1. Fear and Loathing in Resident Land: Responding To Unexpected ACGME Survey Results Greg Kirschner MD, MPH Advocate Lutheran General Hospital Park Ridge, IL

2. Disclosures There are no relevant financial disclosures for this presentation.

3. The ACGME Resident/Fellow and Faculty Survey The ACGME’s Resident/Fellow and Faculty Surveys are an additional method used to monitor graduate medical clinical education and provide early warning of potential non-compliance with ACGME accreditation standards. Word for word samples of surveys not available Not all survey takers see the same questions January to June each year http://www.acgme.org/Data-Collection-Systems/Resident-Fellow-and-Faculty- Surveys/DataCollectionSystems/ResidentFellowandFacultySurveys

4. ACGME Resident/Fellow and Faculty Survey Results Data compared to national norms Historical trends included Converted to “% program compliance” across the content areas DUTY HOURSFACULTY EVALUATIONEDUCATIONAL CONTENT RESOURCESPATIENT SAFETY/TEAMWORK

5. ACGME Resident/Fellow and Faculty Survey Results “Residents can raise concerns without fear” YEAR% Program compliant Program Mean % National compliant National Mean

6. ACGME Resident/Fellow and Faculty Survey Results

7. Fear

8. REACTING AND RESPONDING This isn’t true !!!!! Who said this???? Not again this year... Is the ACGME going to visit me now? How have I failed? How have WE failed? How can we improve?

9. Fear and Loathing In Las Vegas In Life In Residency In Residency Land In MY Residency????

10. UNDERSTANDING RESIDENT RESPONSES Do a “plain reading” of the question(s) for this item, and see if there is already an apparent explanation you know about. –Should look at the question(s) itself. –“To what extent does your program provide an environment where residents/fellows can raise problems or concerns without fear of intimidation or fear of retaliation?”

11. UNDERSTANDING RESIDENT RESPONSES Consider carefully how to hear from residents directly or indirectly on: –How residents understood the question –Why they answered the way they did

12. THE PROBLEM WITH A QUESTION ABOUT FEAR/INTIMIDATION... Even the act of exploring the answers to the survey could be seen as “interrogation” and “intimidation”

13. UNDERSTANDING RESIDENT RESPONSES OPTIONS: Program Director, Associate Program Director, or other Faculty meeting with residents as a group: “Town Hall Meeting” format Keep focused on desire to listen for purpose of program improvement Create environment of openness/safety Come ready to listen and hear new things

14. UNDERSTANDING RESIDENT RESPONSES OPTIONS: PD/APD/Faculty meeting with subgroups of residents Meet by class –Graduating residents may be key...or maybe not Meet with key resident leaders Possible other subgroups –International Medical Graduates

15. UNDERSTANDING RESIDENT RESPONSES OPTIONS: Send others to go meet with the residents Allow residents to choose who they meet with Can be resident lead meetings –Role of the Chief Residents May be a role for behavioral scientist, or other specific faculty –These need a focused agenda, but also freedom to explore

16. UNDERSTANDING RESIDENT RESPONSES OPTIONS: Commit to a ‘suggestion box’ Remind residents of other institutional options for being heard (e.g. GME, hotline, DIO, Other specialty faculty resource) Adjust strategies by differences in the resident leadership, changing class personalities, etc. Try to create an avenue so that issues even with senior leadership can be voiced

17. Seek out sources of fear and intimidation And don’t just look causes of fear that relate to “express concerns without fear of intimidation or fear of retaliation; Greg’s theory: the questions are not always thought through completely; issues “generalize” The words “fear” and “intimidation” trigger responses Look out for issues with confidentiality; Look across the whole survey for themes

18. Look across your institution Compare survey results across disciplines

19. Identified contributors to resident fear/intimidation over 4 years “Demanding” faculty: –Other specialties or our family physician faculty –Residency program leadership Demanding fellow residents Feedback and evaluation process: not enough positive feedback; not enough direct, specific behavioral feedback Resident self confidence Residents on “learning plan” and international graduates; -- afraid to show what they don’t know Desire to avoid “being labeled” as a problem resident—even our chiefs Confidentiality breaches Generational issues?

20. What about faculty fear? Doesn’t appear on the faculty survey... Faculty can model fear of intimidation/retaliation We can be afraid of the ACGME –How DOES the ACGME use the results from this section?

21. Turning findings into actions... OWN the responsibility for making change Probably will be asked to develop an action plan: –Annual Program Evaluation/Program Evaluation Committee –Develop collaboratively Share your findings broadly, and your commitment to make real change; –Lay out a specific time frame for changes, and accountabilities Make real progress and then communicate that Do prep the residents and faculty each year for the survey

22. Examples from our action plan Feedback taken to FM residency faculty individually, as well as other specialists; Highlighted confidentiality across the program Town Hall meetings scheduled Follow up exploratory sessions with reports on progress, including with IMGs

23. Casting out fear Own the data, even if flawed Transparency Information Accountability Action Love

24. To Summarize: Responding To Unexpected Survey Results Plain reading of the question Seek to hear how the residents understood and answered Seek out sources Look for patterns Make action plans with accountabilities Communicate

25. Discussion/Questions From “Fear and Loathing in Las Vegas” movie