ACGME Milestones Project and LengthofTraining 4 year Pilot

ACGME Milestones Project and Length-of-Training (4 -year) Pilot Perry A. Pugno, MD Vice President, Education – AAFP ~ James C. Puffer, MD President and CEO – American Board of Family Medicine

Perry A. Pugno, M. D. , MPH, FAAFP, FACPE Vice President for Education American Academy of Family Physicians Author / co-author of many articles and the book “Physicians as Leaders” Other Affiliations • AAFP Alternative Delegate to the American Medical Association (AMA) • AAFP Representative to the Council for Medical Specialty Societies (CMSS) • AAFP Liaison to the Council for Academic Family Medicine (CAFM) Conflict of Interest Disclosure Previous Affiliations / Responsibilities: • Director, Division of Medical Education, American Academy of Family Physicians • Director, Residency Program Solutions (RPS) • Founding Chair, National Institute for Program Director Development (NIPDD) • President, Association of Family Medicine Residency Directors (AFMRD) • President, UC Medical Alumni Association • Chair, ACGME Residency Review Committee (RRC) for Family Medicine • Family Medicine Residency Program Director, various public, private and university programs • VP of GME and Medical Affairs, Mercy Healthcare Sacramento – a division of Catholic Healthcare West • Public Health Officer and Medical Director, Mercy Health Plan (CHW) • Family Physician, National Health Services Corps, Barstow, CA Educational Background: • University of California – Davis, School of Medicine • Ventura General Hospital Family Medicine Residency (UCLA-affiliated) • Masters of Public Health – Loma Linda University School of Public Health • Board-certified , Family Medicine and Emergency Medicine • Fellow of the AAFP, American College of Emergency Physicians, and American College of Physician Executives

Milestones Project • Joint initiative of the ACGME and the specialty certification boards • Process driven by ACGME • Working Group: Individuals representing the constituencies of the RC-FM, ABFM, AAFP, STFM, AFMRD, ADFM and ACGME • Timeline: March through December 2012

Milestones Project Working Group • • • Suzanne Allen* Tanya Anim David Araujo Diane Beebe† Julie Dostal Tricia Elliott Larry Green Amy Mc. Gaha Richard Neill* Steven Nestler • • • Perry Pugno† Martin Quan† Adam Roise* Allen Shaughnessy Penny Tippy* ACGME STAFF • Eileen Anthony (Exec Dir) • Erin Axley (Admin Asst) *current RC-FM member †past RC-FM member

The Progress of Development Medical School Beginner Residency Advanced Beginner Practice Competency Proficiency Mastery

Milestones • Milestones describe performance levels residents are expected to demonstrate for skills, knowledge, and behaviors in the six general competency domains. • Milestones will lay out a framework of observable behaviors and other attributes associated with residents’ development as physicians. • Identification of assessment methods that will be effective in evaluating performance on the milestones is a part of this effort.

Milestones “How far along the road to your goal are you right now? ”

Implications and Uses

How Does This Relate To What We Know? ACGME Competencies Milestones Entrustable Prof. Activities

Entrustable Professional Activities “EPAs are simply the routine professionallife activities of physicians based on their specialty and subspecialty. ” JGME – Sept ‘ 10

Entrustable Professional Activities

Sometimes, directions are not clear…

LENGTH-OF-TRAINING PILOT PROJECT

Family Medicine Length of Training Pilot (FM-LTP) “The purpose of the pilot is to examine whether extending the length of Family Medicine training to 4 years through the development of innovative training paradigms further prepares family physicians to serve as highly effective personal physicians in a high performance health care system. ”

Family Medicine Length of Training Pilot (FM-LTP) BACKGROUND 1966 Willard Report – “The program [should] be kept flexible in order that it might be tailored to the individual’s background, future need, and level of progress”, and that “a satisfactory program for family practice will generally require 3 -4 years after medical school, the exact time will vary with the organization of the program and the individual trainees’ particular needs. ”

Family Medicine Length of Training Pilot (FM-LTP) BACKGROUND 1969 First RRC Program Requirements – “There is wide variation of circumstances under which the family physician will function, both geographically and in his association with other physicians. His educational program is to be designed in conformity with the general principles set forth in the following basic program. Flexibility is necessary and the program may be adjusted according to his predicted needs and should be carried out under the guidance and control of his program director. ”

Family Medicine Length of Training Pilot (FM-LTP) BACKGROUND 2004 Task Force II, FFM Project – “That, in the interest of promoting active experimentation in Family Medicine education, the relative merits of 3 year versus 4 -year training programs be evaluated through a national experiment based in pilot programs approved by the American Board of Family Medicine (ABFM) and the RC-FM that will measure and report on learning, outcomes, costs, benefits, and disadvantages. ”

Preparing the Personal Physician for Practice (P 4) • • Hendersonville Middlesex University of Missouri Loma Linda (and others)

Should I. M. Residency Training Be Extended? the-hospitalist. org Survey Results 1 6% Unsure 2 25% No Ref. The Hospitalist April 2011 3 69%Yes

The Pilot • Designed as a cross-sectional study of 20 -25 residency programs (based on power analysis) with an equal number of programs to serve as controls • The ACGME RC-FM will provide ultimate oversight – – – Establish policies for the pilot Define selection criteria Choose participating residencies With the ABFM, appoint a Steering Committee to oversee evaluation Assure communication among RC-FM, ACGME, and the family medicine organizations… as well as other key stakeholders from other fields – Assist with interpretation of the evaluation results

Steering Committee • • • Jim Martin, Chair Peter Carek Colleen Conry Steve Crane Perry Dickinson • • • Alan Douglass Jay Fetter Lars Peterson Jim Puffer Perry Pugno

Key Assumptions and Founding Principles • Decreased clinical experience and responsibility in medical school • Decreased hours of training • Increased scope of biomedical knowledge and the need to obtain skills using new technologies • Increased scope of responsibility • Increased flexibility of training is a desired feature of residency redesign

Evaluation Framework • The ABFM Foundation has committed up to $2 million to finance the evaluation of the pilot • The Steering Committee (appointed by RCFM/ABFM) will guide the process and report results – – – Comparative case study Mixed methods approach Quantitative and qualitative methods Specific hypotheses evaluated Measurement of both processes and outcomes Core evaluation team plus on-site faculty project leader and evaluator – Pre-, Interim, and Post-study periods

Evaluation Framework Core to the evaluation process will be the assessment of core competencies (i. e. patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systembased practice) as well as the ability of residents and graduates to manage the health of populations through both quantitative and qualitative research methods.

Length-of-Training Pilot Announced in ACGME Newsletter ACGME e-Communication February 20, 2012 RRC News―Family Medicine • The RRC for Family Medicine (in partnership with the American Board of Family Medicine) has submitted and received approval from the ACGME Board of Directors for a pilot project that will examine the length of residency education in family medicine. Specifically, the purpose of the pilot is to examine whether extending the length of family medicine residency education to four years through the development of innovative education paradigms further prepares family physicians to serve as highly effective personal physicians in a high performance health care system. Additional details of the pilot, including the application process, will be posted to the RRC for Family Medicine web page within the coming weeks. Once the details are posted, the links will be included in an upcoming issue of ACGME e. Communication.

Timeline • Announcement – February 2012 • Selected Programs Notified – Summer 2012 • Programs Begin Pilot – July 2013 • Pilot Duration – 2013 - 2019

To be announced soon… • Eligibility Parameters • Application Process (including the standardized ACGME Proposal for Program Experimentation and Innovation Project form) • Selection Criteria • Requirements for Participation