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Creating a Seamless World of Learning George Maxted, MD Chris Simons, MD Tufts University Family Medicine Residency at Cambridge Health Alliance – TUFMR/CHA STFM Annual Spring Conference. 5/4/13
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Objectives Describe a framework, a fabric of a Family Medicine Residency Identify the quality and quantity of the seams in the fabric. Describe a P4 approach, the evolution of curricula, and opportunities for future growth
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Competencies Info Mastery Exec Skills Longitudinal Curriculum Community Teams Seams: Stitching to hold the fabric together The Clinic AOCs
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Seams: Space, light, opportunity
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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?
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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 - P4 Curriculum Redesign project begins –The Clinic as Teacher –Family Medicine taught by Family Docs –Longitudinal Curriculum
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Essential Elements of a Family Medicine Residency A Home – with parking A Director –And a “Mom” Faculty –With clinical, academic, administrative support Residents Curriculum
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Bloom’s Taxonomy Encourage higher order learning
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The Kolb Learning Cycle Kolb, D. A. (1984). Experiential Learning: Experience as the Source of Learning and Development. Upper Saddle River, NJ, Prentiss Hall.
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Rotations 80% Rotations 44% Rotations 20% Office Practice 60% Office Practice 42% Office Practice 8% FM Inpatient -12 wks FM Inpatient-7wks FM Inpatient-6wks Didactics 10% PGY-1 Interns PGY-2 PGY-3 Seniors TUFMR/CHA P4 Curriculum Community Health Executive Skills/Applied Leadership Didactics 8%
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Year to Year First Year Orientation Rotations Inpatient Svc Office Practice Behavioral Health Didactics Support Group Third Year Transition Rotations Inpatient Svc Office Practice Behavioral Health Didactics AOCs Electives Professionalism Executive Skills Second Year Transition Rotations Inpatient Svc Office Practice Behavioral Health Didactics AOCs Elective Community Professionalism Applied Leadership
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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
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TUFMR/CHA P4 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
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TUFMR/CHA P4 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
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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/FamilyMedicineMilestones.pdf
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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.
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How TUFMR developed competencies - 2008 Literature search Models from UK and Denmark Delphi method with P4 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
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Competency Competency Comments Office: Addictions The patient with a nicotine addiction Brief counseling, readiness to quit, motivational interviewing and planning. The patient with a substance addiction Describe signs, symptoms of intoxication/addiction.withdrawal, treatment. The patient with an alcohol addiction Describe signs sx of intoxication/addiction.withdrawal, treatment Office: Cardiovascular The patient with a murmur Evaluation and work-up. When to use prophylactic antibiotics The patient with an irregular heart beat Palpitations, A.Fib. Know EKG findings. When to anticoagulate and/or refer The patient with chest pain DDx and evaluation. CAD and PE. Secondary prevention.
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Anatomy of a Competency/EPA Preventive Measures Diagnosis Secondary Prevention/Monitoring Comorbidities – knowledge and prevention Treatment Quality Improvement/Systems
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TUFMR/CHA P4 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
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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
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TUFMR/CHA P4 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
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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.
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TUFMR/CHA P4 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
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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
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TUFMR/CHA P4 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
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Longitudinal Curriculum Precepting –POwER: Prepare, Orchestrate, Educate, Review* Teaching on the fly – “just in time” –Point of care EBM, Library, iPhone apps Shadowing Longitudinal elective time *Lillich et al. Fam Med 2005;37(3):205. Wisconsin
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Assessment Tools: Compass→E*Value Current components –Cognitive Skills Evaluations - preceptors –Basic Skills Qualifications (BSQ’s) –Procedure Assessment - preceptors –Shadow Precepting –360 ⁰ Evaluation Other sources of assessment: –Feedback from rotations –ITE results
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Screenshot of E*Value Cognitive Skills Assessment page. Example of Competencies – there are 62, in 21 domains
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Example of E*Value Cognitive Skills Assessment
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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
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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
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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
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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
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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
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