A resident's reflections on becoming an agent of curricular change

A resident's reflections on becoming an agent of curricular change
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  A resident’s reflections on becoming an agent ofcurricular change Wendy L Bennett, Scott M Wright & Steven J Kravet  INTRODUCTION The American health care system is complex andconstantly changing. 1 In collaborating with teams of health care providers and administrators, postgradu-ate medical trainees can begin to reflect upon andunderstand their roles within the larger system.Teaching residents the requisite skills to makeimprovements in the systems in which they work andempowering them to instigate these transformationsmay improve patient care and help in the develop-ment of doctor leaders. The Accreditation Councilfor Graduate Medical Education (ACGME) has rec-ognised the need for residency programmes torestructure their curricula to include these skills. 2,3 In 2003, the Achieving Competence Today (ACT)curriculum was created through the Partnerships forQuality Education, a national initiative funded by theRobert Wood Johnson Foundation. 4 Each year,selected residents participate in an intensive,1-month elective, which immerses them in systems-based practice (SBP) and practice-based learning andimprovement (PBLI) concepts and practical experi-ences. These ACT residents then become agents of change by creating new curricula for their fellow trainees.This paper describes one resident’s personal experi-ence with the ACT programme and illustrates how the competencies of SBP and PBLI were concretisedin an internal medicine residency programme. Thisstory is presented through the personal narrative of the case resident and highlights the lessons learnedand the resident’s  reflections   (which will be itali-cised). 5 Section 1 describes the ACT elective. Section2 focuses on the process of curricular reform. It ishoped that recounting this experience can serve topresent a model for other programmes wishing toaccomplish similar successful transformations. 1. THE ACT ELECTIVE Setting and elective structure The Johns Hopkins Bayview Internal Medicine resi-dency programme includes a primary care track andhas a total of 54 residents. Because of my interests, I was invited to participate in the ACT elective along with another resident colleague. The elective month was established as a 4-week block in keeping with thestructure of the ACT online curriculum. 4 My only other responsibility during the month was a weekly continuity clinic. The rest of the working week wasdevoted to prepared readings and assignments.Other elective activities included interviewing anumber of health care stakeholders, including apatient from my continuity practice, hospital andoutpatient administrators, representatives from alocal Medicaid managed care organisation (MCO),and a hospital benefits manager. At least twice weekly, my co-resident and I met with our committedpreceptors, a full-time general internal medicinefaculty member and a general internal medicineeducation fellow, both with expertise in quality improvement (QI).To truly immerse myself in this rotation, it was very helpful to have ample protected time from otherclinical responsibilities to read and reflect. Thisallowed me to explore the systems of care in whichI was practising and to consider ideas for QI projects.It provided a unique opportunity to think critically  my story Division of General Internal Medicine, Johns Hopkins Bayview MedicalCenter, Johns Hopkins University School of Medicine, Baltimore,Maryland, USA  Correspondence  : Wendy L Bennett MD, MPH, Department of GeneralInternal Medicine, Johns Hopkins Bayview Medical Center, 4940Eastern Avenue, B2N-Rm 235, Baltimore, Maryland 21224, USA.Tel: 00 1 410 550 0521; Fax: 00 1 410 550 1094;E-mail: wbennet5@jhmi.edudoi: 10.1111/j.1365-2929.2006.02642.x   Blackwell Publishing Ltd 2006. MEDICAL EDUCATION 2007;  41 : 2–5 2  about my role within the health care system andpurposively to gain skills that enabled me to begin tomake small changes. The frequent meetings with the faculty preceptors were a core  feature of the month that truly enhanced my learning and understanding of the theory and concepts. They also co- ordinated meetings with administrators, insurers and other stakeholders, and reviewed my QI proposals. Although independent learning was vital to this experience, the rotation would have had less impact on me were it not for the  preceptors probing and facilitating my reflective practice,and for being able to share ideas with my co-resident. Interviewing my patient   As part of the elective, I chose to interview a patient from my continuity practice who had difficulty accessing care and who had concerns about thequality of care she had received. My patient was a46-year-old woman who had reached a high level of frustration with her frequent heavy menses. I chosethis patient because her situation exemplified thefragmentation of care that can occur when patientssee both specialists and a primary care doctor. She was also receiving disability benefits for chronic lowerback pain. Her insurance provider was the localMedicaid MCO.I asked my patient questions about her medical care,her providers, including myself, and perceived barri-ers to care. She stated that she would prefer to have asingle provider who knew her well and who would becapable of providing both her gynaecological andprimary care. She described how each time she had afollow-up appointment in the gynaecology practice,she would see a different provider, who started anew  with a review of her medical history. In seeingmultiple doctors over several years, she felt that herconcerns about her menorrhagia had not beenaddressed or managed appropriately. She told methat she wished I would communicate directly withher gynaecology providers to facilitate and co-ordin-ate her care towards the resolution of this long-standing problem. Interviewing my patient was an invaluable experience in  practice-based learning. It created an opportunity for me to discuss with a patient what I could do to make it easier for her to navigate the complicated medical system. I was struck by how infrequently I ask my patients how they are managing in our system. After this exchange, I felt more confident that I would be able to serve this patient and address these issues with other patients in the future.Although I was not prepared to tackle the bigger issue of all specialist  )  primary provider co-management, our interview  formed the basis for a QI proposal to change the provision of  women’s health in our housestaff practice. I also became motivated to make changes in both my individual practice and that of the entire practice. Interviewing other members of the health care system I also interviewed my medical practice’s manager, thehospital vice president for medical affairs, and ahealth insurance purchaser for hospital employees, as well as representatives from our local Medicaid MCO.Like the meeting with my patient, the goal of theseinterviews was to begin to understand the multiplelayers of health care delivery at the local level. Theseadministrators were also potential stakeholders toinvolve when developing and implementing pro-posed systems changes.One of the most interesting meetings was with theadministrator of the disease management pro-grammes at the Medicaid MCO, the insuranceprovider for many of my patients. The goal of theseprogrammes is to co-ordinate care for patients withcomplicated medical conditions, and ultimately tosave money while improving outcomes. During thismeeting, I talked about the patient I had interviewedas well as about some of my other medically compli-cated patients. I learned about numerous innovativeprogrammes that were available to help both my patients with chronic illness and myself in my quest tokeep them healthy and functioning at their optimallevel. I was surprised to find out later that, like me,many providers in our practice were not aware of these patient resources. I asked:   How can we get more involved? How can we connect our nursemanager with your nurses to learn more? How can Ienrol my patients?   But probably the most important question was:   How did this disconnection happen inthe first place, when we work with the same patientsand have similar goals of quality patient care?   Afterthis meeting, I changed my practice by thinking moreabout the available resources, such as disease man-agement programmes, for patients with complicatedchronic illnesses and difficulties with self-care. I alsobegan to think about how to disseminate this infor-mation to my colleagues.  Analysing the systems These meetings motivated me to take a closer look at the health care system I work in and helped me to   Blackwell Publishing Ltd 2006. MEDICAL EDUCATION 2007;  41 : 2–5 3  identify specific systems problems. After defining theproblems, I learned to perform a systems analysis. I was also taught about the steps involved in proposingand implementing a QI plan to make effectivechanges. 6 I identified a systems problem in ourmedical practice: routine gynaecological care isfrequently and probably unnecessarily referred to thegynaecology practice, which causes fragmentation inthe continuity of primary care.To acquire feedback from important stakeholdersabout this problem, I first developed an informalsurvey of other house officers. The survey revealedthat many lacked confidence in their pelvic exam-ination skills and therefore tended to refer morefrequently to gynaecology. I also met with theinternal medicine and gynaecology practice manag-ers to discuss and identify possible solutions andbarriers to change.My final QI proposal was to create a    women  s healthmaintenance visit’, with its own clinic dictationformat, reminder cards for patients, and an expan-ded time-slot. I presented a business-style proposaland detailed cost-benefit analysis to stakeholders toaddress whether offering this visit would reduce thenumber of routine gynaecological care referrals andimprove the quality of care in our practice. Through this activity, I began to apply the theory and methodology of QI using the plan-do-study-act cycle of rapid change, 6  which I had learned during the ACT curriculum,to a problem in my own clinical setting. I learned the importance of involving all stakeholders early on in the  process to gain greater understanding of their perspectives on the problem, to work together towards a solution, and to establish buy-in and support of the proposal. It was this sense of empowerment arising from the ability to create incremental changes in a system that I most wanted to share with other residents in our programme. 2. REFORMING THE CURRICULUM It became my goal to propose and implement meaningful curricular changes to teach other resi-dents the important concepts I had learned duringthe ACT elective. My co-resident, preceptors and Iused a stepwise approach to curriculum develop-ment, 7  whereby we conducted a needs assessment by analysing our current curriculum, developed edu-cational goals, defined strategies, implemented theprogramme and, finally, measured outcomes. Wediscovered that our residency programme wasalready rich in SBP   ⁄   PBLI, but these concepts werenot formally taught until fairly late in residency training.Our curricular proposal was to integrate the conceptsof SBP and PBLI into the evidence-based medicinecourse (a non-call rotation for 4–5 interns permonth). In order to highlight the broader objectivesand perspectives, the course was renamed   Evidence-based Medicine and Practice   (EBM & P). Changingthe name of this well established rotation addedemphasis to the importance of these core compe-tencies and choosing an existing forum helped beginthe curricular change process immediately.The SBP and PBLI component of the EBM & Pcourse had 2 components. First, my co-resident and Iintroduced the concepts of systems and QI duringinteractive, small-group discussions. In the secondcomponent of EBM & P, one intern each monthchose to complete a QI project by conducting a moredetailed problem analysis, proposing a QI plan andformally presenting it at a conference to houseofficers and core faculty members. My co-resident and I mentored the interns through their projects. It was gratifying to learn through the evaluations of this curriculum that both the initial teaching session and the mentored projects were valued and appreciated by the interns and those that attended the conferences. The evaluations demonstrated that we had met our educational goals.Mentoring interns through the process of researching and developing their own projects was especially rewarding. The benefits of pairing a resident who had studied and practised QI with an intern new to the topic included the creation of  mutual teaching and learning opportunities. This process became analogous to the    see one, do one, teach one    method.  AFTERWARDS In contemporary medicine, medical trainees anddoctors need to recognise and understand thesystems in which they work and to know how to adapt to a rapidly evolving health care system. Educatorsteaching trainees SBP and PBLI should become rolemodels for analysing their own performance andmaking improvements that can be sustained in ourcomplex health care systems. Medical trainees can beencouraged to reflect upon their own clinical prac-tice and make changes accordingly. Through the ACT elective, I felt as if I became a role model  for SBP and PBLI and worked to become an agent of  curricular change to successfully integrate these concepts to make sustainable improvements to our programme. my story 4   Blackwell Publishing Ltd 2006. MEDICAL EDUCATION 2007;  41 : 2–5  Contributors:   all authors contributed to the concep-tion and design of the project and the drafting of themanuscript. Acknowledgements:   SMW is an Arnold P Gold Founda-tion Associate Professor of Medicine. SJK and SMW are both Coulson-Miller Scholars and are indebted tothis family for their support.  Funding:   none. Conflicts of interest:   none.  Ethical approval:   not applicable. REFERENCES 1 Shine KI. Health care quality and how to achieve it.  Acad Med   2002; 77  (1):91–9.2 Leach DC. Evaluation of competency: an ACGME per-spective. Accreditation Council for Graduate MedicalEducation.  Am J Phys Med Rehab   2000; 79  (5):487–9.3 Accreditation Council for Graduate Medical Education.Outcome Project: General Competencies. 2006. http://[Accessed 5 July 2006.]4 Partnerships for Quality Education. AchievingCompetence Today.[Accessed 5 July 2006.]5 Hellmann DB. Eurekapenia: a disease of medical resi-dency training programs?  Pharos Alpha Omega Alpha Honor Med Soc   2003; 66  (2):24–6.6 Langley GJ, Nolan KM, Norman CL, Provost LP, NolanTW, Norman CL.  The Improvement Guide: a Practical Ap-  proach to Enhancing Organizational Performance  . New York: Jossey-Bass, Inc. 1996;49–73.7 Kern DE, Thomas PA, Howard DM, Bass EB.  Curriculum  Development for Medical Education: a Six-step Approach  .Baltimore, Maryland: Johns Hopkins University Press1998;8–98. Received 16 May 2006; editorial comments to authors 23 June 2006; accepted for publication 1 September 2006    Blackwell Publishing Ltd 2006. MEDICAL EDUCATION 2007;  41 : 2–5 5
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