SMALL PROGRAM FORUM SPRING APPD 2013

You never know when lightning will strike you !!

Chattanooga, TN

It Can Happen to You Open email from APPD asking you to be

in charge of 3 hr session Me: I like to quietly listen and learn at the

small program forum. I don’t think I am the right person to lead it.

APPD: You are a Program Director, therefore, you are capable of organizing and facilitating. You are IT.

Children’s Hospital at Erlanger -University Affiliated Program 45 Inpatient beds 60 bed NICU 14 bed PICU Ped ED with ~40,000 visits/year 1-4 employed physician faculty in all subspecialties except

rheumatology 8 general pediatrics faculty

8 residents/yr ◦ Requesting increase to 10-not likely to happen ◦ Family practice, emergency medicine, transitional year residents

involved (and counted on) as well No med-peds No fellows

Program is running on ~30 years of combined PD experience Janara Huff (peds ID)—PD for 11 years ◦ Marielisa Rincon (peds endo)-APD 2 years

Annamaria Church-ex PD from Michigan

and currently Director of General Pediatrics

Melissa Hamp-ex PD from Michigan and currently Director of Adolescent Medicine

PD Milestone Achievement Developing Tracks and 6 Individualized

Months

Converting to Milestone Evaluations

Developing Clinical Competency Committee

Faculty development

RECRUITING AND “ALL IN”

Lets take a few minutes to discuss how interview season went.

How did recruiting change with the “All In” policy? ◦ We interviewed 50% more students in larger

groups of 8 with shorter interviews ◦ Filled in upper 1/2 of our list with mixed group of

AMGs and IMGs Better interview experience? More students wanting pediatrics this year?

◦ What did everyone else do? ◦ Concerns or problems with recruiting? ◦ Budgetary cutbacks that might affect recruiting? How many pay for hotels? Food away from hospital?

Audience Discussion-Recruiting

No negative comments about “all in” Strong IMG pool Less stress with all in Many of us are facing budget cuts and

recruiting may take a hit >50% pay for hotel and meals currently

Most Frequent Topics from Email Question Clinical competency

committee formation and written mission

Faculty development on change in evaluations and other new requirements

Milestones evaluations –how to make this change meaningful

Variable program tracks

Individualized months ◦ Mentors for advice and

development of this ◦ Change in resident

experience.

Scheduling problems with more resident choices

Coverage of critical areas with fewer residents

Topics We Thought Might be of Interest Requirement for 1.0 FTE

liason person Difficulty getting

subspecialty faculty and experiences in small programs

Scholarly activity from faculty and residents

Does anyone know where to schedule vacations with the new requirements?

***New Program Evaluation committee responsibilities

Emerging atmosphere of superfluity of residents and faculty burnout

Budgetary problems New AAP parental leave

policy—12 weeks for all Confidentiality issues in

small programs Dis-continuity clinic Others

Small Program Forum Goals--will be very short session if people don’t talk and share their program’s efforts and problems

Individualized months and variable tracks (30-45 min) ◦ Progress UTCOM-Chattanooga ◦ Audience suggestions to collate

Faculty Development—Dr. Mark Bugnitz (30-45 min)

Confidentiality, 1.0 liaison person and vacation issue briefly ◦ Discussion

Open discussion of any other topics listed or unlisted ◦ (above 2-- 30-45 min)

Changing to Milestone evaluations and clinical competency committees—rest of session or do earlier? ◦ Where we are and discussion of ways to proceed ◦ Milestone session wants our thoughts, questions

Tracks—How Many Do You Need?

Fall APPD mention of at least 7 ◦ Subspecialty ◦ Intensive—NICU, PICU, ED, Hospitalist ◦ Rural health ◦ Global Health ◦ Ambulatory ◦ Legislative/advocacy ◦ Research

Options more limited in many smaller programs No global health No basic science research infrastructure Limited opportunities in areas like rural health, legislative and

advocacy training Not all subspecialties available Some patient types not available (no ECMO, no complex

congenital heart surgery, no transplant surgeries) Limited budgets ◦ Can you afford “away rotations” for residents? ◦ Less ability to replace residents with mid-level providers in

rotations like hem-onc, inpatient Adequate mentors for selection of individualized rotations

and limitations of possible rotations

Our Approach Asked each subspecialist, hospitalist group, and

general pediatric group which subspecialty and individualized months they would recommend and put information in a table ◦ Not all listed 7 subspecialties or 6 individualized, but it is a

start We decided to offer all 6 individualized months but

required one to be a supervisory month ◦ Removed 1 month from IP each year 1 month from clinic 1 month from NICU 1 month from ED or evening clinic

◦ Hope most of the residents will put many of these back in their schedule

Summary recommendations for subspecialty and individualized months from all subspecialists, hospitalists and general pediatricians

Subspecialty Individualized Rotations Supervisor #5

It would probably be better to have recommendations from fellowship directors than small faculty pool (ex. GI)

RRC minimums Our Current Plan

10 inpt ◦ 2 PICU ◦ 2 NICU ◦ 5 IP ◦ 1nursery

5 ambulatory ◦ 3 ED or 2 ED and 1 other acute care ◦ 2 ambulatory to include

community/advocacy

9 subspecialty including dev/behavior and adol

6 individualized 6 months not stipulated -presumably program choice and

vacation time

12 inpt ◦ 2 PICU ◦ 2 NICU (was 3) ◦ 7 total IP (was10) Milestone dependent so

many will do more if not “supervisor ready” ◦ 1nursery

8 ambulatory ◦ 3 ED or 2 ED and 1evening clinic (was 4) ◦ 4 months acute care clinic (was 5) ◦ 1 community/advocacy rotation

6 individualized months(1 as supervisor)

10 subspecialty, adol, dev/beh 9-12 weeks vacation +conf comes out

somewhere

Balance of Required Subspecialty and Individualized Months—gray zone 7 subspecialty months plus 6 individualized months = 13 mos 3 months maximum overlap, therefore 10 months is minimum

between them Can one of the individualized months be a supervisory month? How many programs are using10 months? Is it OK to routinely do this?

Master Schedule-worst case if the individualized months were all “creative” Loss of 30% IP time Loss of 25% clinic workers Loss of 33% NICU time Loss of 33% ED time

How much will we get back from

individualized months? ◦ So far residents are making choices that are very

reasonable and do partially replace lost time How many more residents or midlevel

providers are needed to cover the deficit?

Discussion Where are you taking the individualized

months from? How many programs are allowed “away

rotations” for individualized months if you don’t have a needed rotation or they want another experience in larger program?

How many are doing just 3 vs 6 months of individualized time by double counting?

How is this affecting your master schedule and number of residents on key rotations?

Do you have enough mentors to help residents decide on individualized month?

Discussion Individualized Months

Loss of resident work force on core rotations is a big concern

If midlevel providers are the solution, residents may become more superfluous

DIOs needs to hear that the individual months are a mandate not elective—need more residents

Many worry adequate exposure to core rotations is going to be lost with the individual months

Discussion—Use of individualized rotations Focus needs to be on identifying residents who need more

core rotation experience and inform their mentor to use their individualized months to help them

Can one use a longitudinal experience as an individualized rotation?

“Away rotations” very expensive way to meet needs of residents with subspecialty interests not at the main program

Use individual months for remediation All residents need more IP training than was recommended Maybe first years should not have any individualized months Military residencies do not want anything other then well-

trained general pediatricians

Discussion-fellowship/individualized rotations Early fellowship applications forcing the

process of interest focus Has fellowship survey been done to see if

they want residents with more general education vs. more focused education approach?

Need to think about quality and skills and well rounded pediatrician entering fellowship

Faculty Development An Approach for Big and Small Dr. Mark Bugnitz Program Director from UT-COM Memphis

Facutly Development—What Works? Make it Interactive Borrow and steal to make it easy on yourself Use the Internet No death by PPT Use Flipcharts Group exercises Role play Use trainees Change the day but do at noon Start on time Serve lunch and use candy rewards Ask other faculty to do one or two—not just PD

A Few Smaller Issues Confidentiality in small programs, 1.0 FTE liaison requirement, where are you putting vacations in the new curriculum

Confidentiality

Big problem in smaller programs Rumors and facts can spread like wildfire ◦ Resident evaluation of faculty or rotations ◦ Residents with various problems-personal,

professional, academic leak out ◦ Who complained about what

Confidentiality Improvement Batch rotation and faculty evaluations over 1 year

or 2 if necessary Resident council ◦ Elected 2/class-meet q 1-2 months and prn ◦ Provides safe way for complaints, problems to be

brought forward and cleansed of identifiers ◦ Issues and suggested solutions discussed at

curriculum ◦ Has been effective in fixing problems before they

become “major issues” New CCC—more than the PD and mentor will

now be aware of all evaluations. Confidentiality agreement???

Confidentiality discussion

Ideas other than closed lips? How are you addressing this? Have other programs had citations for

this?

Confidentiality Discussion Residents should make comments general rather than

specific on evaluations to remain anonymous Use Comment cards rather than noted on a monthly

evaluation may help preserve anonymity Have residents evaluate all faculty once a year based

on all of their experiences with them-- not just after a rotation

Faculty want feedback so everything possible should be done to give them feedback while maintaining resident confidentiality

Use resident discussions to get information on faculty Should one share information that a struggling

resident is going to be on your rotation? Positives and negative comments

1.0 FTE liaison person

Fourth year chief resident ideal, but what if no one wants the job?

We are facing an empty position next year ◦ Have advertised for 6 months without success ◦ Will ask 2 PGY3s to be co-chiefs, but this

does not meet RRC requirements

Is anyone else struggling with this requirement?

1 FTE liaison person discussion

Hard to always have a fourth year chief Use junior faculty and define their role of

liaison person Any solution harder in smaller programs

where third year chiefs have been used traditionally

Vacation Problem Education Units are 4 weeks,1 month, or 40-

42 half-days ◦ Take away 4 half-day continuity clinic ◦ 4 half-day block lectures Don’t want to give up because we achieve near 100%

attendance ◦ You are now at 32 ½ days No room for “make up continuity clinics” or vacation

days except if it is a 2 week subspecialty Do vacations come out of months above the minimum,

ie third month PICU, 6 th month IP, second cardiology?

Vacation Discussion

Use of 13 blocks rather than 12 months makes vacation scheduling easier

No one thinks the RRC will have a problem with taking vacation out of a 1 month educational unit, except for adolescent and development, even though you then have <4 weeks EU

Counting hours or ½ days is only for longitudinal rotations

Other Areas People are Struggling With? No one brought anything up

Milestones and Clinical Competency Committees Chattanooga is not yet ready for prime time

Milestone Evaluations

One problem is how to make this a meaningful change ◦ We know it should be more than a switch

from one Likert scale to another Developmental progress should be easy for all

pediatricians to understand But…. Unless all faculty fully embrace this concept to the

extent of perusing each descriptor for each milestone before checking a box, we may not get what we really want

Milestones--Our Program Several faculty sessions including Grand Rounds (Ann

Burke), annual program reviews for 2 years and other shorter reminders, snippets at faculty mtgs.

New Innovations ◦ Spent many moons developing evaluations that are

“rotation and level specific”-no two are the same Faculty are fairly wedded to their current questionaire

◦ New Likert scale inserted under each evaluation point-- novice to expert Go live July 1, 2012 when we thought everyone was informed

◦ Not exact milestone terminology, but faculty were given both paper and electronic short version of milestone descriptors to help them define resident abilities

Yikes! They Did Not Understand

August, PGY2, second month NICU

Several Explanations Later General pediatric faculty and faculty on the

curriculum committee “get it” Subspecialty faculty have figured out not to

label PGY1 or 2 residents as “expert”, but I am worried that little consideration is being given to where the true ability is based on milestone descriptors. ◦ PGY1 novice – competent ◦ PGY2 advanced beginner-proficient ◦ PGY3 competent-proficient ◦ Professionalism—proficient-expert

New Innovations Can track milestone data on evaluations –

update coming soon ◦ Does not pop up descriptors on routine

evaluations but does on a 21 milestone evaluation sheet that is in the resident portfolio section ◦ Working with us to put the descriptors in other

evaluation questionnaires that include milestones Will keep average score on every resident

for each milestone for ACGME report ◦ CCC will still have to review all evaluation

documents and place resident appropriately

Clinical Competency Committee- Powerful Group Think Most already have a group of dedicated faculty that meets

about residency issues ◦ In smaller programs this pool is limited ◦ The same ones you call on for everything else will probably help

with CCC work ( and now PEC) Done correctly this will be time consuming but probably

very informative and allow accurate placement of resident ability in each milestone ◦ Each person likely to have seen something about the resident

they can assess or substantiate Positives –CCC faculty will be more informed about

residents true abilities and may be able to help them better ◦ Mentors can be given better feedback on where their mentee is

doing well or needs to focus

Our New CCC (and PEC)—old curriculum committee Working Group ◦ PD ◦ APD ◦ Chief resident- if fourth year (new problem) ◦ Hospitalists (2 share 1 position) ◦ Gen peds faculty (adolescent, continuity clinic director, gen

peds director) ◦ Hem-onc education director (works with many residents

over time on inpatient and subspecialty) Very few other faculty have opportunity to see resident

progression over time

Support- if needed to clarify milestone level ◦ Mentor of resident ◦ Subspecialists who worked with resident

Milestone Distribution -some of these are difficult 5 patient care 1 MK 4 PBLI 2 IPSC* 6 Prof** 3 SBP* Who has tools for evaluation of these?

Practice Run—May or June 2013 Ask coordinator to make sure evaluation pieces are complete for

review: ◦ 6 global evaluations Rotation paperwork

EBM (clinical question) form Tests Modules completed Self assessments 360 evals- especially colleague and nursing

Program requirements progress Scholarly activity progress QI progress ( 1 M and M and 1 QI project plus IHI modules) PREP question progress (250 required/year)

All commendation and warning cards or emails

◦ ILP ?? ◦ Mentor report ◦ ITE or spring exam score

Do one intern and see how much time it takes and what more information we need

Discussion We need better tools for faculty training on how to use milestones

◦ Who has things that work?

Milestone group wants our questions about Milestones? Make list Some Milestones seem difficult to assess—are tools in development?

Should all evaluations be redone in milestone terminology or can we just label pieces as relating to Milestone 5, milestone 21?

Difficulty with faculty time to do better evaluations Difficulty in finding faculty who have time for CCC work

◦ At least 30-60 minutes/resident likely ◦ Faculty worry about productivity

Other Issues ◦ Written mission statement ◦ What if your faculty aren’t all under same roof? ◦ Confidentiality*

Milestone and CCC Comments Many comments about time and limited number

of faculty doing this Concern we don’t have reporting tool Small programs know their residents well and this

should be easier for them Should data be used for promotion or prevention

of promotion? Use self-assessment milestone evaluation People are worrying too much about this Should we just change evaluations to the 21

milestones that need reporting?—no Dr. Burke