The Holy Grail of the Paper Trail

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The Holy Grail of the Paper Trail

• Polly E. Parsons MD
• University of Vermont College of Medicine
• Fletcher Allen Health Care

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Things Could Always Be Worse!
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The Process
Request for input on existing program
requirements
APCCMPD ATS ACCP (SCCM)
Program requirements revised and distributed for
comment
New program requirements approved
Courtesy of Dr. S. Murin
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The Process
Request for input on existing program
requirements
1. Remove requirement for onsite Trauma
Services Sleep and Rehab Micro lab 2. Get rid
of 2 key faculty /specialty rqmnt 3. Change
language re modes of ventilation 4. Remove
outdated rqmnts Pleural bx Transthoracic
needle bx Respiratory drive assessment Peritonea
l dialysis 5. Change from expertise to
competence Admin functions 6. Asked for less
continuity clinic
Program requirements revised and distributed for
comment
Adapted from Dr. S. Murin
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The Process
Request for input on existing program
requirements
1. Nearly every one of our suggestions was
incorporated into new requirements, often
verbatim 2. A bunch of alarming and unexpected
additional changes were made 24 months of
block time 3 months non-MICU More clinic (2 more
yeas of continuity)
Program director at primary site Generous
support for program director
Program requirements revised and distributed for
comment
New program requirements approved
Adapted from Dr. S. Murin
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Our Counter-Offer

• 18 months of block time
• 1-2 months of non-medical critical care (with
  caveats)
• Less clinic, not more, allow for blocks

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What Did We Get?
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Common Themes

• Documentation
• Communication
• Evaluation
• Education (not service)
• Competency
• Research

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Changes in General Program Requirements for
Fellowship education in the Subspecialties of
Internal Medicine
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Sponsoring Institution
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Not New But May be More Important

• The sponsoring institutions must demonstrate a
  commitment to education and research sufficient
  to support the fellowship program
• The institution must assure significant research
  in each subspecialty for which it sponsors a
  training program

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• The sponsoring institution must assure that
  adequate salary support is provided to the
  program director for the administrative
  activities of the subspecialty program. The
  program director must not be required to generate
  clinical or other income to provide this
  administrative support. It is suggested that
  this support be 25-50 of the program directors
  salary depending on the size of the program.

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Proposed Change to Common Program Requirements
(for all ACGME Training Programs)

• The sponsoring institution must provide the
  program director with sufficient financial
  support and protected time for his/her
  educational and administrative responsibilities
  to the program. The program director must not be
  required to generate clinical or other income to
  provide this support.
• Approved by RRC Council of Chairs February
  2005
• (effective date July 1, 2006)

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Rationale

• High turnover rate of program directors
• Increased administrative burden due to ACGME
  mandates
• Institutional demands to generate income

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Participating Institution
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• Section expanded from previous program
  requirements
• The Primary Training Site is defined as the
  health-care facility that provides the required
  training resources, should be the location of the
  program directors major activity, the location
  where the fellow spends the majority of their
  clinical training time and the primary location
  of the core program in internal medicine

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Program Directors
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Qualifications

• 1. Must possess the requisite subspecialty
  expertise, as well as documented educational and
  administrative abilities
• 2. Must be based at the primary teaching site.
• 3. Must be responsible to the sponsoring
  organization.

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Responsibilities

• 1. 20 hours per week averaged over the year
  (not new) with sufficient time for administration
  of the program and receive institutional support
  for that administrative time
• 2. The program director must participate in
  academic societies and in educational programs
  designed to enhance his or her educational and
  administrative skills

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• 3. Must implement a program of CQI in medical
  education for the faculty, especially as it
  pertains to teaching and evaluation of the ACGME
  competencies

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Faculty

• The responsibility for establishing and
  maintaining an environment of inquiry and
  scholarship rests with the faculty...
• Each program must have an active research program.

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Scholarship

• 1. Discovery
• - peer review funding/publications
• 2. Dissemination
• - review articles, textbook chapters
• 3. Application
• - presentation or publication of case reports,
  clinical series,

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• The majority of faculty must be involved in
  scholarship
• The majority of key clinical faculty must
  demonstrate evidence of productivity in either
  Discovery or Dissemination
• At least one faculty member must be active in
  the scholarship of discovery.

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Questions

• Does the individual active in the scholarship of
  discovery have to be a key clinical faculty
  member?
• Can that individual be a nonphysician faculty
  member?

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Resources

• All deaths of patients who received care by
  fellows must be reviewed and autopsies performed
  whenever possible.

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Curriculum
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Research

• Majority of fellows must demonstrate evidence of
  recent research productivity through
• publication of manuscripts or abstracts in
  peer-reviewed journals
• Abstracts presented at national specialty
  meetings
• NOTE does not apply to CCM fellowships

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The Six Competencies

• 1. Patient care
• 2. Medical knowledge
• 3. Practice-based learning and improvement
• 4. Interpersonal and communication skills
• 5. Professionalism
• 6. Systems-based practice

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Didactics

• 1. Total teaching time in combined
  management/teaching rounds must exceed by a
  minimum of 5 hours per week the time required to
  supervise the care of the patients
• 2. Conferences
• must have a weekly core curriculum conference -
  must cover basic science as well as clinical
  topics

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Duty Hours SupervisionEvaluation
Independently review each of these sections
carefully!
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• At least 80 of fellows eligible for ABIM
  subspecialty certifying exams must have taken
  ABIM exam.
• Pass rates for first time takers of ABIM cert
  exams will be examined at each program review

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Experimentation and Innovation

• Hidden here is the
• Performance improvement process
• - program must have one ongoing PI activity
  related to the competencies
• - must involve fellows and faculty
• - should result in measurable improvements in
  patient care or fellow education

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Changes in Program Requirements for Fellowship
Education in Pulmonary Disease and Critical Care
Medicine
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Educational Program

• 18 clinical months still allowed
• Programs with lt 24 months additional ambulatory
  care clinic for 6 months (not during the clinical
  months)
• 3 months in care of critically ill non-medical
  patients. At least one month must be direct
  patient care activity

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Clinic

• 1. Must have continuity clinic for the length of
  training program
• 2. Extra 1/2 day per week for six months
• - cannot occur during the 18 clinical months
• - suggestions longitudinal experience in
  CF, ILD

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A Gift?

• Fellows may be excused from their continuity
  care clinic experience while on critical care
  rotations

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Faculty

• The program director and critical care teaching
  staff must have primary responsibility for
  admission, treatment and discharge of all
  patients on critical care teaching service.
• Must be ABIM subspecialty certified clinical
  faculty members in nephrology, GI, cardiology,
  ID, hematoogy, oncology, and geriatrics who
  participate in educational program.

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Facilities and Resources PCCM

• Must be present at primary training site
• - thoracic surgery service
• - at least three accredited subspecialty
  programs (cards, GI, ID, nephrology, pulmonary -
  ?)
• - an active emergency service
• - MICU - program director should be responsible
  for educational program

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Program Content PCCM and Pulmonary

• Review this section carefully!
• Subtle changes
• PE,post-op management of critically ill patients
• Not so subtle changes
• Minimum of 50 flexible fiber-optic bronchoscopy
  procedures
• No more pleural biopsies

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Common Citations

• Lack of written goals and directives
• All full-time faculty dont engage in active
  research
• Clinics are not continuity clinics
• Insufficient number of conferences
• Non-compliance with evaluation requirements
• Duty hours