
Family Medicine
Internal Medicine
Psychiatry
Fellowship Programs
Child Psychiatry
Geriatrics
Sports Medicine
Hospice and Palliative Medicine (pending accreditation)
Non-Accredited Programs (Fellowships)
Family Medicine-Obstetrics
We have been working on a GME strategic plan and it will be presented to the Nevada Hospital Association leaders on Dec. 3. Stay tuned for additional details.
As we move forward with new programs, we need to continually remember the needs of the already accredited ones. Budget cuts, program cuts at hospital sites and other challenges will be things that we will need to be cognizant of as we try to address educational needs.
Despite our challenging times, I hope everyone takes time to reflect on the positive aspects of their lives and to make resolutions for the upcoming year. Best wishes for a healthy and happy new year.
m
Miriam Bar-on, M.D.
Associate Dean for Graduate Medical Education
Designated Institutional Official
From the ACGME
Involving Residents in Quality Improvement: Contrasting "Top-Down" and "Bottom-Up" Approaches
Ingrid Philibert, Ph.D., MBA
A collaboration between the ACGME and the Institute for Healthcare Improvement (IHI) resulted in a recently completed “90-Day Project” that explores practical methods to involve residents in clinical quality improvement (QI) efforts. The project was initiated in response to a recommendation in the September 2007 report of the ACGME Committee on Innovation (CI). It called for the identification of opportunities to enhance quality and safety in teaching settings by studying the outcomes of resident involvement in organized clinical quality improvement initiatives, such as the IHI’s 100,000 and 5 Million Lives Campaigns. The report explores practical methods to involve residents in clinical quality improvement (QI) efforts. It contrasts institution-level quality improvement projects, such as the IHI Campaigns, and program- and resident-initiated QI projects. The focus is on how both approaches meet the dual goals of improving care and advancing residents’ professional development in Practice-Based Learning and Improvement (PBLI) and Systems-Based Practice (SBP). It also analyzes advantages and drawbacks of “top-down” (institution-initiated) and “bottom-up” (resident and program-initiated) approaches, and provides answers to the question whether “top-down” approaches for involving residents in QI can overcome some of the reported limitations of “bottom-up” QI.
The report discusses what the two models of engagement in QI teach residents, finding they provide different and compatible learning opportunities. “Top-down” approaches benefit residents and institutions, with residents learning from their involvement, and bring real-life knowledge and a fresh perspective to institutional efforts. “Bottom-up” approaches offer residents opportunities to address problems they see in their practice and to learn how to improve care. However, a reported limitation of bottom-up QI is that residents left to their own devices often are limited to a focus on residency specific problems instead of more significant institutional issues. A key learning opportunity in “bottom-up” approaches relates to the identification of problems and development of solutions tailored to local realities. “Top-down” approaches let residents participate in QI within a collaborative environment involving clinical and institutional leaders, and both differ from much of the traditional teaching of QI that focuses predominantly on improvement concepts. Engaging residents requires the integration of two parallel initiatives — institutional clinical improvement efforts, and teaching residents PBLI and SBP with the goals of 1) preparing them for life-long practice and 2) allowing them to assume an expanded role in QI initiatives in their programs and sponsoring institutions. The findings also suggest that larger QI goals can benefit from broad involvement of multiple professionals across disciplines and support from institutional leaders. Many efforts to involve residents in QI blur the boundaries of the two models.
Successful institutions and programs take advantage of three drivers for resident involvement in quality improvement: 1) effective curricula, role models and mentors, 2) infrastructure that imbeds QI in residents’ day to day experiences, and 3) the appeal of QI to residents. The drivers help overcome challenges that include a dearth of curricula and teaching approaches to prepare residents for a role in quality management and improvement, and involving a sufficient number of residents to allow the intervention to gain momentum in the resident community, while being mindful of residents’ limited time and multiple commitments. At some institutions, resident involvement in institutional QI also has been able to establish a relationship between residents and institutional leaders. This empowers residents and gives leaders a better view of the clinical micro-systems in which residents work and learn. For “bottom-up” approaches, attending to the three drivers helps deal with the absence of links to organizational goals and can contribute to overcoming faculty and leadership assumptions that QI is something residents do not truly need to become competent in until they have completed their clinical education. In both approaches to QI, faculty physicians active in teaching, who improve their own work, are an invaluable teaching and learning resource, giving residents exposure to QI as part of their daily experiences. In summary, the findings highlight that residents’ participation in QI and enabling them to see data showing improved care is a more powerful form of education than merely learning QI theory and processes.
The 90-day Project approach is adapted from Proctor and Gamble’s Connect and Develop approach to innovation. Elements include interviews with experts in health care and other fields to develop a theory about the problem and the key components of a response. This is followed by studying examples that support, refine, or revise the theory, and summarizing lessons learned.
The complete report from the 90-Day Project Involving Residents in Quality Improvement: Contrasting “Top-Down” and “Bottom-Up” Approaches is available from the ACGME’s web site (PDF).
Best Practices
Ramping Up Board Passage Rates
Beverly Parker, M.D., Residency Program Director, Internal Medicine-Reno
In the 2004-2005 academic year, the IM-Reno program developed a series of monthly mini-exams to assist residents who were in academic remediation programs to assess their funds of knowledge on an ongoing basis. The exams were 45 questions over 1 hour and were specialty specific to correlate with our board review topic of the month. Although initially developed as a remediation tool, the program was developed into a more formal program for all residents in the 2005-2006 academic year and participation was encouraged but not required. As we noted that our board passage rate was declining, in the 2006-2007 academic year, participation in the exam series was made mandatory for all residents.
As the same exam was taken by residents at all levels of training, a variable passing standard was set with 40 percent correct for PGY-1, 50 percent correct for PGY-2 and 60 percent correct for PGY-3 set as the minimums. All residents were required to take at least 9 of the 12 offered exams per year but passing the exams was not required as the purpose of the exams was for ongoing self-evaluation to help residents identify areas of weakness on which to focus.
In an effort to help residents work on test-taking skills as well as fund of knowledge, we increased the time pressure of the exam by increasing the number of questions to 50. We change out approximately one third of the exam questions each year so that over the course of a 3 year residency, residents are exposed to 85 different exam questions in each specialty but still have the opportunity to retry some questions.
As the program has been developed, we have seen a steady increase in our certifying examination pass rate with 100 percent of residents passing the exam in 2007 and an increase in our 3 year rolling pass rate from 70 to 82 percent.
For additional information, contact Dr. Parker.
In the Spotlight
Recognitions
Welcome to Jim Lopez, the new administrative assistant for graduate medical education office. His office is on the fifth floor in the 2040 building. He can be reached at 702-671-6401 or email.
Welcome to Dianne Paniagua, the new human resources staff responsible for resident activities such as benefits, employment agreements, and insurance. Her office is on the fourth floor of the 2040 building and she can be reached at 702-671-2391 or email.
Residents to Pursue Fellowships
This year has been a banner year for residents matching or being accepted for fellowships in subspecialties of their chosen disciplines. Sending residents across the country to do their fellowships demonstrates the quality of our trainees and publicizes the school. Congratulations and kudos to the residents, their program directors and their faculty.
- Ming Zhou, OB/GYN 2008: Maternal Fetal Medicine at Wright State University Boonshoft School of Medicine (OH);
- Aimee Fluery, OB/GYN: Gynecological Oncology at Johns Hopkins School of Medicine;
- Naseem Sulayman, Pediatrics: Pediatric Critical Care at Case School of Medicine-Rainbow Babies and Children’s Hospital (OH);
- Jeremiah Nielson, Pediatrics: Neonatology at Children’s Hospital of Los Angeles, University of Southern California Keck School of Medicine;
- Kanayo Ezeanolue, Pediatrics: Neonatology at Children’s Hospital of Michigan, Wayne State University School of Medicine;
- Paul Do, Pediatrics: Pediatric Pulmonary at Miller Children’s Hospital, University of California, Irvine;
- Neepa Gurbani, Pediatrics: Pediatric Pulmonary at Cincinnati Children’s Hospital Medical Center, University of Cincinnati School of Medicine;
- Shruti Kant, Pediatrics 2008, present chief: Pediatric Emergency Medicine at Children’s Hospital, University of Alabama-Birmingham School of Medicine;
- Shyama Kamat, Pediatrics: Pediatric Emergency Medicine at Miami Children’s Hospital of Florida International University College of Medicine
- Harinder Singh, Internal Medicine 2007, chief 2008: Endocrinology at Dartmouth School of Medicine (NH);
- Elham Taherian, Internal Medicine 2008, present chief: Rheumatology at Cleveland Clinic, Case School of Medicine (OH);
- Hilary Crawford, Emergency Medicine: Emergency Sports Medicine at Geisinger Health System (PA)
Surgical Critical Care Fellows
- Congratulations to the Department of Surgery who filled both openings in their match for surgical critical fellows. After completing this aspect of their training, these fellows will proceed to the acute care surgery fellowship. This fellowship, which was fully sanctioned by the American Association for the Surgery of Trauma, is the first such program in the country. The fellowship director is John Fildes, M.D.
Psychiatry
- Greg Brown, M.D., psychiatry program director, along with Tami Abu Hantash, C-TAGME, coordinator, will present a poster titled From Rating Scales to Specific Competencies: the Evolution of Resident Evaluation Forms at the University of Nevada Psychiatry Program, Las Vegas. The poster will be presented at the American Association of Directors of Psychiatric Residency Training in Tucson.
- Dr. Brown will also present a workshop at this meeting with Alison Netski, M.D., associate program director titled Jung and Campbell: Introducing a Framework for Presenting Spirituality in a Psychiatry Curriculum.
- Kudos to Ryan Ley, M.D., first-year child psychiatry fellow, who was selected to be a Child PRITE fellow. This is a very competitive, national position as only two child psychiatry fellows are selected from fellowships across the country. Dr. Ley’s role as a Child PRITE fellow will be to participate in the writing questions for the national in-training examination. This experience will give Dr. Ley the opportunity to meet and work with prominent child psychiatrists from across the country. This is also another opportunity to get the University of Nevada School of Medicine name associated with a national project.
In This Edition
From the Desk of the Associate Dean
The Latest on Graduate Medical Education at the School of Medicine
From the ACGME
Involving Residents in Quality Improvement: Contrasting "Top-Down" and "Bottom-Up" Approaches
Best Practices
Ramping Up Board Passage Rates
In the Spotlight
Residents to Pursue Fellowships
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.