Blog | Thursday, July 12, 2012

Next in residency training: Attack of the tick-box zombies

This weekend, an interesting article on the current state of UK residency training crossed my Twitter feed. Due to restricted residency duty hours in the UK (yes they have a 48-hour work week for residents, aka junior doctors), they fear they are graduating "incompetent doctors who are putting patients at risk."

This debate is not just isolated to the other side of the Pond. In fact, a recent reports in the New England Journal of Medicine documented that nearly half of residents are opposed to restricted resident duty hours, with another paper in Academic Medicine showing that many internal medicine residents were concerned about limited educational opportunities with duty hours.

Finally, in a recent study that we did with the Association of Program Directors of Internal Medicine and the Association of Program Directors of Surgery published in Academic Medicine, program directors feared specific consequences of duty hours related to faculty morale, patient continuity and resident education.

While I could go on, the reason I started to write this post was not to rehash the duty hours debate! Instead, I wanted to highlight a very specific concern that is mentioned in this UK story. One of the chief complaints in the UK medical training system is that junior doctors were being passed on the basis of dreaded 'tick-box forms'. (You gotta love the Brits for colorful names to what we simply call evaluations).

So now at this point, I feel like I am watching 28 Days Later, where all of London was quarantined and zombies took over. Will the tick-box zombies come to the United States and take over our GME system? Have they already? I hope not ... but let's face it. Everyone is wondering what comes next with milestones and GME.

The "Next Accreditation System," or NAS, (not to be confused with the rap artist) is about documenting the achievement of specific milestones related to specific "entrustable professional activity," or EPA. An EPA is "simply the routine professional-life activities of physicians based on their specialty and subspecialty."

For example, for internal medicine, one of the end of year EPAs is "Manage the care of patients on general internal medicine inpatient ward." In this way, EPAs are more granular than the 6 "core competencies" and should in theory be easier to observe and evaluate. Lastly, for each EPA, there will be a "narrative" that programs can select to describe how competent the resident is in that area.

While program directors and others involved in GME are all learning the new "compet-english" that has been developed, many are also concerned about the burden of evaluation in a system that is already overburdened. In other words, will the tick-box zombies attack us stateside?

Well, some of this is up to how the residency educator community responds to the charge. To prevent tick-box zombie attack, program directors must resist the urge to create hundreds of milestone evaluations and add them to existing evaluations. The key is not to reinvent the wheel but to modify existing evaluations to link them to milestones and EPAs.

In some cases, old evaluations that were not helpful should be re-evaluated to see if they are necessary. Moreover, to prevent tick-box zombies from striking, it's important to design and implement good measures of resident performance. A good measure would adhere to some of the same properties of optimal National Quality Forum quality measures: reliable, valid, linked to meaningful outcomes, feasible to collect, and distinguish between good and bad performance.

When good measures of residency performance do not always exist, there is an opportunity to work together to figure out what they are. While this is definitely a work in progress, one nice thing is that no one is alone. In Chicago, a citywide meeting of residency leaders of over 10 programs was held to share how best to do this and learn from each other. After all, to truly make our next step in GME, we must all work together to prevent the tick-box zombie attack.

Vineet Arora, MD, is a Fellow of the American College of Physicians. She is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.