“It is a big shift in how we evaluate residents, and it does take a lot of work to convert.”
genitourinary complaints, whereas more advanced “Level 4” residents can rou- tinely identify subtle or unusual findings pertinent to genitourinary conditions. Dr. Coburn, who helped develop the
Rather than penalize, the intent be- hind the NAS is to identify training is- sues early in the process and get them fixed sooner rather than later so resident training can continue to improve and ul- timately innovate.
As with any change, Texas GME lead- ers expect the transition will require substantial time and effort early on, and the Texas Medical Association Council on Medical Education is exploring col- laborative ways among the state’s teach- ing institutions to address program chal- lenges, facilitate training opportunities, and share best practices along the way. But for the most part, program lead-
ers are optimistic that the NAS moves GME in a positive direction. “It is a big shift in how we evalu-
ate residents, and it does take a lot of work to convert. It may even take sev- eral years to figure out what’s feasible and what meets the requirements,” said council member Troy Fiesinger, MD, a Houston family physician and faculty member of the Memorial Family Medi- cine Residency Program.
But the new system appears to offer
more flexibility and “lets us better assess what [residents’] actual needs are and be more personal in the way we teach them. And we welcome the bigger pic- ture approach, instead of the very pre- scriptive” nature of the current accredita- tion system, he says.
Hitting milestones ACGME began phasing in the new re-
28 TEXAS MEDICINE April 2014
quirements in July 2013 with seven specialties: emergency medicine, inter- nal medicine, neurological surgery, or- thopedic surgery, pediatrics, diagnostic radiology, and urology. All remaining ACGME-accredited core specialties must implement the changes by this July. Full details about the program are available online at
www.acgme-nas.org. A cornerstone of the NAS is the use of milestones in each specialty to gauge residents’ progress in six core competen- cies. They track those required of phy- sicians board certified by the American Board of Medical Specialties and used in the maintenance-of-certification process for physicians in practice:
• Patient care, • Medical knowledge, • Practice-based learning and improve- ment,
• Systems-based practice, • Professionalism, and • Interpersonal and communication skills.
Instead of using general evaluation forms to rate residents on a 1–10 scale or relying only on documenting a certain number of procedures done, as under the previous accreditation system, the milestones spell out by specialty what makes for a well-prepared practitioner based on five levels of progression. In pa- tient care, for example, “Level 1” urology residents must show they can perform an accurate physical exam and ask about
urology milestones, acknowledges that programs will have to invest the time and effort to learn a new assessment system and come up with tools to im- plement it. Programs also will have to organize a formal “clinical competency committee” to assess residents based on the milestones. “ACGME knows the process will evolve over an extended period of time, and we were carefully counseled to identify key aspects of the six competencies that ap- ply to [each specialty]. But we were not to be dissuaded in identifying areas we thought were important simply because we knew there were not yet in existence valid assessment tools to evaluate those specific capabilities,” he said. Ultimately, Dr. Coburn believes it is a better way of evaluating residents and identifying training problems early on. Though Baylor’s residency program is only six months into the process, al- ready “the most visible impact for us are the discussions our clinical competence committee has about each trainee, how they excelled or had certain challenges, and the notes we made to support our semiannual performance evaluation for the milestones. Those discussions are by far the most detailed and thoughtful and analytical discussions we’ve had about the progress residents are making in all areas.”
The NAS also transforms the accredi- tation cycle and the role RRCs play in re- viewing programs. Instead of the current two- to five-year timeline, ACGME will monitor programs continuously and will electronically collect milestones data and other information on resident per- formance, such as faculty development and program quality, annually.
Fewer site visits The annual reporting also means the on- site visits as programs once knew them will significantly change. Instead of regu- larly scheduled visits under the former two- to five-year accreditation cycle — and the significant preparation and
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