Milestones: Preparing residents for medicine 2.0

May 21, 2014

Faculty member Ruben Halperin, M.D., right, provides real-time feedback to third-year resident Gregg McCord, M.D., and first-year resident Cindi Chapman, M.D.

Faculty member Ruben Halperin, M.D., right, provides real-time feedback to third-year resident Gregg McCord, M.D., and first-year resident Cindi Chapman, M.D.

Health care is undergoing the biggest transformation in memory, so it follows that the physician’s role is changing just as dramatically.

Physicians now are responsible not only for treating the sick but also for ensuring that Oregon’s communities stay well. We need to know about coding and electronic health records systems. We’re accountable for delivering safe, high-quality care without unnecessary costs.

This is a tall order but one that residency programs are embracing. This summer Providence residency programs officially begin a new teaching and evaluation system that will help prepare graduates for this shifting landscape.

The program will formally evaluate residents on six domains of clinical competence – patient care, medical knowledge, professionalism, communication, system-based practice and practice-based improvement – and on the residents’ abilities in several categories within those pillars.

These make up a developmental road map called “milestones,” part of a new accreditation system introduced by the Accreditation Council for Graduate Medical Education. As they progress through their education, residents are expected to reach levels of competence for each of these milestones and subcategories within them.

Historically residency programs considered hours invested as a measure of education. Now “we’re evaluating the residents on what they can do and what they can’t,” says Mari Kai, M.D.. a faculty member with Portland Medical Center Internal Medicine Residency Program.

A novice, for example, should be able to understand the difference between a medical error and a sentinel event while a senior resident should be expert enough in patient safety to find solutions to systemic problems. No longer does excellence in one area compensate for weakness in another; residents are required to demonstrate abilities in all of these milestones.

Providence faculty members have always provided at-the-elbow mentoring for residents, formalized and tied to a specific learning milestone. This approach provides a direct link between educational principles and real-world practice.

“Instead of just giving feedback at the end of the month,” says Courtland Childers, M.D., associate program director for PPMC’s residency program, “we’re giving the residents specific feedback for that clinical task. ‘You told the patient what you suspected was going on. You gave them the opportunity to ask questions. You offered to talk with the family.’”

Although the residency program has spent the past year preparing for the new accreditation system, its learning curve isn’t as steep as it may be for others. For several years, the program has aligned its curricula around Providence’s clinical priorities and the Triple Aim, which calls for providing affordable, high-quality care that improves the health of communities.

Faculty have worked with residents on population health projects, advancing the medical home model and enhancing hospital safety – each of which is now addressed in the milestones model. Likewise the program has expected both residents and faculty to come up with innovative approaches to health care, another emphasis in the new accreditation system.

“Many of our priorities align perfectly with ACGME milestones,” says John Heffner, M.D., the William M. Garnjobst Chair of Graduate Medical Education for Providence Portland. “Now it’s just a matter of linking them.”

The ripple effect

This competency-based learning not only will help to turn out top physicians, but it’ll also benefit the hospitals and clinics in which they practice. Clinics using a medical home model, for example, need physicians who thrive in team-based environments, who pay close attention to the behavioral and social factors that influence a patient’s health and who think about population-based health.

“We have residents who lead multidisciplinary meetings about particular patients, so they get an understanding of how the other team members can be helpful in the overall care of the patient,” says Dr. Kai, who is also medical director of Providence Medical Group-Northeast, an advanced medical home clinic.

“We’re also doing a lot of the milestones work in preparation for taking care of populations of patients, not just individuals,” Dr. Kai adds. “For example, residents would use disease registries to come up with ways to improve care for patients with diabetes.”

Psychologist Ryan Dix, Psy.D., counsels residents on patient communication, one of the six core competencies that frame the Milestone Project. This is especially important for internal medical physicians who will need to build strong relationships with patients who may have a chronic condition, such as diabetes or persistent pain, that requires behavioral as well as medical therapy.

“Many health issues involve something that a patient can be doing differently,” Dix says. “I provide feedback on how to get patients to make changes that are difficult.”

Doug Koekkoek, M.D., chief medical officer for Providence Health & Services in Oregon and a hospitalist, is encouraged that patient safety and quality are among the educational milestones.

“Doing root-cause analyses and developing action plans takes a special skill that few people have,” he says. “In the future this won’t be a novel competency.”

As someone who oversees the professional staffs of eight hospitals, Dr. Koekkoek is also inspired by the philosophy behind the Milestone Project.

“What we emphasize in resident training carries forward in their careers,” he says. “We’re emphasizing a new set of skills. It’s not so much, ‘Can you remember everything you learned about diagnoses?’ It’s how to learn about diagnoses. It’s a culture of learning.”

Excerpted from I.M. In Touch, Providence Portland Medical Center Internal Medicine Residency Program’s alumni newsletter.