Expanding OGME - Shared Resources ... Shared Responsibility

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!?!

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!

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!!

"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

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.