The milestones also allow programs to tailor residents’ experiences and eval- uations, he says. Past requirements could threaten a family medicine training pro- gram, for example, if the hospital didn’t get enough deliveries and trainees could not hit their targets. “We can’t control the macroeconomics of Houston. It upsets [residents’] future careers,” Dr. Fiesinger said. And because faculty don’t have to
rate every trainee on every milestone in every rotation, “I know a resident in an ENT [otolaryngology] rotation can focus on how to treat ear infections and hear- ing loss, and working with specialists. They can get training in systems-based care somewhere else that is more appro- priate. That excites me,” he said. While the milestones may prove to
The Texas Medical Association is advancing the Choosing Wisely® campaign, an initiative to help physicians and patients talk about avoiding unnecessary care.
Through the Choosing Wisely® campaign, TMA is helping Texas physicians spur conversation around evidence- based recommendations created by your medical specialty societies.
One-third of all physicians acquiesce to patient requests for tests and procedures — even when they know they’re not necessary.
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be more useful than what Dr. Fiesinger described as “an abstract scale,” the programs must design measures for the various levels of progressions. That is easier for testing straight-
Funded by the TMA Foundation. 30 TEXAS MEDICINE April 2014 1/3 v 2.25 x 9.75
forward competencies such as medical knowledge; not so, for other less con- crete competencies. “When I get to patient safety or cost- effective care, do I write a test?” he asked. “We can try to come up with measurement tools like the percent of generic drugs a resident prescribes, but only if IT says we can do it and come up with different levels. We will come up with something, but it is more challeng- ing for these gray areas. And then the question is: Does it meet the [accredita- tion] standards?” Many GME programs also rely on a significant number of volunteer com- munity physicians to train residents in various specialties and subspecialties. Reaching and training those commu- nity physicians in the new milestone evaluations could prove challenging for some GME programs, says David P. Wright, MD, chair of TMA’s Council on Medical Education. He supervises resi- dents and directs The University of Texas Southwestern Medical Center’s family medicine clerkship program at Austin’s University Medical Center Brackenridge Hospital. To reach community faculty, TMA is exploring faculty development oppor-
tunities and partnerships with Texas programs. GME leaders also must find a way to design tools that balance pro- grams’ responsibility to collect and re- port meaningful information without overloading those physicians who do- nate their time, Dr. Wright says. “This will involve getting people to think differently, and some aspects will be more intensive. We want to continue to get valid, objective feedback from pre- ceptors but at the same time not burden them,” he said.
Accreditation not at risk Dr. Coburn clarifies that it’s not neces- sary for every volunteer faculty member to be an expert in the milestones. Rather, they should familiarize themselves with the criteria and overall objectives. It is the job of GME programs’ in- ternal competency review committees to compile the feedback and score resi- dents. To prepare, Baylor, for example, gave a grand rounds presentation to all of its faculty on the NAS, and its clinical competency committees likely will have teaching physicians focus on a certain subset of the milestones. During the transition, RRCs gener- ally want to see that programs are put- ting the key elements of the NAS into place, particularly the milestones, Dr. Coburn says, adding it will likely take a few years to start benchmarking perfor- mance levels among the state’s teaching institutions. “The focus of the RRC’s work will be
more of a mentoring role with a focus on continuous improvement, rather than just identifying deficiencies and expect- ing them to be corrected the next time around. And the data will be used to look at ways of doing what we do bet- ter. Right now we want to see that [pro- grams] are doing the work, have clinical competency committees that are func- tioning and meeting, and inputting the data,” Dr. Coburn said. ACGME leaders expect that the vast majority of programs will retain ac- creditation. Barring egregious violations, those that fall short will receive a warn- ing with the chance to resolve the cita- tions more quickly. Dr. Weiss of the ACGME says the
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