STFM Annual Spring Conference 5413 Creating a Seamless

STFM Annual Spring Conference. 5/4/13 Creating a Seamless World of Learning George Maxted, MD Chris Simons, MD Tufts University Family Medicine Residency at Cambridge Health Alliance – TUFMR/CHA

Objectives • Describe a framework, a fabric of a Family Medicine Residency • Identify the quality and quantity of the seams in the fabric. • Describe a P 4 approach, the evolution of curricula, and opportunities for future growth

Seams: Stitching to hold the fabric together Info Mastery Competencies The Clinic Teams Longitudinal Community Curriculum Exec Skills AOCs

Seams: Space, light, opportunity

Seams • Is the quality and quantity enough to hold things together? • Is there enough space for light to shine through, air to breathe, opportunity to “break through” if necessary? • But not too “leaky”. • Easy enough to repair, revise, take down, build up?

TUFMR/CHA 1991 - ACGME accreditation – Malden Hospital Family Practice Residency 2001 -TUFMR to Cambridge Health Alliance 2007 - New clinic opens: Malden Family Medicine Center 2008 - P 4 Curriculum Redesign project begins – The Clinic as Teacher – Family Medicine taught by Family Docs – Longitudinal Curriculum

Essential Elements of a Family Medicine Residency • A Home – with parking • A Director – And a “Mom” • Faculty – With clinical, academic, administrative support • Residents • Curriculum

Bloom’s Taxonomy Encourage higher order learning

The Kolb Learning Cycle Kolb, D. A. (1984). Experiential Learning: Experience as the Source of Learning and Development. Upper Saddle River, NJ, Prentiss Hall.

TUFMR/CHA P 4 Curriculum PGY-3 Seniors FM Inpatient-6 wks Rotations 20% Office Practice 60% PGY-2 FM Inpatient-7 wks PGY-1 Interns Rotations 44% Didactics 10% Office Practice 42% FM Inpatient -12 wks Didactics 10% Rotations 80% Office Practice 8% Didactics 8% Community Health Executive Skills/Applied Leadership

Year to Year First Year • Orientation • Rotations • Inpatient Svc • Office Practice • Behavioral Health • Didactics • Support Group Second Year • Transition • Rotations • Inpatient Svc • Office Practice • Behavioral Health • Didactics • AOCs • Elective • Community • Professionalism • Applied Leadership Third Year • Transition • Rotations • Inpatient Svc • Office Practice • Behavioral Health • Didactics • AOCs • Electives • Professionalism • Executive Skills

A week in the Family Medicine Center • 7 Clinic Sessions • 1 Lecture/Didactic/Workshop session – 2 Hours plus 1 hour support/reflection time • 1 Session for Longitudinal Elective (AOC) • 1 Session for specialist or special clinic • 0. 5 Session for Academic Experience (AE) or Administrative Time • Extra carve-outs for Community Health, Chief Resident time, special tasks/committees

TUFMR/CHA P 4 Curriculum • Competencies drive the curriculum – “Entrustable Professional Activities” • Information Mastery • Areas of Concentration (AOC) – Longitudinal and Elective Time • Executive Skills – With PCMH, now includes Applied Leadership • Longitudinal Curriculum – The clinic as teacher. Goal: 60% of learning occurs in the family medicine center, with family physicians

TUFMR/CHA P 4 Curriculum • Competencies drive the curriculum – “Entrustable Professional Activities” • Information Mastery • Areas of Concentration (AOC) – Longitudinal and Elective Time • Executive Skills – With PCMH, now includes Applied Leadership • Longitudinal Curriculum – The clinic as teacher. Goal: 60% of learning occurs in the family medicine center, with family physicians

ACGME: Next Accreditation System Milestones Project (June 2013 – July 2014) • Dreyfus Scale: 1 to 5 by. 5 increments • Performance descriptors/targets • Six domains: Patient Care, Medical Knowledge, Professionalism, System Based Practice, Practice Based Learning and Improvement, Communication http: //www. acgme-nas. org/assets/pdf/Milestones/Family. Medicine. Milestones. pdf

Identify Competencies “Entrustable Professional Activities” (EPAs) • Specific, measurable areas of practice • Clinical situations in which residents shall be entrusted to perform competently upon graduation • The “mass of critical elements that operationally define” Family Medicine. Cate and Scheele. Acad Med. 2007; 82(6): 542 -547.

How TUFMR developed competencies - 2008 • Literature search • Models from UK and Denmark • Delphi method with P 4 participants and STFM Competency Measurement Task Force • Tested in outpatient setting • Initial list of 92, revised to 76. – 62 final outpatient EPAs Shaughnessy et al. Journal of Graduate Medical Education, March 2013. DOI: http: //dx. doi. org/10. 4300/JGME-D-12 -00034. 1

Competency Comments Office: Addictions Brief counseling, readiness to quit, motivational interviewing and The patient with a nicotine addiction planning. Describe signs, symptoms of intoxication/addiction. withdrawal, The patient with a substance addiction treatment. Describe signs sx of intoxication/addiction. withdrawal, treatment The patient with an alcohol addiction Office: Cardiovascular The patient with a murmur Evaluation and work-up. When to use prophylactic antibiotics Palpitations, A. Fib. Know EKG findings. When to anticoagulate The patient with an irregular heart beat and/or refer The patient with chest pain DDx and evaluation. CAD and PE. Secondary prevention.

Anatomy of a Competency/EPA • • • Preventive Measures Diagnosis Secondary Prevention/Monitoring Comorbidities – knowledge and prevention Treatment Quality Improvement/Systems

TUFMR/CHA P 4 Curriculum • Competencies drive the curriculum – “Entrustable Professional Activities” • Information Mastery • Areas of Concentration (AOC) – Longitudinal and Elective Time • Executive Skills – With PCMH, now includes Applied Leadership • Longitudinal Curriculum – The clinic as teacher. Goal: 60% of learning occurs in the family medicine center, with family physicians

Information Mastery The application of evidence-based medicine. Internship orientation – Didactics and small group sessions – June and January orientation (4 weeks total) Longitudinal Experience – Look-up conferences: PICO – Mythbusters – Journal club: PICO Measures: – Fresno EBM Questionnaire – Cognitive Skills assessments PICO = Population/Patient, Intervention, Comparison, Outcome

TUFMR/CHA P 4 Curriculum • Competencies drive the curriculum – “Entrustable Professional Activities” • Information Mastery • Areas of Concentration (AOC) – Longitudinal and Elective Time • Executive Skills – With PCMH, now includes Applied Leadership • Longitudinal Curriculum – The clinic as teacher. Goal: 60% of learning occurs in the family medicine center, with family physicians

Area of Concentration (AOC) • Additional education, and additional proficiency, in a specific content area of Family Medicine. A “minor”. • Specific structure, content, criteria approved by entire faculty. AFMRD Guidelines. • Currently: Education, Research, Community Health, International Health, Women’s Health, Maternity Care, Hospital Medicine, Sports Medicine, Child and Adolescent Health, Integrative Medicine • In Process: Geriatrics, Palliative Care, Leadership • The “hybrid” or “Self-Directed” AOC • Measures: Explicit in each AOC. Assessment by faculty supervisor.

TUFMR/CHA P 4 Curriculum • Competencies drive the curriculum – “Entrustable Professional Activities” • Information Mastery • Areas of Concentration (AOC) – Longitudinal and Elective Time • Executive Skills – With PCMH, now includes Applied Leadership • Longitudinal Curriculum

Executive Skills/Applied Leadership • Development of leadership and management skills. With PCMH this has evolved toward more team-building, team-work, collaborative skills. • A dynamic element of the curriculum, as we adopt the principles of a PCMH. – Residents lead the clinical teams and led the achievement of NCQA Level III accreditation • Political advocacy, QI/TQM methods, Systems, Financial Planning, Meetings, Managing Change, Relationships, Collaboration, Conflict, Negotiation

TUFMR/CHA P 4 Curriculum • Competencies drive the curriculum – “Entrustable Professional Activities” • Information Mastery • Areas of Concentration (AOC) • Executive Skills • Longitudinal Curriculum – The clinic as teacher. Goal: 60% of learning occurs in the family medicine center, with family physicians

Longitudinal Curriculum • Precepting – POw. ER: Prepare, Orchestrate, Educate, Review* • Teaching on the fly – “just in time” – Point of care EBM, Library, i. Phone apps • Shadowing • Longitudinal elective time *Lillich et al. Fam Med 2005; 37(3): 205. Wisconsin

Assessment Tools: Compass→E*Value • Current components – Cognitive Skills Evaluations - preceptors – Basic Skills Qualifications (BSQ’s) – Procedure Assessment - preceptors – Shadow Precepting – 360⁰ Evaluation Other sources of assessment: – Feedback from rotations – ITE results

Screenshot of E*Value Cognitive Skills Assessment page. Example of Competencies – there are 62, in 21 domains

Example of E*Value Cognitive Skills Assessment

Residents identify and exploit seams • Morning Conferences • Journal Club • Feedback to curriculum coordinator Needs. Weak areas. Clinical situations likely to be encountered, but not often. • Synergy • Portfolio problems

Clinical Blogging (reflection) • We have integrated a reflective exercise into our curriculum at Tufts: “clinical blogging” • Specific time allotted • Format: – Process vs. product – Privacy honored • Linked to competency you are reflecting about

Why Add Reflection to Residency Training? • Facilitating the switch from passive to active learners • Fosters adult self-directed learning • Gives residents time to process their educational “tasks” to learn from them • Changes the culture to one where it is “ok not to know” • Hopefully create life-long learners

Challenges • Ongoing development of competency assessment. • Encouraging adult learning through reflection – Portfolios: Competencies, evaluations • Video-taped assessments • Rapid response to residents’ perceived needs • Transition issues between internship and second year – clinic efficiencies and adult learning

Wrap-Up • Family Medicine Residencies are complicated fabrics. The quality and character of the seams are critical. – Design an intentional curriculum – Competencies (EPAs) - Teach/Learn and Assess • Know where the seams are, and be prepared to strengthen, revise, take down, alter. • Adapt to needs of residents – Identified by them, and by others