1. Changes in Pediatric Education Amy Jost Starmer, MD, MPH UNC Pediatrics Residency Class of 2007 Assistant Professor of Pediatrics Oregon Health and Science University

2. Overview Changes in Pediatrics Implication of change on pediatric trainees and education Importance of measurement and reflective thinking Embracing Change

3. Pediatricians and Change "Rather than taking an overall leadership role in the continuous improvement of the health care delivery system, too many medical professionals either ignore the problems of the system in order to concentrate in their own specific practices or focus their energies and talents on protecting the status quo." - George Halvorsan, Chairman and CEO, Kaiser Permanente

4. We’re not alone Feel prepared for expected change Expect high / very high level of change over next 5 years

5. Pediatricians and Change In what direction is the profession of pediatrics going? – What forces will most influence the future? – How does the current direction match up against our desired vision for the profession? – How are pediatricians coping and planning for the future?

6. 6 Vision of Pediatrics 2020 Task Force Directives Review data from internal/external experts as to the most powerful forces likely to change or influence the future of pediatrics Identify the forces most likely to influence the future and construct scenarios Identify gaps between current AAP activity and desired AAP activity to best address scenarios Make recommendations to the Board as to what changes in AAP might yield greatest return in mission and member value based on future scenarios

7. Vision of Pediatrics 2020 This project was about CHANGE, not PREDICTION – Removing blinders so all can be seen – Considering likely scenarios – Preparing for likely scenarios – Flexibility to move and manage change when strategically important

8. Outcome of the Vision of Pediatrics 2020 Project: The Eight Megatrends

9. The Eight Megatrends 1. Changing Demographic and Clinical Characteristics of Children and Families 2. Burgeoning Health Information Technology 4. Alterations in the health care delivery system 3. Ongoing medical advances

10. 7. Globalism 8. Changes in pediatric workforce 5. Growth of consumer driven healthcare 6. Increased frequency of disasters The Eight Megatrends

11. Changes in the Pediatric Workforce THEN NOW

12. Changes in the Pediatric Workforce

17. Additional examples of changes affecting the pediatric workforce… Duty hours restrictionsShift towards competency based training

18. What are the implications of these changes on pediatric education? Are we appropriately training pediatricians to meet evolving health care needs? Does one residency curriculum suffice for all general pediatric residents? Is it essential for pediatric residents to be exposed to the greatest possible breadth of knowledge and experience?

19. Reconsidering the State of Pediatric Residency Training - the R3P project Residency Review and Redesign in Pediatrics (R3P) Convened by the ABP on behalf of the broad community of pediatric care providers

20. The Residency Review and Redesign Project Purpose: to re- examine the structure of pediatric residency education and assumptions on which it is based

21. Broad discussions about future of pediatric health care How do current educational strategies align with RRC competencies Explore possible modifications in resident education Residency Review and Redesign Project Goals

22. Residency Review and Redesign Project Conclusions No single approach to general pediatric residency education is best for all residents General pediatric residency programs should not attempt to provide all learning that every pediatrician should conceivably need Residency training must be considered within the context of continuum of learning from medical school to post-residency practice An ongoing “quality improvement” like process is necessary to identify and implement effective approaches to resident education

23. The Initiative for Innovation in Pediatric Education Established on recommendation of the Residency Review and Redesign in Pediatrics (R 3 P) Project Mission: To initiate, facilitate and oversee innovative change in pediatric residency education through carefully monitored, outcome-directed experimentation Aim: To support high quality research in medical education through regular calls for proposals, Innovation/Improvement Plans (I-Plans)

24. The Importance of Measurement AVOID ENCOURAGE

25. The Importance of Measurement “….when you can measure what you are speaking about and express it in numbers, you know something about it,” and, “If you cannot measure it, you cannot improve it.” Lord Kelvin of Glasgow mathematician and physicist (1824-1907)

26. The Importance of Measurement “Jost--where are you? Show your face out from the subterranean existence in the ED. If you can sign these things I'll get them sent off to the IRB.” Lord Steiner of Chapel Hill Mentor and Preceptor “Who said I was doing power calculations? I don't know squat about this stuff. My daughter on the other hand is a prodigy, instead of crying when she was born she came out and screamed "logistic regression!!!". Needless to say she's on tap to be the Director of the CDC in about 35 years.”

27. Trends in Medical Education Research, 1969-2007 1969-19701979-19801989-19901999-20002006-2007 Number of Studies1152367147 Multi-institutional01 (7%)3 (13%)5 (8%)9 (6%) Objective outcome1 (100%)8 (53%)17 (74%)53 (79%)91 (62%) Validated Outcome03 (20%)3 (13%)17 (25%)23 (16%) Outcome assessed >1 month later 04 (36%)4 (21%)16 (27%)35 (26%) Statistical Power estimated 002 (9%)3 (4%)21 (14%) Cost estimated01 (7%)2 (9%)5 (7%)5 (3%) Funding reported04 (27%)5 (22%)30 (45%)66 (45%) Source: “Trends in Study Methods Used in Undergraduate Medical Education Research, 1969-2007” JAMA 298 (9): 1038-1045.

28. Pulling it all Together: An Example DUTY HOURS CHANGESINCREASED FREQUENCY OF HANDOFFS OF CARE

29. Pulling it all together: Capitalizing on Change The I-PASS Resident Handoff Study – Rigorously testing the impact of a bundle of interventions to standardize handoffs at 9 pediatric institutions – Supported by Initiative for Innovation in Pediatric Education – Linking impact of educational intervention with key patient outcomes including medical error rates

30. Conclusions The only constant is change, continuing change, inevitable change, that is the dominant factor in society today. No sensible decision can be made any longer without taking into account not only the world as it is, but the world as it will be. — Isaac Asimov We should embrace change as an opportunity Measurement is critical

31. Embracing Change: A Personal Example

32. Embracing Change: A personal Example

33. My favorite example of why change is a good thing Thank You!

34. Vision of Pediatrics 2020 Methods Literature review within and outside pediatrics – 48 forces likely to influence practice Electronic survey to all AAP leaders and membership – Rank trends Qualitative interviews with thought leaders Consolidated data into lists of “Megatrends” and “Wild-Card Trends”

35. Vision of Pediatrics 2020 Methods Scenario Planning to envision potential influence of trends on pediatrics Identified best-case, worst-case, and most-plausible scenario for each megatrend

36. The need to reconsider the state of medical training Abraham Flexner’s 1910 Report on Medical Education in the United States and Canada Argued schools were ill equipped with too much focus on didactics Recommended closing 124 of the 155 schools he visited

37. Direct Observation of Resident Performance at UNC Study Aims – Explore resident and parent perceptions and preferences for direct observation and determine impact of direct observation on parent satisfaction with care Results – Residents report low rates of being observed – Residents have specific preferences for how Direct Observations should be conducted – Resident favorable perception of direct observation – Parent satisfaction and perception of care with direct observation is no different than standard visit

38. Capitalizing on Change: Opportunities for Measurement Example 1: The ACGME Pediatric Milestones Project –