Transforming Passive Rotations Blake Fagan, MD Lisa Ray, MD MAHEC Family Practice Residency Program Asheville, NC April 2012

Goals Define passive rotation Define ideal rotation Describe how –Curriculum website –Rotation check list –Half day of rotation specific didactics helped use to remodel our passive rotations 2

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Identifying the Problem Review of our curriculum identified 6 of 22 rotations which were consistently getting mediocre evaluations by residents Described as passive Shadowing experience with a private attending in their office Bottom line: Residents hated them

Identifying the Problem Do any of you have this problem?

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What worked about our successful specialty rotations Cardiology –Expected part of the team –Involved in direct patient care, procedures and documentation –Cardiologist depend on them – felt they were necessary to get the work done –Resident expected to give a talk during cardiology grand rounds

Ideal Rotation Resident and attending both understand what the resident needs to learn Resident needs to be an essential part of the team involved in direct patient care, procedures and documentation Attendings need to be like our faculty High expectations of residents, understanding of what their baseline knowledge is and willing to teach something with each patient encounter

Our Vision Create a curriculum website Devote a 1/2 day of each rotation to rotation specific self directed learning Engage the specialist attendings as teachers 11

Tackling the Problem Family Medicine faculty buy-in Develop checklist for revamping the rotations Develop the curriculum website 12

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The Check List I am addicted to checklists I just read The Check List Manifesto I believe all problems can be solved with a check list Goals –Manageable –Leave nothing out –Keep each faculty accountable

The Check List: Assessment Phase Admin staff produce rotation packet –ACGME curriculum guidelines –Current Goals and Objectives –Copies of Completed Evaluations –Blank copy of Evaluation of Resident –Available pre-tests, articles and readings –Current schedule

The Check List: Assessment Phase Rotation Packet –Current contact information, including addresses –Overview of other longitudinal experiences, clinics, etc. –List of ongoing didactics that address specialty topic –List of residents who have been on the rotation (to get feedback) –Evaluations from attending and residents

The Check List Review the Packet Make sure information is correct Develop rotation specific didactics 17

Rotation Specific Didactics Create required reading list of 3-5 articles Create lecture introducing 5-6 most important topics in specialty Make pre test of 10 questions 18

The Check List Review the Packet Make sure information is correct Develop rotation specific didactics Identify weaknesses of the rotation and propose solutions –Meet with residents –Brainstorm with residency director 19

The Check List Review the Packet Make sure information is correct Develop rotation specific didactics Identify weaknesses of the rotation and propose solutions Communicate with rotation attendings 20

The Check List Communication phase Admin Staff set up meetings with private Faculty confirmed meetings by and attach basic information –Goals and objectives, evaluations, readings, –Echo, pre-test –Instructions to log onto web site –Ask attending to review prior to meeting.

The Check List Communication phase Meet with attending – listen! –Be prepared to hear complaints (that you may not be able to fix or have answer for). –Ask what we can do to help.

Barriers with Attendings Private practices are businesses and driven by need to see lots of patients Many of private practices have EMR’s unfamiliar to the resident Many privates felt their patients might not be open to the idea of seeing a resident Attendings felt teaching more or having residents see patients would slow them down

Proposing the Ideal –Resident sees patient first –Presents patient –Teaching point on every patient even if only 30 seconds –Involved in any procedures –Does documentation – Should speed them up or be time neutral

The Check List Review the Packet Make sure information is correct Develop rotation specific didactics Identify weaknesses of the rotation and propose solutions Communicate with rotation attendings Put it all together 25

The Check List Review Phase Revise plan after meeting with attendings Review new plan with Residency Director Contact private attending shortly after meeting Think of all the ways that we address the rotation material

The Check List REPORTING PHASE Faculty present at Curriculum Retreat and mid-year to Residency Director CHECK IN 6 months later receive the interim evaluations about the rotation from admin staff and touch base with attendings by or phone Yearly meet with attendings –Vitally important!

The Curriculum Website –Needed a new tool to help us organize and present information –It’s cool –Place to access practical rotation information –Place to access educational information related to the rotation RRC guidelines Rotation goals and objectives List of procedures to learn on rotation List of topics to be covered while working with specialist Required and recommended reading list Required ECHO Rotation specific practice board questions (Pre-test) Links to related websites or on line resources

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Engaging the Specialists Appreciating what they were already doing –Teaching certificates of appreciation –Developing the one on one relationship Trying to address existing problems Clarifying that they should expect resident to have baseline knowledge Asking for their participation in developing required reading list, and ECHO Show them the Web page

Engaging the Residents Required first ½ day of rotation to be done at our clinic –Pretest –ECHO lecture 5-6 topics –Required reading list 3-5 articles

Engaging the Resident Expectations were increased Academic goals of the rotation were made more clear –ECHO FM summary of key things to learn on rotation –List of procedures to learn on rotation –List of topics to be covered by attending on rotation

Engaging our Faculty Ongoing relationship with private attending Identify the weakest teachers Ownership of rotation – increases ownership of whole curriculum Increase in creativity/ sharing ideas

Outcomes The website –Information on any rotation found in one location for anyone to access –Rich resource for residents Reading lists Can access lectures anytime Access to lectures they missed Access to great links “Residents eyes only” section –Rich resource for Faculty Makes review of curriculum much easier Great teaching resource

Outcomes The Rotations –All are better –Some are remarkably better – passive teacher became totally active –Poor teachers eliminated –Residents highly value the ½ day of ECHO and required readings –Biggest successes website and ½ day of didactics

Comments and Questions