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

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

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!!

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!

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 Quality Compare 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

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.