blOGME - Osteopathic Graduate Medical Education Blog

Everything flows...nothing stands still...the final installment

2012-03-06T22:26:00.000-05:00

I know that you have all been on the edge of your seat for part 3, so without further adieu, here it is, the last facet, organizational flows…

· The AODME is in the midst of a strategic planning process. This has entailed using proven methodology to flesh out our goals and aspirations as an organization. The board held a planning retreat in July (in conjunction with the AOA House of Delegates) and there were surveys of membership before and after this retreat. One large move is the decision to focus on excellence in Clinical Osteopathic Medical Education. This includes the undergraduate, graduate and continuing medical education spheres, with an emphasis on OGME.

· As many of you know, the AODME has purchased management services from the AOA since 2003. This contract has been automatically renewable on a yearly basis. The AODME shares a close working, teamwork relationship with the AOA and recently had Susan Sevensma, DO appointed as the liaison from the AOA Board to the AODME Board. This is a first for both organizations.

· Finally, the AODME underwent a by-laws change in December of 2011. This change culminated four years of discussion on the topic, through three annual meetings, multiple surveys and drafts of the changes. The by-laws were ratified by a 90% positive vote of two thirds of the members. This was not small accomplishment for a small and diverse organization. The changes brought the AODME in line with the current structure of OGME, including the realization that most DMEs commune as OPTIs.

Everything flows…nothing stands still. The AODME and OGME are certainly proof of this.

Everything flows...nothing stands still...Part 2

2012-03-05T23:13:00.000-05:00

To continue on from yesterday’s beginning financial flows in OGME are the next topic.

· Last week Bloomberg Government released a study that discussed the impact of several cuts in payment from Medicare for Graduate Medical Education. The bottom line is that both the Simpson-Bowles Commission’s proposed $60 billion cut over 10 years and President Obama’s ~ $10 billion over 9 years would have a significant impact. One of the most interesting findings – a particularly ominous one for OGME and the osteopathic profession – is the notion that the cuts would disproportionately impact primary care. This is because Medicare pays hospitals for medical education and primary care is not done in hospitals. As hospitals look to recoup the lost revenue, it holds that they may wish to have more service for the trainees. Trainees that provide service to hospitals are specialty trainees, not primary care trainees.

· The second financial concern on the minds of osteopathic directors of medical education (DMEs) is the now enacted fee change for OGME programs. This was enacted by the Executive Committee of the AOA Board in early December. Some might remember that there was a great deal of concern surrounding this policy amongst DMEs last Spring. blOGME commented on the topic in the inaugural post and again here and here. I’m sure that we can expect more comment in Louisville in April.

· The final financial concern on the DME mind is the stability of hospitals where OGME takes place. There has been no shortage of hospital consolidations, bankruptcies and closures over the last ten plus months. Again, OGME may be disproportionally impacted in this arena as more community hospitals are targeted. We have seen hospitals in New York, Michigan and Pennsylvania mentioned. What impact lasting consequences this has on OGME remain to be seen.

The goal is to have more tomorrow.

For some additional reading, see several worthwhile blog posts on primary care’s future and funding.

Everything flows...nothing stands still

2012-03-05T00:14:00.003-05:00

I had the honor to represent the AODME this past week at the AOA’s Midyear Board of Trustees meeting. On Friday, I delivered a brief review of issues and happenings in OGME and the AODME. I will share them with you here, in a somewhat expanded outline form. Over the next few months, I hope to expand on several of the topics.

I have noted the Greek philosopher Heraclitus previously. He is the one who noted that nothing endures but change. In the same breath, he also noted that “everything flows” and that “nothing stands still.” This latter two points probably sum up well Graduate Medical Education in the United States and OGME in particular.

Recent flow can be highlighted in three areas: operational/accreditation, financial and structural.

Operational/accreditation

· The “new” AOA program standards in many specialties and new crosswalks have been in play for several months now. Early feedback from programs, OPTIs and the November PTRC meeting were generally positive. More change is coming in this area in the form of institutional accreditation. This is new to AOA programs and the devil will be in the details of implementation.

· The AOA match has come and gone. While the match statistics are interesting (and pontification on their meaning is an annual early February topic much like Punxsutawny Phil’s shadow), “matching” for osteopathic programs is a 5 part process – AOA match, scramble, wait, NRMP match and finally another scramble. The wait until the final process is delayed this year by SOAP – not what you wash one washes their hands with – by the Supplemental Offer and Acceptance Program of the NRMP. The structured scramble. The uncertainty for OGME is that unmatched DO students are bound to SOAP prior to scrambling “back” to OGME programs. The impact remains to be seen, but many osteopathic DMEs and program directors are rightfully concerned.

· The final area of uncertainty comes from the proposed ACGME rule that would require AGCME training as a prerequisite for further ACGME training. ** I purposefully linked to a Google search for "ACGME proposed rule" here so you can see the reaction yourself. ** blOGME has previously highlighted the details. It seems clear that the proposed rule will have some impact on current students given anecdotal reports from the field. The AOA and the ACGME are meeting on the topic of collaboration. I am honored to be part of those deliberations. If readers have not yet viewed ACGME CEO Tom Nasca’s piece in the New England Journal of Medicine on the Next Accreditation System (NAS) they should do so ASAP.

That is probably enough to keep one busy for now. I will follow-up on the other two topics in the coming week.

AODME By-laws changes...

2011-12-05T21:54:00.000-05:00

As the members of the AODME know, an update to the organization's by-laws are now out to the membership for a vote. This is the culmination of a two year process that is aimed at aligning the by-laws of the AODME with the realities that currently exist in OGME.

The key changes are:

The executive committee terms move from two to one year and the position of immediate past president is added. This reflects a desire to have more members be involved in the executive leadership of the organization. Currently, there are 5 positions (Secretary, Treasurer, President-elect, President and Past-president) with two year terms. This limits the elections to odd numbered years and results in 10 years on the executive committee. The change would have a 6 member executive committee with yearly elections and 6 years on the committee. The addition of immediate past president (or past president depending on one's perspective) was sought to lend institutional memory to the board.
Removal of 4 sub-category (OPTI, COM, Specialty College and Hospital) trustees. These positions have been difficult to define since their inception and do not serve a constituency.
The addition of OPTI Council Appointed Trustees. As has been noted at the last several meetings, the AODME, the AODME is seeking to work with OPTIs and the DMEs that comprise OPTIs to provide a advocacy and educational voice for this significant cog in the OGME machine. This change recognizes that DMEs are aligned as much with OPTIs as they are with regions and allows for a blend of leadership. OPTI Council Appointed Trustees must maintain the same membership requirements as regional trustees.
Changes to terms of of trustees from three to two years. The overall limit would remain 6 years. This change also allows more members to have the opportunity to be members of the board.
Re-distribution of the AODME's regions to represent the current make-up of OGME.
Codification of governance items such as quorums, committees and special meetings. In each case, the bar was set to allow inclusion and representative participation.

Many members worked hard to bring this to fruition. This includes both members of the executive committee, board and rank and file members from all regions and backgrounds. This process began in 2009 and there have been multiple avenues for comment and evolution. This includes, but is not limited to:

Both the 2010 and 2011 Annual meetings
Email appeals in the Fall of 2010 and 2011
Multiple surveys of membership

I set a goal to move the organization forward. I do not expect all to agree on what this means. I do expect to be transparent and build consensus. I am comfortable that we have accomplished both with these proposed changes.

Part of this goal is a up or down vote on the by-laws change. It is time to fish or cut bait. While no proposal will be perfect, this is a good, team approach. Regardless of your view, it is important to participate in this endeavor. I appreciate the collegial and professional debate.

Thanksgiving, a time for reflection.

2011-11-26T20:19:00.001-05:00

It seems that for many, Thanksgiving is a time for reflection. There are many things, some personal - some collective, for which to give thanks. In the spirit of reflection, I'd like to give some updates on past posts and see where we are now in the OGME worlds.

It has been some time since my last post! I was hit by the confluence of MBA residency, two sons and a daughter headed back to school and the realities of a turn in my professional life. But, enough about me...I'm back for now!

In an earlier post, I noted that there were a multitude of AOA standard's changes up for comment. These included the changes to the standards for Osteopathic Postgraduate Training Institutions (OPTIs). This were subsequently approved by the AOA's Council on Postgraduate Training (COPT) at their November meeting. There, for better or for worse, were few comments. While I'm sure that some will come back and wonder the who, why, when and where of these standards changes, little can be said about the transparency of the process.

I have noted several times that I participated in a conference on the future of graduate medical education in the United States in May. This was sponsored by the Macy Foundation. The report from this conference was published online and the monograph has been printed. There has been quite a bit of discussion in both the lay press and the medical media on this report. The Federal government's Council on Graduate Medical Education discussed this at their most recent meeting.

In October the ACGME published proposed changes to their Common Program Requirements. The changes would require ACGME (or Royal College of Physicians and Surgeons of Canada) accredited training as a prerequisite for further ACGME training. This would significant alter several ACGME residency programs' practices, such as Family Medicine, Radiology and Physical Medicine and Rehabilitation residencies. It would also significantly impact fellowships in several specialties.

These changes have several potential unintended consequences to GME and physician workforce. There are also several direct consequences to osteopathic trainees. The changes included an impact statement that tangentially questioned the veracity of AOA accreditation of GME. The AODME along with the AOA and AACOM submitted comments on the proposed changes. Many other organizations, both within and outside the osteopathic community also commented on the proposals negative impact on osteopathic physicians. We all eagerly await the outcome.

As the end of the year holidays come upon us, the AODME has published for approval changes to the organization's by-laws. These changes, which I will discuss in a subsequent post, aim to update the by-laws and the AODME to be in line with the current realities of OGME.

Finally, in a weekend of thanks, I am thankful most for my family. Thanksgiving weekend is always a joy to spend time with my immediate and extended family. I am especially thankful for Ava, Ben, Ethan and Michele! They keep me going through thick and thin!

Proposed Standards changes up for comment

2011-08-19T08:07:00.000-04:00

Follow-up is now available from a previous post on vigilance and the comment period for new standards. Earlier this month (in the last week or two) the standards approved at the July Council of Postdoctoral Training meeting were posted. The can be found on the AOA's web site at this link.

There is also a link to the email address where comments should be directed. This is: Postdoc@osteopathic.org

The comment period is 45 days - so this should be around the end of September.

There are substantive changes in the Osteopathic Postdoctoral Training Institution standards up for comment. These implement policy changes that have been discussed at multiple forums.There are also re-writes of many specialty standards.

This is the opportunity for the osteopathic graduate medical educators to be part of the process.
All are encouraged to comment!

Rested doc + EHR + ACO > tired doc + paper chart + solo practice...right?

2011-08-16T23:26:00.001-04:00

The answer is likely not right or wrong. This is the conundrum of patient safety. It is multifaceted. Fixing one thing in isolation may do little. In addition, "fixing" may actually make things worse because of the unintended consequences of the fix.

There are several areas that are great examples of this: duty hours rules and the electronic health record (EHR).

First, a little more on the complexity of patient safety. If it was easy, there wouldn't be a problem. There wouldn't be a Quality Chasm to cross.

One of the better visual schema on medical errors is the Swiss cheese model. This was formulated in England by James Reason. The logic is that we have many fail safes in medicine to keep errors from occurring. Each process is like a slice of Swiss cheese - each has many holes. When the processes are put together - like a block of Swiss cheese - the holes do not line up and all is well. But, every now and then, the holes line up and bad things happen.

Near misses? The hole went almost all the way through, but one or more slices saved the day - maybe a timeout in surgery or a second nurse double checking the label on a bag of blood.

Think of trainees cognitive ability like a slice of Swiss cheese. Pretty solid, but some holes. The duty hours changes made the holes that represented sleepy, cognitively impaired trainees smaller. But they still make mistakes (holes).

The changes opened up big holes on other slices, namely situational awareness. This lack of situational awareness happened because there was a hand-off. This hand-off is generally poorly done. This was an unintended consequence. This is why the changes didn't improve patient safety.

We need to do a better job teaching and standardizing hand-offs!

We can do this - check out several publications and presentations by Vineet Arora. You can also check out her blog. In one recent publication she and colleagues showed that pediatrics interns only handed-off topics well 2/3 of the time - at best. It was about a third for knowledge items. In spite of this, they generally thought they were doing well.

The electronic health record is another mystifier. Again, it seems to make perfect sense that having a legible record that is readily available, and can offer some decision support, should make care safer. But...we all know that there are many unintended consequences. These are so numerous, that we have a taxonomy of EHR unintended consequences.

The EHR has also stifled consultant verbal communication. Why talk, it is in the chart?!?

Finally, the EHR has given us the millennial version of medical cheating: CoPaGA - Copy and Paste Gone Amok. This entails plagiarism of others notes and confirmation bias when erroneous information is carried forward without thought.

Are the holes winning?? It is a neck and neck race from my seat.

So, to bring this back around to osteopathic graduate medical education, it is our job as medical educators to keep the holes from lining up!!

We need to teach hand-off communication, both written and verbal. It needs to be taught formally and tested formally (I see an OSCE in your future).

We also need to teach how to use the EHR and the new professionalism that goes along with this tool. This is not typing 101. It is how to study and implement effective process changes. Another need is professional communication and the roles of each member of the healthcare team.

The alternative is 1 + 1 will equal zero, or, the will be many holes lining up in our Swiss cheese.

I'm so tired, I haven't slept a wink...Duty hours and OGME

2011-08-10T17:03:00.001-04:00

July 1, 2011 brought new duty hours rules to OGME programs and their ACGME counterparts. This has led to a significant number of commentaries in the print media (LA Times, NY Times) and on-line in the blogosphere.

It is a common sense (I realize that this is not "common") given that less long hours is a satisfier for trainees. I cannot blame them. While I trained in the halcyon days of 48 hour shifts and minimal supervision, I consider myself wise enough to see the error in those ways. I do not remember enjoying any part of that experience.

I think that there is adequate evidence that less sleep to less cognition. Poorer quality of cognition leads to gaps in patients' care. Patient care gaps are bad.

I am also a pragmatist and realize that duty hours rules are not going away. I also am aware that there are those who feel that they do not go far enough.

Given this reality, what are some of the other unintended consequences of this paradigm shift? Here are a few:

1. If the current residents are not going to be around to care for the patients, who will? This is a significant policy question. The call for 24/7 coverage of hospitals compounds this reality. A recent blog post by Brad Flansbaum, DO for the Society of Hospital Medicine elucidates more issues on this topic.

2. While the QUALITY of education rises with a higher level of cognition, the decrease in hours (and in many instances census) decreases the QUANTITY of education. This may not be all bad as there is some evidence that our current quantity paradigms are flawed. In a competency-based world it is outcomes that matter, not time served. The problem is that we are “not there” yet. There is also a suggestion, both anecdotal and some evidence that time (likely maturity) may matter.

3. See #1 and #2…If we need more physicians to care for the patients and if those physicians are trained in a paradigm of decreasing workload (hours and volume), then we will need even more physicians. It is a self-perpetuating cycle.

While I do not have the answers to solve this problem, we need to look at #2 for answers. What is the needed education? What does the physician of the future need to know and how to we train this in the new paradigm? Who are our partners on the healthcare team and how can they help solve this dilemma?

Some of solutions are beginning to be developed. We have discussed some of them in past posts. We need to change what, when and how we teach.

We need to train thought not facts.

We need to train leaders not managers.

We need to communicators not commanders.

The solutions will require open minds and innovation.

Rest assured there is no turning back!

July Education Cluster - Eternal vigilance is the price of liberty.

2011-07-27T13:01:00.002-04:00

In the middle of the heat wave, the July education cluster meetings took place last week, both in person and virtually.

For those of you not familiar with these meetings, they generally occur in Chicago at the O'Hare Hilton. Many people ask me "How was the weather in Chicago?" My general response is that "I have no idea!" Chicago is a misnomer in this case as the Hilton and the airport is connected by a tunnel and after I walk into the airport in Wilkes-Barre I don't feel the outside air until I return to Wilkes-Barre.

The Council on Osteopathic Postgraduate Training Institutions (COPTI) met by phone on Wednesday. There was an active discussion and subsequent approval of new OPTI standards. COPTI also discussed a new approval paradigm for OPTIs. This would create a process much like hospitals and colleges of osteopathic medicine where fully accredited OPTIs have a five year approval. It also includes interim monitoring rubrics on a regular basis.

The Program and Trainee Review Council (PTRC) met on Thursday. Hospitals, OPTIs and Specialty College Evaluating committees (SPECs) collaborated on accreditation decisions on 71 OGME programs. The PTRC also discussed the inspection protocols for Emergency Medicine, Family Medicine, Internal Medicine and General Surgery programs. As of July 1, these specialties have "new" accreditation standards. These standards are devoid of institutional standards as the future plan is to review this as part of to-be-implemented institutional review. A hybrid approach will be used employing the specialty crosswalk and a modified institutional crosswalk. A multi-specialty team developed this approach.

Finally, the Council on Postdoctoral Training (COPT) met on Friday and Saturday. The bulk of this meeting encompassed approval of another round of "new" specialty Basic Standards. SPECs and the COPT have done yoemans work over the last 12 months to re-write, edit and approve these standards. The COPT also addressed several other policy issues involved with OGME.

It is also worth noting that all COPT actions will be available for public comment. Those comments must then be addressed by COPT. This includes all the specialty college standards and OPTI standards. A programing note...the current standards on this link are from the April COPT meeting. (UPDATE: old standards removed July 29, 2011)

blOGME will do its best to alert the OGME community of the opportunity to comment. The suggestion is not that everything needs changed or comment. By the same token, we should no longer hear "How did that happen?"

Transparency is here!

Eternal vigilance is the price of liberty! It is up to the OGME community to accept the challenge of keeping vigil.

AOA BOT and HOD Update

2011-07-26T21:57:00.001-04:00

First, let me apologize for the hiatus. It has been two weeks since my last blog.

Those two weeks were filled with the AOA Board of Trustees meeting and House of Delegates. Also that week was the AODME board retreat. Finally, the AOA’s COPTI, PTRC and COPT – the GME Cluster – met this past week.

Some updates on all in the coming days!

AOA Board of Trustees

· The AODME sponsored repeal of resolution 29 – discussed in an earlier blog – was approved. This resolution calls for the AOA’s Bureau of Osteopathic Medical Education (BOME) – now led by the able hands of Don Sefcik, DO – to produce a White Paper on the AOA’s Approval of ACGME training. This makes sense since it is made up of Directors of Medical Education, College of Osteopathic Medicine (COM) reps, OPTI reps other educators and intern/resident and a student.

· A resolution from the Bureau of OGME Development to codify the exceptions for program directors of OGME programs was approved. I will elaborate on this in a later post.

· The concept of “Independent Inspectors” for OGME programs was endorsed. This will begin in July 2013. Specialties will be able to approve inspectors from a short list (3 to 8) provided by the AOA.

· The OGME fee schedule discussions were tabled...for now. This will return closer-in to 2013 and the implementation of the previous bullet.

· The concept of OPTI Academic Sponsorship and expanded Base Institution definitions for OGME were endorsed by the board.

The AOA House of Delegates followed and was exciting was usual, but did not include any large OGME issues.

One particular note was the AOA's support of the new NRMP "All in" proposal (see left column). This would require all entrants in the NRMP match to go through the match. As the OGME follower knows, this is a significant departure from current practice where COM grads can sign outside of the match. While this was approved by the NRMP board it is not final. Comments can be offered here. The NRMP is specifically looking for comments on "Programs accredited by the ACGME and the AOA."

Finally, following the Board and House meetings, the new AOA appointment book was released. This contains a nice mix of volunteers whose service to the profession and OGME are greatly appreciated!

The AODME has made a commitment to keep our membership, and the blOGME universe, informed of AOA happenings through many of these appointments.

Finally, the week included the inauguration of Martin Levine, DO as the new AOA President. Dr. Levine's inaugural address is worth a view or read. He urged us to "Think Osteopathically" and to "Practice It, Prove It, Publish It and Promote It"

blOGME intends to continue to do just that!!

What kind of work?? TEAMWORK!!

2011-07-12T15:16:00.002-04:00

For those of you with young children, you may recognize the title as a catchy (sometimes so catchy that one can't get it out of their head) theme song for Nick Jr.'s Wonderpets. Every time I hear the song (and I hear it frequently) I cannot help but think of Karen Nichols, DO's (current President of the American Osteopathic Association) them for this year of TEAMWORK.

Teamwork is essential to the delivery of quality medical care. Given this, teaching and mentoring teamwork is also essential for OGME.

I played on Juniata College's baseball team many years ago (glory days alert). Baseball has 9 players on the field at a given time and a successful team has many pitchers and non-starters that contribute. My college baseball team had arguably (I may be biased) the most successful three year stretch in the schools history. There was only one player on those TEAMs who I would label a star (and it wasn't me). We were successful because we were a cohesive team.

Medical care is much the same. High quality care in the 21st Century is delivered best by a health care team. These teams are not one-size-fits all. Physicians need to be members of these teams, but may not lead every aspect of these teams...but...physicians need to be leaders.

To be leaders, physicians need to understand team dynamics. To be leaders, physicians need to understand the perspectives of other members of the team (advanced practitioners, nurses, care managers, physical therapists, social workers, etc.). To be leaders, physicians need to be able to effectively communicate.

So, do we teach all of this in our OGME programs?

The honest answer in my view has to be: No, not very well...yet. At the yet is the takeaway from this post.

A recent monograph from the Josiah Macy Foundation on Intraprofessional Education give a good road map of how to achieve yet. The topic of teamwork was also the foundation of the recent AODME/AACOM meeting in Baltimore.

Our current Basic Standards for residency training do not promote teamwork and intraprofessional training as much as they should, but they also do no inhibit programs from innovating. The former needs to be bolstered.

It should not be possible for future residents to graduate from our programs without having both training and experience with working in health care teams. They should also have explicit opportunities to lead health care teams. We also need to look for opportunities to leverage intraprofessional relationships that exist within some of our Colleges of Osteopathic Medicine to learn side-by-side with other professionals.

My personal sentinel model of health care was a brilliant team. It was a "womb to tomb" primary care physician and his wife. Together they were doctor, nurse, pharmacist, counselor, receptionist, secretary and office assistant. Other than the first two roles they shared almost everything else. That TEAMWORK provided excellent medical care for 40+ years. That team was my grandparents. Our patients need more relationships like this.

TEAMWORK needs to be one focus for OGME in the future. TEAMWORK requires both give and take - and this will likely be one large challenge as we move forward, but our patients will demand the quality of care that only TEAMWORK can provide.

Accountable Osteopathic Educational Organizations - AOEOs coming to a hospital near you!

2011-07-08T21:57:00.001-04:00

So the buzz in the health care community right now is Accountable Care Organizations (ACOs). The concept is an entity that is accountable for the care of populations of patients. This entity encompasses hospitals, physicians, care management entities, home care, dialysis centers, etc., etc., etc. The overarching goal is that there is improved value (quality and cost) to the patient. There are multiple entities that are mentioned as shining examples of this model. Critics proclaim that this cannot be done broadly and that we should not even try.

Apart from, yet concomitant with this trend is the discussions in Washington about accountability in graduate medical education. This is coming, maybe sooner than we think.

Students of the game are well aware of the MedPAC report on the subject of accountability of Indirect Graduate Medical Education (IME) dollars. There was a New England Journal Opinion piece from MedPAC on the same topic. In addition, there was a front page article today in the Boston Globe discussing both decreases in GME funding from the Federal government and the lack of accountability in the current system.

What will accountability mean? It is any one's guess, but if I had to read the tea leaves I would start at the Compare Quality web site mentioned in a previous post. The Center for Medicare and Medicaid Services (CMS) has laid the groundwork for what it sees as transparency here. It has also given a glimpse of the clinical metrics that it intends to use in the future in recent rules and proposed rules regarding Value-Based Purchasing (VBP). The OGME world can expect educational metrics in the not-so-distant future.

Specifically, expect to see: program size, program retention, board pass rates, graduates that practice in under served areas, graduates that practice within 25 miles of the training site, graduates of internal medicine and pediatrics programs that practice primary care.

Secondary, one may see: does the hospital have an EHR, how much of the training is ambulatory, what are the procedure rates when applicable, is there training directly with other types of providers?

A next level may be: continuous certification results for graduates, VBP results like HbA1C, LDL cholesterol, ACE inhibitors for CHF, etc. for graduates, state board of medicine actions for graduates. Maybe I'm stretching, maybe I'm not. If you were looking for a doctor, wouldn't you want to know how the program where he trained performs. And by performs, you wouldn't really care how big the library is...would you??

The list is endless. VBP is approaching 100 inpatient and outpatient measures, so, while I am being provocative, I am not wildly outside the box.

One additional note is that most of the VBP metrics have been vetted by and endorsed by the National Quality Forum. There have been calls for a similar group for GME metrics. It will be critical that OGME is represented at that table.

Change is coming! It will make the present discussions look quite petty. Are we ready??

AOA BOT in 3 days HOD in 7

2011-07-08T21:22:00.003-04:00

A quick shout out to the upcoming AOA policy meetings next week in Chicago. The AOA's website has the most up-to-date information on these meetings. One can find the SCHEDULE, BOARD of TRUSTEE resolutions and HOUSE of DELEGATE resolutions.

The AODME board will also meet in Chicago for a strategic planning retreat in hopes of charting a path for the future of OGME.

An added highlight from my previous post on the meeting is BOT Resolution 58 which changes both the make-up and charge of the Bureau of Osteopathic Education (BOE). It will take some time to digest what these changes mean, but it appears that the resolution moves in the direction of removing a layer from the AOA's OGME processes. The functionality of the resolution remains to be seen.

Expanding OGME - Shared Resources ... Shared Responsibility

2011-06-29T08:32:00.001-04:00

There was an interesting article in the New York Times on June 17^th that discusses Medicare’s claim that CT scanning is overused in many of the nation’s hospitals. This was especially apparent in non-academic centers. “Double scanning” means ordering both a contrast and non-contrast scan of the same body part on the same patient. This is part of Medicare's new "use of medical imaging core measures" on their Hospital Compare site.

Also of interest was the fact that, as with most Medicare data, there were wide disparities both locally and nationally. For instance, the rate of “double scanning” was only 1% in Massachusetts and was 13% in Oklahoma.

So what does this have to do with OGME you ask??

Well, if one follows the link to the article, they will see that there is a wonderful interactive map attached. While this map is intended to give the viewer an idea of the CT problem spots, it also provides a wonderful interactive look at ever hospital in the United States that does CT scans (and every hospital in the US that sponsors OGME). A quick glance and the reader will note that most of those hospitals are on the East Coast. The reader will also note that there are relatively fewer West of the Mississippi.

Much like OGME programs…

Much like ACGME programs…

The geographic misdistribution of AOA accredited OGME programs is a real problem that gains much air time in educational debates. There is an excellent map showing this data published in the recent education edition of the JAOA.

As noted, this is not unique to OGME. When I ran the data in 2006, the distribution of OGME shared significant correlations with both US population and ACGME programs by state (California and Texas being the glaring exceptions). While I have not run the data recently, I see no reason to suggest that this has changed in a negative way.

I want to be clear – I’m not suggesting that there is not an OGME distribution problem. There are clearly issues in the West and some of the South. There are also discrepancies in New England as well, but we rarely here about this. I make the comment because I believe that we should resist the temptation to focus only on areas of perceived need. When we worry about the size of the slices of pie, we simply get in our own way and do not move forward to accomplish our ultimate goal - making the OGME pie bigger.

The solution is to build programs – anywhere that we can build them – anytime we can build them.

It seems synergistic to build these programs in areas that are geographically contiguous with our Colleges of Osteopathic Medicine, but … we need programs anywhere that we can make them happen.

It seems to make sense to have Osteopathic Postgraduate Training Institutions (OPTIs) involved in building programs – many have done a superb job – but … we can’t afford to limit our scope to just OPTI generated growth.

Maybe we should look to virgin hospitals (those without any current GME)? Maybe we should look to dual accredit programs that are already ACGME accredited? Maybe we should look to alternative sites like Federally Qualified Health Centers (FQHC)? The answers to these questions?? YES, YES and YES!!

Should we build specialty programs or primary care programs? I think that by now you know my opinion...

To increase the size of the OGME pie – our ultimate goal to train our COM grads and provide value to the public – we cannot be parochial in our means to meet the end. Any time, any where and by anyone. In the words of Harry Truman: It is amazing what you can accomplish when you do not care who gets the credit.

The gorilla in the room and what are we going to do about it!?!

2011-06-22T15:05:00.002-04:00

Last night I presented a consultant training webinar for the AOA’s Bureau of OGME Development. Check out the link if you are interested. One of the astute questions (and I’m paraphrasing) was:

What is the AOA going to do about GME when the American Association of Medical Colleges (AAMC, organization of MD schools, organization of schools that are accredited by the Liaison Committee on Medical Education (LCME) – the accrediting body for MD schools) just announced that their numbers of graduates will be up 27.6% by 2015? (Adding the DO graduate increase will bring that total to 35%)

This is the gorilla in the room!!

The short, analytical answer is: barring significant paradigm shifts, the numbers do not and will not compute. One can sugar coat this problem as much as they like, but without significant change, 1 + 1 will not equal 10.

This is why I think that change will happen…shortly. This is also why I think that it is critically important that we stop living in the OGME past. There are many calls for reform out there (COGME, Macy, ACP). We pride ourselves on being nimble and efficient. Do we have the vision (and the drive) to heed these calls and change?

Some of the most obvious change targets which I will discuss over the next several weeks are:

· Providing training where patients receive their care.

· Encouraging team-based training in our residency programs.

· Changing the national financing structure of OGME.

· Looking to alternative institution sponsorship of programs (not to be confused with academic sponsorship).

Who will we lead this change?

There will be a new generation of leaders in OGME (and I am in no way suggesting that I am one of them). There are currently around 78,000 DOs in the United States. There are over 18,000 students enrolled in our schools. One doesn’t need Excel to do the math. The tipping point is near. This is not a doomsday prediction and don’t even believe that this is hyperbole.

I would suggest that our biggest problem right now is that an OGME educator farm system does not exist. Even worse (yes another sporting world analogy) we do not have any bench strength. This is what keeps me up at night!

Almost all know the oft quoted warning from George Santayana’s The Life of Reason: “Those who cannot remember the past are condemned to repeat it.” This is sometimes used to suggest that absolute change is good and the past was bad. The overlooked preceding lines state: “Progress, far from consisting in change, depends on retentiveness. When change is absolute there remains no being to improve and no direction is set for possible improvement: and when experience is not retained, as among savages, infancy is perpetual.”

The leaders of the future remain to be seen. Our institutional memory will be important to osteopathic medicine’s future. It behooves those of us that were or are currently in leadership positions to CONSTRUCTIVELY (my purposeful emphasis) recruit and mentor these new leaders, help them with the history and not handicap them with the current “toolbox.” One important role for the AODME moving forward is nurturing future OGME leaders.

Feedback is good!

2011-06-16T17:41:00.002-04:00

Feedback is good! Yet all to often, we are reticent to provide feedback to our colleagues, our trainees and ourselves.

There is a large body of research that suggests that one of the key drivers of human behavior is feedback. This feedback may come from within - completing a task and gaining satisfaction from the completion - or from without - a faculty member/program director/DME providing feedback to a trainee. How this latter feedback is delivered is critical as destructive feedback can do much damage.

The AODME recently received feedback on the 2011 joint Annual Meeting with AACOM. This feedback was all GOOD!!! That is not to say there there were not both positive and negative comments - there were both - but the simple task of attendees taking the time to honestly comment and the review by both the program committee and individual faculty members is nothing but GOOD. Over the years, I have learned from playing both roles - program planner and faculty member.

As a program planner, it is clear that our members want interactive sessions that provide practical information on how to perform their daily job. As DMEs one is an educator, leader, manager, human resource specialist, counselor, marketer and cheerleader all wrapped up in to one. The AODME needs to provide support for all of these roles. There is also a need to inform our members of how outside agencies and outside regulations impact their jobs. Members are also quite sensitive to extreme opinions on topics. Those appear to be better received when they are balanced by a panel of varied views.

As an individual, I relish the feedback to help me improve. Generally individuals flow right to the negative comments. The second reaction is usually defensive. Once one gets past these knee-jerk tendencies, the real meat of personal improvement ensues. Willie Stargell (I'm a Pirates' fan and Willie was the captain in 1979 when they last won the World Series) said: "I eventually became proud of my strikeouts, because each one represented another learning experience." One of my personal shortcomings is the use of acronyms - alphabet soup. I have set a goal to work on this. Thanks for the tip!! I received a curious comment several years ago, someone in the audience interpreted an aviation reference that I used regarding Tenerife and patient safety as all wrong. This person was a pilot. I missed the point. I subsequently improved the delivery. Thanks again!! I used a reference to ACGME DIO's that there were not degree requirements. I said that one didn't "even need a high school diploma." My point was that the ACGME has an open process. My comment though was perceived as condescending. I appreciate the perspective - thanks! I'm always reminded that we all touch a different part of the elephant!

The bottom line is that each comment has helped me grow. We never stop learning!

The bottom line...generous amounts of collegial, professional feedback is one of the greatest learning tools we have.

Resolutions for AOA BOT and HOD are TRANSPARENT!!

2011-06-14T10:16:00.002-04:00

"If a tree falls in a forest and no one is around to hear it, does it make a sound?"

You may have heard me use this same quote as a metaphor for transparency. We talk much about transparency in our lives. My view is that many times it is false transparency - practically opaque. The World Wide Web has only heightened this illusion. Just because something is posted on the web doesn't mean that those who need to see it have seen it, or digested it or understood what they saw. This is part of the theory behind the "seven times...seven ways" marketing strategy. Humans need to see things multiple times and in multiple forums before the light bulb "turns on." Telling a trainee once to give ACE inhibitors to patients with CHF will not encourage them to do this all the time. Nor will giving them a textbook, or showing them a web site or listening to a lecture. But doing all of these over and over will embed the knowledge and the process.

So, in search of transparency, we bring you the following facts and opinions...

If you follow the AOA Daily Report Blog, you may have noted last night that the resolutions for the AOA's Annual Business meeting are up on their site. They can be found HERE.

A quick review of the Board of Trustees resolutions relevant to OGME:

B-7 - Resolves to increase the size of the PTRC to include all subspeciaties that are both permanent and rotating members as permanent members. (FYI, I personally support this)

B-12 - Resolves to amend the requirements for program directors. This comes from the Bureau of OGME Development - on which I and several other AODME members participate. This resolution would allow acceptance both AOA and ABMS certification for DOs who are program directors. It would also codify the needed mentorship for MDs to be program directors. Several important points: it does not effect the DME role, in fact, it should help DMEs recruit well suited program directors and it does not make it easier to have MDs as program directors. It does standardize practices across disciplines. I support the language and the intent of this resolution. It will make enhance DMEs ability to recruit willing, able and qualified program directors.

B-13, B14 and B-49 all address Resolution 29. They are resolutions from POMA, OOA and the AODME respectively. The AODME resolution has also been forwarded through the Bureau of Osteopathic Education (BOE).

B-15 and B-16 are from the ACOFP. They deal with independent inspectors and the AOA's proposed post-doc fee schedule respectively. I have several earlier posts on the latter topic.

B-21 - Resolves to allow Category I-A CME credit for the AODME Convention. It should be obvious that I support this. Having chaired this meeting for two years, it is gratifying to see the level of quality education continually improve.

B-22 through B-43 are revisions to specialty standards. These have been approved by Specialty College Evaluating Committees (SPECs), the Council on Postdoctoral Training (COPT) and the BOE.

B-45 address sponsorship of OGME programs. This specifically moves to have OPTIs become the academic sponsors of programs. Right now, either HFAP accredited hospitals or Colleges of Osteopathic Medicine (COMs) can sponsor programs. In addition, all programs must be associated with an OPTI. The goal of this resolution was to streamline the process and only mandate the OPTI association -- call it academic sponsorship. It has been construed by some that this language lessens HFAP accreditation. While I respect that argument, pragmatically, HFAP accreditation is not required now to sponsor OGME. In addition, those COMs that do oversee sponsorship well do this through their OPTI. Finally, requiring both COM sponsorship and OPTI affiliation for almost 2/3 of our programs is redundant and not helpful. (I will concede that one rebuttal is to not require OPTI affilation - this is a thought, but not an option with legs...)

Blue Ribbon Commission

2011-06-06T14:16:00.000-04:00

At the inaugural meeting of the joint AOA/AACOM Blue Ribbon Commission on the Osteopathic Profession's Role and Responsibility in Meeting America's Health Care Needs Through Medical Education Reform. More to come on this in the coming days.

Also, there will be feedback on the survey that was sent regarding changes to the fee structure. We received 22 survey results - only about 10% of DMEs, but not bad for an internet survey. We also received some very interesting comments.

I'd have to say the comment that struck me the most was the notion that the cost of inspections was an incentive to improve program quality and strive for longer cycle lengths. This is an curious concept to me. It is a concept shared by several - this is not the first time that I have heard it in as it relates to the proposed changes in the OGME fee structure.

I can honestly say that this paradigm has never crossed my mind. While I cannot come right out and say that I disagree with the concept, I do think that it is a rather dangerous constuct. There are many reasons why a program should strive to provide quality OGME to physicians. One of the least of these would be to save money on accreditation fees. As I noted though, it is quite clear to me now that this idea is not unique to one or two within our profession and needs to be considered in the discussion. It is important that we have open minds to all perspectives.

AOA Bureau of Education meets...

2011-05-24T16:23:00.002-04:00

The AOA’s Bureau of Osteopathic Education (BOE) met over the weekend. Among other topics on the agenda, they considered the AODME’s resolution to repeal Resolution 29. This resolution was approved by the BOE and will now be considered by the AOA’s Board of Trustees at their Annual Meeting in Chicago in July. By all accounts there was a lively, collegial discussion on the issue of AOA approval of ACGME Training.

An important point to remember, that I cannot stress enough (apologies for the bolding): Resolution 29 is germane ONLY to the FIRST YEAR of training and ONLY applicable after COMPLETION of ACGME residency training. It appears that there is continued confusion on this topic.

Macy Foundation

2011-05-17T23:04:00.000-04:00

I'm in Atlanta (with Bob Cain, DO) attending the Macy Foundation conference on Reforming Graduate Medical Education to Meet the Needs of the Public. This meeting follows a Macy sponsored conference in October entitled: Recommendations for an Accountable Graduate Medical Education System.

For those or you who are students of GME history and GME reform, you will know that the Macy Foundation has sponsored conferences on Medical Education many times in the past. These can be found on their web site. If you are interested in further historical perspective, consider reading the works of Kenneth Ludmerer, MD, one of the conference participants.

There are many significant issues facing GME and specifically OGME. It is critical, now more than ever, that we keep our focus on our customers - the public - as we shape OGME policy.

JAOA Education Issue has Arrived!!!

2011-05-13T16:02:00.004-04:00

An abbreviated re-post since a Blogger crash seems to have erased Wednesday's entry...

The annual JAOA Education Issue "arrived" in my in-basket this week. As usual it is a treasure trove of information regarding OME and OGME in particular. As many of you know, I have been compiling data from both the JAOA and the JAMA education issues for some time. I will be sharing some of this data over the next several months.

In addition, Wednesday's Daily Report Blog contained a note about the AOA Executive Committee meeting and several AODME advocacy issues.

Fees and OGME

2011-05-11T18:06:00.000-04:00

Follow-up from the Annual Meeting...

My read on the discussion was a concern more with the magnitude of the fee change than with the change to a flat rate fee structure based on FILLED positions. The flat rate also includes inspections. In addition, I think that it is critical that we have beyond anecdotal (show of hands) data the impact of changes to DMEs.

Some givens with opinion (my view - you may disagree that these are givens):

The funding of OGME is convoluted at best. It is a conglomeration of the AOA, Specialty Colleges, OPTIs, COMs, hospitals and BOS member board certified osteopathic physicians.
Transparency is a concern in the current system. It is difficult to "follow the money." I am not suggesting that anyone is hiding anything. The lack of transparency is primarily related to the first bullet.
The multitude of stakeholders results in as many (and likely more) opinions on the topic. A Specialty College may have one opinion based on their direct role in sponsoring an evaluating committee and another opinion based on their advocacy for their programs.
The AOA "raised" fees two years ago (2009) as a result of the $25 per trainee fee that goes to specialty colleges to support the work of Specialty College evaluating committees (SPEC).
The previous fee increase was in June in 2001 for AY 2002 ($300 per program, $120 per trainee).
Comparing ACGME fees and AOA fees is comparing apples and oranges.
It is more efficient in total to operate an AOA-accredited program than ACGME-accredited program. We can argue the definition of efficiency. I would argue that the total costs (accreditation fees, faculty, administration, etc.) are much lower for osteopathic programs if for no other reason than paid faculty/program directors are not mandated. I would also argue that there are no data to suggest that outcomes are disparate for graduates of AOA and ACGME accredited programs. But…
In almost all cases, dually accredited programs originated from gaining AOA accreditation for established ACGME accredited programs. Therefore, AOA accreditation fees and other added costs (dues, required courses and attendance) are additive.

At the EPPRC collaborative in October of 2010, there was general agreement from stakeholders in OGME that spending more money to promote quality training was appropriate. While that seems laudable, this cannot be adjudicated until we have an accurate accounting of the current system – the entire system. I believe that a simplified fee structure can help this happen.