Changes in Pediatric Education

Amy Jost Starmer, MD, MPHUNC Pediatrics Residency Class of 2007

Assistant Professor of PediatricsOregon Health and Science University

Overview

• Changes in Pediatrics• Implication of change on

pediatric trainees and education

• Importance of measurement and reflective thinking

• Embracing Change

Pediatricians and Change

• "Rather than taking an overall leadership role in the continuous improvement of the health care delivery system, too many medical professionals either ignore the problems of the system in order to concentrate in their own specific practices or focus their energies and talents on protecting the status quo."

-George Halvorsan, Chairman and CEO, Kaiser Permanente

We’re not alone

Feel prepared for expected change

Expect high / very high level of change over next 5 years

Pediatricians and Change• In what direction is the profession of

pediatrics going?– What forces will most influence the

future?– How does the current direction match

up against our desired vision for the profession?

– How are pediatricians coping and planning for the future?

6

Vision of Pediatrics 2020 Task Force Directives

• Review data from internal/external experts as to the most powerful forces likely to change or influence the future of pediatrics

• Identify the forces most likely to influence the future and construct scenarios

• Identify gaps between current AAP activity and desired AAP activity to best address scenarios

• Make recommendations to the Board as to what changes in AAP might yield greatest return in mission and member value based on future scenarios

Vision of Pediatrics 2020

• This project was about CHANGE, not PREDICTION– Removing blinders so all can

be seen– Considering likely scenarios– Preparing for likely scenarios– Flexibility to move and

manage change when strategically important

Outcome of the Vision of Pediatrics 2020 Project: The Eight Megatrends

The Eight Megatrends

1. Changing Demographic and Clinical Characteristics of Children and Families

2. Burgeoning Health Information Technology

4. Alterations in the health care delivery system

3. Ongoing medical advances

7. Globalism 8. Changes in pediatric workforce

5. Growth of consumer driven healthcare

6. Increased frequency of disasters

The Eight Megatrends

Changes in the Pediatric Workforce

THEN

NOW

Changes in the Pediatric Workforce

Changes in the Pediatric Workforce

Changes in the Pediatric Workforce

Changes in the Pediatric Workforce

Changes in the Pediatric Workforce

Additional examples of changes affecting the pediatric workforce…

Duty hours restrictions Shift towards competency based training

What are the implications of these changes on pediatric education?

• Are we appropriately training pediatricians to meet evolving health care needs?

• Does one residency curriculum suffice for all general pediatric residents?

• Is it essential for pediatric residents to be exposed to the greatest possible breadth of knowledge and experience?

Reconsidering the State of Pediatric Residency Training - the R3P project

• Residency Review and Redesign in Pediatrics (R3P)

• Convened by the ABP on behalf of the broad community of pediatric care providers

The Residency Review and Redesign Project

• Purpose: to re-examine the structure of pediatric residency education and assumptions on which it is based

• Broad discussions about future of pediatric health care

• How do current educational strategies align with RRC competencies

• Explore possible modifications in resident education

Residency Review and Redesign Project Goals

Residency Review and Redesign Project Conclusions

• No single approach to general pediatric residency education is best for all residents

• General pediatric residency programs should not attempt to provide all learning that every pediatrician should conceivably need

• Residency training must be considered within the context of continuum of learning from medical school to post-residency practice

• An ongoing “quality improvement” like process is necessary to identify and implement effective approaches to resident education

The Initiative for Innovation in Pediatric Education

• Established on recommendation of the Residency Review and Redesign in Pediatrics (R3P) Project

• Mission: To initiate, facilitate and oversee innovative change in pediatric residency education through carefully monitored, outcome-directed experimentation

• Aim: To support high quality research in medical education through regular calls for proposals, Innovation/Improvement Plans (I-Plans)

The Importance of Measurement

AVOID ENCOURAGE

The Importance of Measurement

• “….when you can measure what you are speaking about and express it in numbers, you know something about it,” and, “If you cannot measure it, you cannot improve it.” Lord Kelvin of Glasgow

mathematician and physicist (1824-1907)

The Importance of Measurement• “Jost--where are you? Show your face

out from the subterranean existence in the ED. If you can sign these things I'll get them sent off to the IRB.”

Lord Steiner of Chapel Hill Mentor and Preceptor

“Who said I was doing power calculations? I don't know squat about this stuff. My daughter on the other hand is a prodigy, instead of crying when she was born she came out and screamed "logistic regression!!!". Needless to say she's on tap to be the Director of the CDC in about 35 years.”

Trends in Medical Education Research, 1969-2007

1969-1970 1979-1980 1989-1990 1999-2000 2006-2007

Number of Studies 1 15 23 67 147

Multi-institutional 0 1 (7%) 3 (13%) 5 (8%) 9 (6%)

Objective outcome 1 (100%) 8 (53%) 17 (74%) 53 (79%) 91 (62%)

Validated Outcome 0 3 (20%) 3 (13%) 17 (25%) 23 (16%)

Outcome assessed >1 month later

0 4 (36%) 4 (21%) 16 (27%) 35 (26%)

Statistical Power estimated

0 0 2 (9%) 3 (4%) 21 (14%)

Cost estimated 0 1 (7%) 2 (9%) 5 (7%) 5 (3%)

Funding reported 0 4 (27%) 5 (22%) 30 (45%) 66 (45%)

Source: “Trends in Study Methods Used in Undergraduate Medical Education Research, 1969-2007” JAMA 298 (9): 1038-1045.

Pulling it all Together: An Example

DUTY HOURS CHANGES INCREASED FREQUENCY OF HANDOFFS OF CARE

Pulling it all together: Capitalizing on Change

• The I-PASS Resident Handoff Study– Rigorously testing the impact of a bundle of

interventions to standardize handoffs at 9 pediatric institutions

– Supported by Initiative for Innovation in Pediatric Education

– Linking impact of educational intervention with key patient outcomes including medical error rates

Conclusions

• The only constant is change, continuing change, inevitable change, that is the dominant factor in society today. No sensible decision can be made any longer without taking into account not only the world as it is, but the world as it will be.— Isaac Asimov

• We should embrace change as an opportunity

• Measurement is critical

Embracing Change: A Personal Example

Embracing Change: A personal Example

My favorite example of why change is a good thing

Thank You!