Accreditation Council for Graduate Medical Education competencies: practice-based learning and systems-based practice

The Role of Standardized Patient Programs in Promoting Equity, Diversity, and Inclusion: A Narrative Review

PURPOSE

Integrating equity, diversity, and inclusion (EDI) in curricula for training health professionals is a frequent institutional goal. The use of standardized (or simulated) patient programs (SPPs) to support EDI in health sciences training is not well described. Here the authors present a theoretical model based on a synthesis of the literature for using SPPs in EDI training, along with a narrative review of the available literature.

METHOD

The authors searched PubMed, Scopus, Science Direct, and Google Scholar databases for studies published between January 2000 and October 2019 describing the use of SPPs to support EDI in health sciences education. Studies were included if they described standardized patient (SP) education involving EDI and reported empiric data about its design, delivery, or effectiveness. The authors conducted a narrative review and provided a synthesis of the available literature, identifying key themes.

RESULTS

Out of 117 studies identified, 17 met the inclusion criteria. Most studies (53%; n = 9) focused on cultural competence; many focused on communication with diverse patients (29%; n = 5) or health inequity (18%; n = 3). Studies employed portrayal of diversity (71%; n = 12) or learning objectives supported by diversity (29%; n = 5) as approaches to EDI relevant to SP training. Three primary themes emerged: improving cultural competence, effective communication with diverse patients, and highlighting health inequalities.

CONCLUSIONS

This review outlines approaches to EDI-based SPPs, with the perspectives and priorities of institutional approaches in mind. SP education around specific EDI issues is reported; however, programmatic approaches to EDI by SPPs are lacking. More research is needed to provide further evidence for the challenges, effectiveness, and outcomes of developing and implementing EDI-based SPPs in health sciences education.

Patient Safety Education 20 Years After the Institute of Medicine Report: Results From a Cross-sectional National Survey

OBJECTIVES

Educating healthcare professionals in patient safety is essential to achieving sustainable improvements in care. This study aimed to identify the key constituents of patient safety education alongside its facilitators and barriers from a frontline perspective.

METHODS

An electronic survey was sent to 592 healthcare professionals and educators in patient safety education in the United Kingdom. Two independent reviewers conducted a thematic analysis of the free-text data. Themes focused on effective content, learning practices and facilitators and barriers to patient safety education.

RESULTS

Of 592 individuals completing the survey, 545 (92%) submitted analyzable responses. Interrater reliability of coding was high with Cohen k value of 0.86. Participants endorsed experiential and interactive learning as ideal modalities for delivery and expressed a need for content to be based on real clinical cases and tailored to the needs of the learners. The most commonly mentioned facilitators were standardization of methods and assessment (49%), dedicated funding (21%), and culture of openness (20%). Staffing problems and high workload (41%) and lack of accessibility of training (23%) were identified as primary barriers of efficacy and uptake.

CONCLUSIONS

This study identified key factors to the success of patient safety education in terms of content and delivery alongside facilitators and barriers. Future curricula developers and interventions should improve standardization, funding, culture, and access so as to optimize education programs to enhance patient safety.

Adaptive entropy theory polymerization method for path optimization in edge computing educational systems

In this paper, through the edge computing application path, the educational evaluation system was optimized using the adaptive entropy theory polymerization method which based on applying the path. By adding multiple constraints to filter out nodes and educational evaluation edges that do not meet the requirements, the improved algorithm is used to optimize the redundant paths to avoid loops and node detour problem. To improve the accuracy of education evaluation and evaluation, ensure the load balance in the domain, and solve the problems of single evaluation attribute and high overlap of education evaluation paths. This paper proposes a multi-attribute education evaluation model that refines the evaluation attributes of education evaluation and uses analytic hierarchy process perform weight distribution. The algorithm can improve the accuracy of the evaluation of the education evaluation system while ensuring the computational efficiency, and can ensure the load balance within the domain, and improve the network survival time.

Multi-Institutional Implementation and Evaluation of a Curriculum for the Medical Student Clerkship in Radiation Oncology

PURPOSE

Radiation oncology curriculum development is challenging because of limited numbers of trainees at any single institution. The goal of this project is to implement and evaluate a standardized medical student clerkship curriculum following the multi-institutional cooperative group research model.

METHODS

During the 2013 academic year, a standardized curriculum was implemented at 11 academic medical centers consisting of three 1-hour lectures and a hands-on radiation treatment planning workshop. After the curriculum, students completed anonymous evaluations using Likert-type scales (1 = "not at all" to 5 = "extremely") and free responses. Evaluations asked students to rate their comfort, before and after the curriculum, with radiation oncology as a specialty, knowledge of radiotherapy planning methods, and ability to function as a radiation oncology resident. Nonparametric statistical tests were used in the analysis.

RESULTS

Eighty-eight students at 11 academic medical centers completed the curriculum de novo, with a 72.7% (64 of 88) survey response rate. Fifty-seven students (89.1%) reported intent to pursue radiation oncology as their specialty. Median (interquartile range) student ratings of the importance of curricular content were as follows: overview, 4 (4-5); radiation biology/physics, 5 (4-5); practical aspects/emergencies, 5 (4-5); and planning workshop, 4 (4-5). Students reported that the curriculum helped them better understand radiation oncology as a specialty (5 [4-5]), increased specialty decision comfort (4 [3-5]), and would help the transition to radiation oncology residency (4 [4-5]). Students rated their specialty decision comfort significantly higher after completing the curriculum (4 [4-5] versus 5 [5-5]; P < .001).

CONCLUSIONS

A national standardized curriculum was successfully implemented at 11 academic medical centers, providing proof of principle that curriculum development can follow the multi-institutional cooperative group research model.

The Systems SOAP Note: A Systems Learning Tool

OBJECTIVE

Systems-based practice (SBP) is the only Accreditation Council for Graduate Medical Education (ACGME) competency concerned with public health and is relatively neglected in residency curricula. A tool was developed and pilot-tested to improve SBP learning on inpatient psychiatry rotations.

METHODS

A four-step approach was used: (1) literature review, (2) expert consultation, (3) tool development, and (4) pilot testing on four cases and evaluation for completion time and preliminary efficacy.

RESULTS

Out of 51 SBP articles, six (12%) focused on psychiatric residency programs, and none had a practical SBP learning tool. The "systems SOAP (subjective, objective, assessment, plan) note" (S-SOAP) was structured after a clinical SOAP note and was easy to use (mean completion time = 60 min), and residents self-reported more insight into systems issues.

CONCLUSIONS

The S-SOAP tool was effectively integrated into clinical experience and provided insight into systemic complexities. Future research should assess SBP knowledge acquisition after the use of such tools.

Commentary on competency-based medical education and scholarship: creating an active academic culture during residency

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Competency-based medical education and scholarship: Creating an active academic culture during residency

The competency-based medical education movement has been adopted in several medical education systems across the world. This has the potential to result in a more active involvement of residents in the educational process, inasmuch as scholarship is regarded as a major area of competency. Substantial scholarly activities are well within the reach of motivated residents, especially when faculty members provide sufficient mentoring. These academically empowered residents have the advantage of early experience in the areas of scholarly discovery, integration, application, and teaching. Herein, the authors review the importance of instituting the germinal stages of scholarly productivity in the creation of an active scholarly culture during residency. Clear and consistent institutional and departmental strategies to promote scholarly development during residency are highly encouraged.

COCATS 4: Securing the Future of Cardiovascular Medicine

The latest iteration of the Core Cardiology Training Statement (COCATS 4) [Corrected] provides a potentially transformative advancement in cardiovascular fellowship training intended, ultimately, to improve patient care. This review addressed 3 primary themes of COCATS 4 from the perspective of fellows-in-training: 1) the evolution of training requirements culminating in a competency-based curriculum; 2) the development of novel learning paradigms; and 3) the establishment of task forces in emerging areas of multimodality imaging and critical care cardiology. This document also examined several important challenges presented by COCATS 4. The proposed changes in COCATS 4 should not only enhance the training experience but also improve trainee satisfaction. Because it embraces continual transformation of training requirements to meet evolving clinical needs and public expectations, COCATS 4 will enrich the cardiovascular fellowship training experience for patients, programs, and fellows-in-training.

Perspectives on the changing healthcare system: teaching systems-based practice to medical residents

PURPOSE

The Accreditation Council for Graduate Medical Education restructured its accreditation system to be based on educational outcomes in six core competencies. Systems-based practice is one of the six core competencies. The purpose of this report is to describe Weill Cornell Medical College's Internal Medicine Residency program curriculum for systems-based practice (SBP) and its evaluation process.

METHODS

To examine potential outcomes of the POCHS curriculum, an evaluation was conducted, examining participants': (1) knowledge gain; (2) course ratings; and (3) qualitative feedback.

RESULTS

On average, there was a 19 percentage point increase in knowledge test scores for all three cohorts. The course was rated overall highly, receiving an average of 4.6 on a 1-5 scale. Lastly, the qualitative comments supported that the material is needed and valued.

CONCLUSION

The course, entitled Perspectives on the Changing Healthcare System (POCHS) and its evaluation process support that systems-based practice is crucial to residency education. The course is designed not only to educate residents about the current health care system but also to enable them to think critically about the risk and benefits of the changes. POCHS provides a framework for teaching and assessing this competency and can serve as a template for other residency programs looking to create or restructure their SBP curriculum.

Teaching and assessing systems-based practice: a pilot course in health care policy, finance, and law for radiation oncology residents

BACKGROUND

Under the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project, residency programs are required to provide data on educational outcomes and evidence for how this information is used to improve resident education.

OBJECTIVE

To teach and assess systems-based practice through a course in health care policy, finance, and law for radiation oncology residents, and to determine its efficacy.

METHODS AND MATERIALS

We designed a pilot course in health care policy, finance, and law related to radiation oncology. Invited experts gave lectures on policy issues important to radiation oncology and half of the participants attended the American Society for Therapeutic Radiation and Oncology (ASTRO) Advocacy Day. Participants completed pre- and postcourse tests to assess their knowledge of health policy.

RESULTS

Six radiation oncology residents participated, with 5 (84%) completing all components. For the 5 residents completing all assessments, the mean precourse score was 64% and the mean postcourse score was 84% (P  =  .05). Improvement was noted in all 3 sections of health policy, finance, and medical law. At the end of the course, 5 of 6 residents were motivated to learn about health policy, and 4 of 6 agreed it was important for physicians to be involved in policy matters.

CONCLUSIONS

Teaching radiation oncology residents systems-based practice through a course on health policy, finance, and law is feasible and was well received. Such a course can help teaching programs comply with the ACGME Outcome Project and would also be applicable to trainees in other specialties.

Addressing the systems-based practice requirement with health policy content and educational technology

Duke University Hospital Office of Graduate Medical Education and Duke University's Fuqua School of Business collaborated to offer a Health Policy lecture series to residents and fellows across the institution, addressing the "Systems-based Practice" competency.During the first year, content was offered in two formats: live lecture and web/podcast. Participants could elect the modality which was most convenient for them. In Year Two, the format was changed so that all content was web/podcast and a quarterly live panel discussion was led by module presenters or content experts. Lecture evaluations, qualitative focus group feedback, and post-test data were analyzed.A total of 77 residents and fellows from 8 (of 12) Duke Graduate Medical Education departments participated. In the first year, post-test results were the same for those who attended the live lectures and those who participated via web/podcast. A greater number of individuals participated in Year Two. Participants from both years expressed the need for health policy content in their training programs. Participants in both years valued a hybrid format for content delivery, recognizing a desire for live interaction with the convenience of accessing web/podcasts at times and locations convenient for them. A positive unintended consequence of the project was participant networking with residents and fellows from other specialties.

The patient panel conference experience: what patients can teach our residents about competency issues

PURPOSE

In 2007, the Scott & White/Texas A&M HSC College of Medicine began requiring all internal medicine residents to attend quarterly patient panel conferences, during which former Scott & White patients speak frankly about their inpatient and outpatient experiences. The main purpose of this mixed-methods pilot study was to determine whether residents' competency education could be enhanced via the conferences.

METHOD

Of the 54 internal medicine residents in the residency program, 31, 39, and 41 participated in three patient panel conferences, respectively, between December 2007 and August 2008. Each resident completed an assessment that included a reflection on his or her own practice and the identification of competency issues highlighted by patients' oral narratives. Content analyses of responses to open-ended questions were performed. Consensus on themes was reached. Descriptive statistics were run on quantitative data.

RESULTS

Six themes were identified: improve communication with patients/families, improve patient care, improve professional behaviors, empathize with patients/families, display sensitivity to patients'/families' needs/concerns, and recognize system issues. When asked if the conference highlighted competency problems, residents answered "agree" or "strongly agree" as follows: 82% for professionalism, 82.9% for systems-based practice, 85.2% for interpersonal and communication skills, and 84.4% for patient care. The majority were able to provide examples of competency issues.

CONCLUSIONS

The patient panel conference experience was a powerful mechanism for enhancing competency education. The conferences were an effective means of presenting real-life examples of systems issues in the context of a hospital system.

Lessons learned from a 5-year experience with a 4-week experiential quality improvement curriculum in a preventive medicine fellowship

BACKGROUND

Competency in practice-based learning and improvement (PBLI) and systems-based practice (SBP) empowers learners with the skills to plan, lead, and execute health care systems improvement efforts. Experiences from several graduate medical education programs describe the implementation of PBLI and SBP curricula as challenging because of lack of adequate curricular time and faculty resources, as well as a perception that PBLI and SBP are not relevant to future careers. A dedicated experiential rotation that requires fellow participation in a specialty-specific quality improvement project (QIP) may address some of these challenges.

METHOD

We describe a retrospective analysis of our 5-year experience with a dedicated 3-week PBLI-SBP experiential curriculum in a preventive medicine fellowship program at Mayo Clinic, Rochester, Minnesota.

RESULTS

Between 2004 and 2008, 19 learners including 7 preventive medicine fellows participated in the rotation. Using just-in-time learning, fellows work together on a relatively complex QIP of community or institutional significance. Since 2004, all 19 learners (100%) participating in this rotation have consistently demonstrated statistically significant increase in their quality improvement knowledge application tool (QIKAT) scores at the end of the rotation. At the end of the rotation, all 19 learners stated that they were either confident or very confident of making a change to improve health care in a local setting. Most of the QIPs resulted in sustainable practice improvements, and resultant solutions have been disseminated beyond the location of the original QIP.

CONCLUSION

A dedicated experiential rotation that requires learner participation in a QIP is one of the effective methods to address the needs of the SBP and PBLI competencies.

Resident self-assessment and self-reflection: University of Wisconsin-Madison's Five-Year Study

BACKGROUND

Chart review represents a critical cornerstone for practice-based learning and improvement in our internal medicine residency program.

OBJECTIVE

To document residents' performance monitoring and improvement skills in their continuity clinics, their satisfaction with practice-based learning and improvement, and their ability to self-reflect on their performance.

DESIGN

Retrospective longitudinal design with repeated measures.

PARTICIPANTS

Eighty Internal Medicine residents abstracted data for 3 consecutive years from the medical records of their 4,390 patients in the University of Wisconsin-Madison (UW) Hospital and Clinics and William S. Middleton Veterans Administration (VA) outpatient clinics.

MEASUREMENT

Logistic modeling was used to determine the effect of postgraduate year, resident sex, graduation cohort, and clinic setting on residents' "compliance rate" on 17 nationally recognized health screening and chronic disease management parameters from 2003 to 2007.

RESULTS

Residents' adherence to national preventive and chronic disease standards increased significantly from intern to subsequent years for administering immunizations, screening for diabetes, cholesterol, cancer, and behavioral risks, and for management of diabetes. Of the residents, 92% found the chart review exercise beneficial, with 63% reporting gains in understanding about their medical practices, 26% reflecting on specific gaps in their practices, and 8% taking critical action to improve their patient outcomes.

CONCLUSIONS

This paper provides support for the feasibility and practicality of this limited-cost method of chart review. It also directs our residency program's attention in the continuity clinic to a key area important to internal medicine training programs by highlighting the potential benefit of enhancing residents' self-reflection skills.

A systems approach for implementing practice-based learning and improvement and systems-based practice in graduate medical education

The Accreditation Council for Graduate Medical Education (ACGME) initiated its Outcome Project to better prepare physicians-in-training to practice in the rapidly changing medical environment and mandated assessment of competency in six outcomes, including Practice-Based Learning and Improvement (PBLI) and Systems-Based Practice (SBP). Before the initiation of the Outcome Project, these competencies were not an explicit element of most graduate medical education training programs. Since 1999, directors of ACGME-accredited programs nationwide have been challenged to teach and assess these competencies. The authors describe an institution-wide curriculum intended to facilitate the teaching and assessment of PBLI and SBP competencies in the 115 ACGME-accredited residency and fellowship programs (serving 1,327 trainees) sponsored by Mayo School of Graduate Medical Education. Strategies to establish the curriculum in 2005 included development of a Quality Improvement (QI) curriculum Web site, one-on-one consultations with program directors, a three-hour program director workshop, and didactic sessions for residents and fellows on core topics. An interim program director self-assessment survey revealed a 13% increase in perceived ability to measure competency in SBP, no change in their perceived ability to measure competence in PBLI, a 15% increase in their ability to provide written documentation of competence in PBLI, and a 35% increase in their ability to provide written documentation of competence in SBP between 2005 and 2007. Nearly 70% of the programs had trainees participating in QI projects. Further research is needed to evaluate the cost-effectiveness of such a program and to measure its impact on learner knowledge, skills, and attitudes and, ultimately, on patient outcomes.