Commentary by Jessica Lambert MD
Please also see the clinical vignette presented before Grand Rounds on the 8th of April.
The Medical Grand Rounds presentation on April 8, 2009, titled “10 Moveable Objects,” was delivered by Dr. Jeff Wiese, MD, FACP, an Associate Professor and the Associate Dean for Graduate Medical Education at the Tulane University Health Sciences Center. His discussion focused on the problems currently surrounding the ACGME and Graduate Medical Education.
The ACGME (then the LCGME) was established in 1981 to accredit medical residency programs in the U.S. In 1984, the infamous case of Libby Zion led the public and those involved in medical education to scrutinize resident work hours and address new ways of preventing egregious medical errors. Dr. Wiese referred to this time period as “The Great Abdication,” because it was the window of opportunity for the profession to police itself, an opportunity that was not fully realized. The events set forth a cultural change amongst the regulatory communities, providing an impetus for new program requirements and competencies. However, this cultural change was not embraced by individual residency programs, and this created the dilemma that still exists in part today: how to preserve the core principles that guide patient care for each speciality, while still meeting the new requirements.
For instance, Dr. Wiese described how the desire for continuity of care integral to the practice of Internal Medicine was difficult to reconcile with the new work hour restrictions. He proposed three different solutions, albeit each one with its own problems. First, he noted some programs had shifted work to others (non-teaching services), which can lead to a loss of “good work” (i.e. interesting cases). Secondly, some programs had transitioned into shift work; however, this often creates an inefficient system and overall more work. Lastly, one can attempt to assume all of the work in shorter work hours, but this has proved impractical, even impossible, over time.
By referring to the “7 Organizational Sins,” Dr. Wiese emphasized the need to eliminate all the wasteful and unnecessary components in the medical education system in order to maximize time spent on patient care and medical education, thereby enabling adherence to the work hour restrictions. With particular attention to the problem of fragmentation of time, he exemplified a typical intern day at Tulane, much like that at NYU. His example revealed how an inappropriate amount of time is spent in “transit” rather than on patient care.
His proposed solutions to fragmentation of work and medical education include “The 4 +1” and “The Friday School,” respectively. Having four weeks continuously on wards, ICU or elective, without any continuity clinic during that time, followed by one week of continuity clinic alone, diminishes the time spent in transit, increases the time that residents and interns can learn from each other, and improves patient care through efficiency. Additionally, each team is paired with a “Moondog” third year resident, whose role is to assist the team with ward responsibilities and emergent outpatient needs when the resident or intern cannot attend continuity clinic during his or her four weeks on service.
The intention of “Friday School” is not only to eliminate the fragmentation that occurs when attending morning report and noon conference in the midst of a hectic work day, but also to maximize the amount of knowledge obtained from a single interactive learning environment. During the morning session, residents attend school sans pagers, while attendings and interns manage the patients on the floors; the roles are reversed in the afternoon. By emphasizing team-based learning through interactive sessions, Dr. Wiese has found that knowledge retention increased significantly since instituting this novel form of medical education.
Another problem with graduate medical education addressed by Dr. Wiese includes how to more effectively determine patient caps. He suggests basing caps on a modified APACHE score as opposed to hard numbers. He also referred to “Patient Emeritus Services,” whereby patients hospitalized for long-term are grouped according to need, i.e. antibiotic administration, and are managed by Nurse Practitioners rather than housestaff in order to unburden resident teams and improve the educational quality of admissions.
Overall, Dr. Wiese featured many problems with the current system of medical education and proposed various solutions that have gained success at Tulane. Hopefully his presentation will lead to further discussions in our program about ways to enhance our education and still provide quality patient care.
Jessica Lambert is a Third Year Internal Medicine Resident at NYU Medical Center