DOIM Training Program: An Update 2008

VCU Department of Internal Medicine Training Program

An Update - 2008

VCU Department of Internal Medicine Training Program

An Update - 2008

Stephanie Ann Call, MD MSPH

Training Program Director

June 2008

Educational updateEducational update

Education re-design project Accreditation update Update on 2007-08 initiatives Program demographics update Program evaluation by housestaff Program evaluation by faculty 2008-09 plans

Education re-designEducation re-design

New accreditation requirement changes– July 2009– Less restrictive– Allow flexibility and innovation

Current dissatisfaction and confidence in training structure– Are we training internists effectively in 2008?

Education re-designEducation re-design

One-year project Working groups, focused on specific

issues – summer 2008– “Outside the box” thinking– Focused on core values, concepts, goals

Integration of ideas into final curriculum and training structure – fall/winter 2008

Initiation of new curriculum July 2009

Academic year 07-08Accreditation updatesAcademic year 07-08Accreditation updates

Internal Review– Core program – fall 2007– Most specialties – fall 2007– In general, positive reviews

External Reviews– Cardiology programs – June 2008– Hematology/oncology – June 2008

New accreditations submission – Palliative care – June 2008

ACGME resident surveys– Winter 2007-08 – copy in handout

Update on new initiatives 2007-08

Update on new initiatives 2007-08

Initiatives – 2007-08Initiatives – 2007-08

Pathways– All pgy2 residents entered pathway in July

2007 – generalist, specialist, hospitalist– Pathway curricula and advising initiated– Details of pathways available on ERIC

• 1-2 months focused experience per pgy2/3 year• Focus area advisor, assures mentor established• Monthly pathway meetings

Initiatives 2007-08Initiatives 2007-08

Pathways– Generalists – Dr. Bennett Lee

• Continuity experience in community – Port and Al Rogers – very positive feedback from practice and residents!

• Pilot – Senior level faculty practice month• Monthly generalist educational seminars

– Hospitalists – Dr. Alan Dow • Hospitalist experience• Performance improvement training• Monthly seminars

– Specialists – Dr. Christian Barrett• Focus on mentoring, mentor lunches• Research months – very successful • Fellowship application advising


New rotations– Palliative care

• Curriculum developed• Two-week required rotation pgy 3 • Evaluations

– Peri-operative consultation• Curriculum developed• Incorporated into medicine consult rotation pgy2• Evaluations

– CDU experience • Build into MAR experience• Mixed reviews

– Geriatrics consultation service closed


ACC clinic improvements– Restructure of leadership team

• Multidisciplinary leadership team – led by Stephanie Call• Involves residents on team – clinic ops

– Resident clinic task force– Major medical records improvements

• Dr. Peter Boling and Zee Dabney– EMR

• Electronic prescriptions, med lists• Moving to notes

– Scheduling improvements– Patient flow improvement efforts underway


Resident Performance Improvement Activity– Dr. Bennett Lee, Dr. Andrew Poklepovic, Shelley

Burns– Focused in outpatient setting– Resident-performed review of over 600 charts

from ACC clinic– Evaluation of data– Development of PIM project proposals– Formal presentations– Selection and implementation of project– Evaluation and report


Standardized patient assessments– Dr. Bennett Lee– Core clinical skills focus– All categorical pgy1 residents – Nov 2007– Structured feedback

Simulation-based orientation– Dr. Alan Dow– Will be expanding in 2008-09


Medical technology training– Medical technology Mondays– Stephanie Call, Maia Lavallee

• In collaboration with library and SOM staff– All categorical pgy 1 residents– Curriculum

• The well-formed clinical question• Effective literature searching – medline• Other databases and electronic resources• Powerpoint skills and presentation

– Includes assignments and final presentation– Presented at national AAMC meeting spring, 2008


Work hours – Dr. Jeff Kushinka– Improved tracking and reporting

• Required on all inpatient rotations• Electronic reporting – New Innovations

– Identification of problem areas– Focus improvement projects

• MRICU - update• Inpatient wards


Introduction to clinical research lecture series– Majority of faculty lecturers from DOIM– 10-part series, text by Hulley– Over 100 attendees summer 07– Request by school and GME to repeat this

year– Thursdays, MSB, noon July-August


Reflective writings – Initiated in pgy1 class of 07-08– Three writing assignments

• Logged electronically into portfolio on New Innovations

• Purpose – foster sense of self-reflection as component of professional development for physician

– 90% completion by interns

US Medical School Graduates

US Medical School Graduates

82

100 100 100 100 100 100 100 98 96 96 98 9890

0

20

40

60

80

100

95 96 97 98 99 00 01 02 03 04 05 06 07 08

Percent of entering interns graduating from US medical schools

Office of Educational Affairs

US Medical Schools Represented

US Medical Schools Represented

27

36

45 43 4548 46

52 53 5552 50

46

56

0

10

20

30

40

50

60

95 96 97 98 99 00 01 02 03 04 05 06 07 08


Number of medical schools

Mean USMLE Scores for Entering Interns

Mean USMLE Scores for Entering Interns

217

221

214217

213216

211

222

217216213

216

225

221218

213

200

210

220

230

2000 2001 2002 2003 2004 2005 2006 2007 2008

Step 1 Step 2Excludes preliminary interns


ABIM

Certifying Examination Pass Rate

ABIM

Certifying Examination Pass Rate

7578

62 63

56

65

86 87 89 8791

94 93100

94100

94 94

50

60

70

80

90

100

90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07

Percent

Subspecialty ABIM Certifying Examination Pass Rate

Subspecialty ABIM Certifying Examination Pass Rate

68

80

68

83 84

68

85

79

8893 94 94

50

60

70

80

90

100

95 96 97 98 99 00 01 02 03 04 05 06 07

Percent

Housestaff scholarly activities

Housestaff scholarly activities

Details on ERIC website and program website, publication disseminated

> 110 publications, presentations 07-08– Includes national and international

presentations– > 10 manuscripts– Several investigator awards, presentation

awards

Housestaff End-of-Year Program

Evaluation

Housestaff End-of-Year Program

Evaluation

Best things about residency program (housestaff survey)Best things about residency program (housestaff survey)

People, comraderie – faculty, fellows, housestaff

Resident-centered Pathology, patient population, clinical

experience Clinical training and preparation Supportive environment, friendly Strong commitment to teaching Resident concerns are dealt with openly,

effectively, open to change, responsive

Program LeadershipProgram

Leadership

3

4

5

Chair 4.6 4.6 4.5 4.5 4.7 4.9 4.6 4.7

Program Director 4.7 4.6 4.6 4.5 4.0 4.7 4.4 4.5 4.6

2000 2001 2002 2003 2004 2005 2006 2007 2008

Annual Housestaff Survey, Office of Educational Affairs

PD/CMRs – 2007-08PD/CMRs – 2007-08PD CMRs

Overall leadership 4.6 4.1Teaching 4.6 4.2Clinician/clinical role model 4.6 4.1Administrative role 4.5 4.0Responsiveness to resident concerns

4.3 3.8

Availability/accessibility 4.5 4.4Visibility 4.6 4.5Serving as resident advocate 4.4*Rated 1-5, 1-not at all effective 3-adequate 5-very effective

ConferencesConferences

3

4

5

MCVH MR 4.1 4.5 4.7 4.7 4.5 4.3 4.3 4.3 4.5

VA MR 3.4 4.3 4.7 4.6 4.3 3.5 3.8 4.0 4.2

MCVH GR 3.9 3.6 3.6 3.5 3.9 4.2 4.1 4.7 4.1

VA GR 3.3 3.3 3.1 3.6 3.4 2.9 3.4 3.6 3.9

Didactics 3.9 3.7 3.6 3.0 4.1 3.9 4.0 4.2 4.1

2000 2001 2002 2003 2004 2005 2006 2007 2008


ConferencesConferencesConference Mean

2006Mean 2007

Mean 2008

Key Comments

Journal club 3.74 3.93 4.23 Has become a great conference, would like more clinical expert faculty

Physical diagnosis rounds

3.91 3.98 N/A

M&M 4.03 4.28 4.52 Like faculty panels, great topics for discussion, make me think

EM/IM 3.60 3.73 4.09 Better with Aurora and Suri facilitating, still a bit argumentative

GME 3.40 3.54 3.65 Dry topics, little applicability or usefulness

Housestaff meetings

3.78 3.97 3.92 More time to voice opinions and concerns, would like follow-up

Ward MedicineWard Medicine

3

4

5

MCVH Medicine 4.2 4.3 4.2 4.1 4.4 4.5 4.1 4.3 4.2

VA Medicine 3.1 3.7 3.7 3.7 3.9 3.5 3.3 3.6 3.7

MCVH Hem/Onc 4.2 4.0 4.0 3.9 4.0 3.7 3.5 3.9 4.0

2000 2001 2002 2003 2004 2005 2006 2007 2008


Inpatient servicesInpatient servicesQuality of Education/Teaching (5-excellent)

Quality of Clinical Experience (5-excellent)

Balance – Education-Service (5-excellent)

MCVH wards

4.08 4.47 3.81

VA wards 3.69 3.80 3.65

Heme/onc 4.00 3.96 3.84


Inpatient ward services – general themes


Positive– Excellent patient exposure, case diversity– Many comments on excellent teaching faculty,

skilled clinical supervisors• A few attendings identified as not teaching or not

effective in inpatient setting– VA – good learning environment, much improved,

great patient population, great support from Frank Fulco

– Great autonomy at the VA– Excellent teaching and great support staff on

heme/onc



Constructive/concerns (note significantly fewer!)– A few attendings identified as not teaching, otherwise no

comments on this– Frustration with all systems – resident performance of “social

work” duties– MCVH-specific comments

• Load and acuity are detrimental to teaching efforts– Heme-onc-specific comments

• Too many patients• Routine chemo, other non-teaching admissions – consider admit to

non-teaching service– VA-specific comments

• Too few patients• Dissatisfaction with nursing and ancillary services

Critical CareCritical Care

2

3

4

5

MCVH CICU 3.3 3.5 3.5 2.6 3.3 3.5 3.9 3.8 3.9

MCVH MRICU 4.9 4.9 4.8 4.8 4.8 4.8 4.7 4.7 4.9

VA ICU 3.9 4.0 3.9 4.0 4.2 4.0 3.8 3.8 4.2

2000 2001 2002 2003 2004 2005 2006 2007 2008


ICU servicesICU servicesQuality of Education/Teaching (5-excellent)

Quality of Clinical Experience (5-excellent)

Balance – Education-Service (5-excellent)

MCVH CCU

3.77 3.91 3.73

MCVH MRICU

4.87 4.79 4.64

VA ICU/CCU

4.26 4.09 4.14


Primary Care Clinic

Primary Care Clinic

2.5

3.5

4.5

MCVH 3.5 3.7 3.1 2.9 3.5 2.7 3.2 3.3 3.4

VA 3.4 3.5 3.3 3.2 3.6 2.9 4.0 4.0 4.2

2000 2001 2002 2003 2004 2005 2006 2007 2008


Continuity clinic – general themes

Continuity clinic – general themes

MCVH ACC clinic– Efficiency and organization issues are major concern– Scheduling issues – pervasive complaint– Lack of support and teamwork from nursing– Paperwork and systems problems– Lack of time– Need for EMR– Lack of teaching– Lack of communication with consultants– Lack of social work support in clinic

VA primary care – all positive!– Well-run system– Excellent precepting– Great staff

Housestaff Rating of RotationsHousestaff Rating of Rotations

2000 2001 2002 2003 2004 2005 2006 2007 2008

MCVH wards 4.2 4.3 4.2 4.1 4.4 4.5 4.1 4.3 4.2

VA wards 3.1 3.7 3.7 3.7 3.9 3.5 3.3 3.6 3.7

Hem/Onc ward 4.2 4.0 4.0 3.9 4.0 3.7 3.5 3.9 4.0

MCVH CICU 3.3 3.5 3.5 2.6 3.3 3.5 3.9 3.8 3.9

MCVH MRICU 4.9 4.9 4.8 4.8 4.8 4.8 4.7 4.7 4.9

VA ICU 3.9 4.0 3.9 4.0 4.2 4.0 3.8 3.8 4.2

MCVH ER 3.2 3.3 3.1 3.6 3.4 3.6 3.5 3.3

VA ER 3.9 3.8 3.5 3.6 3.7 3.7 3.3 4.0

MCVH PCC 3.5 3.7 3.1 2.9 3.5 2.7 3.2 3.3 3.4

VA PCC 3.4 3.5 3.3 3.2 3.6 2.9 4.0 4.0 4.2

Scale: 1–5 (1 = poor, 5 = excellent)

Housestaff Rating of RotationsHousestaff Rating of Rotations

2006 2007 2007

Geriatric consults 3.3 3.1 N/A

MAR 3.1 3.2 3.4

Intern ambulatory block

3.6 3.7 3.8

PGY2 ambulatory specialty block

4.2 3.9

PGY3 urgent 3.5 3.6 4.1

Student health 4.1 4.2 4.6

Consultative services

4.1 4.1 See next slide

Scale: 1–5 (1 = poor, 5 = excellent)

Consultative servicesConsultative services

Evaluated individually 2007-08– Education/teaching– Quality of clinical experience– Balance education/service– Overall

Consistent numerical scores > 4.0– Exceptions - GI/hepatology, Peri-operative

Individual data to be posted to web and sent to Division Chairs

What do our clinical faculty do effectively?What do our clinical

faculty do effectively? Allow autonomy, yet still provide effective supervision Provide excellent patient care Respect time, round efficiently Teach Maintain morale Maintain approachability and availability Role model good physician-patient interactions Lead Support the housestaff Express interest in, enthusiasm for, and respect for

the residents

What would the housestaff like to see more from clinical faculty?

What would the housestaff like to see more from clinical faculty?

More evidence-based clinical decision-making and teaching Less conflicting time demands on faculty while on teaching

services – inpatient and outpatient More teaching, more efficient teaching in clinic Greater focus on teaching the fundamentals, physical

examination More feedback More consistent structure to ward rounds More support with consulting team interactions More teaching on inpatient wards and consults - lighter days Higher standards, expectations of students, interns,

residents More bedside teaching

Suggestions for change – training program

Suggestions for change – training program

Increased focus on ambulatory training Improve clinic Move conferences to once/week Increase opportunities for housestaff to express

opinions Re-work pull system so less abused More training in leading a team Reduce number of evaluations Remove clinic from inpatient months Remove Q3 call from VA ICU rotation Preliminary medicine schedule improvements

DOIM Faculty MemberProgram Evaluation

2007-08

DOIM Faculty MemberProgram Evaluation

2007-08

Faculty ratings – strongly agree (> 4)

Faculty ratings – strongly agree (> 4)

VCU IM residents – Demonstrate commitment to excellence– Model professional behavior– Routinely incorporate EBM– See an appropriate volume and variety of patients– Do not frequently exceed work hour limitations– Are adequately supervised– Have adequate instruction and supervision in

procedural skills– Are well-prepared for primary care practice– Are well-prepared for entry into fellowship training

Faculty ratings less than strongly agree ( average

rating 3-4)

Faculty ratings less than strongly agree ( average

rating 3-4) Residents have adequate opportunities

for clinical research Resident primary care clinics are

appropriate and effective ambulatory care triaining sites

Faculty ratings of program

Faculty ratings of program

Question Mean rating (5- strongly

agree)

VCU DOIM provides adequate support for residency training

4.2

MCVH provides adequate resources 4.4VAMC provides adequate resources 4.2Most resident faculty have adequate knowledge and clinical skills

4.5

Most resident faculty are effective clinical teachers

4.3

Most resident faculty have adequate time for resident teaching

3.6

Faculty comments - themes


Strengths– Faculty– Patients, diversity of clinical experience– Tradition of excellence– Commitment to excellence in patient care– Commitment to education– Program leadership– Resident work ethic– Camaraderie among residents and faculty– Quality of recruits– Constant program improvements and initiatives



Improvements– Many clinic and ambulatory training improvement suggestions –

thank you!– Less interruptions to consult services by pulling residents away– More emphasis on humanitarian aspects of medicine in

curriculum– Consideration of alterative inpatient team structures due to work

hours– More outpatient subspecialty exposure– More formal mentoring– Continued procedural training– Patient load too light – Less focus on throughput, more on quality of care– Consideration of all-hospitalist ward attendings

2008-2009Initiatives

2008-2009Initiatives

2008-09 Initiatives2008-09 Initiatives

Conference restructure– 2-3 hour lecture block, Tuesdays 3-6pm– Expect residents to round and be present until

3pm on clinical services– Video-conferenced to VA if unable to duplicate– Podcasts– Incorporation of more active learning styles

• TBL, small group discussions, audience-response systems

– No more noon conferences• Except intern conference Mondays, Grand Rounds,

occasional Wed EM-IM


Work hours– MRICU restructure

• Two-week intermittent blocks over two months• Additional staff to assist with 30-hour violations• Other changes as previously outlined

– Consideration of removal of all overnight call on wards with 7-day night float system


Continuity of housestaff on services– Removal of bridge system for wards– Removal of extra clinics while on consult

and elective services• Exceptions – Womens Health, Med Peds,

Generalist residents who have two ½-day clinics per week


ACC clinic– New practice partner model– Electronic notes, fully electronic medical

record– Continued systems improvement efforts– Re-structure of faculty staffing models and

expectations


New rotations– Geriatric medicine ambulatory experience– Neurology ambulatory experience– Restructure of ACSB pgy2 experience– Restructure of ambulatory block pgy1 – VA cardiology service


Introduction to clinical research lecture series to be repeated

Continued work on pathways Continued work on PIM projects Extension of simulation-based orientation Increased simulation training for procedures Standardized patient assessments Chart-recall project – night float rotations

DOIM Training Program: An Update 2008

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