We gratefully acknowledge the sponsorship of the Wright State University Boonshoft School of Medicine (Dayton, Ohio) for funding the transcription and editing of this section of the Proceedings of the Twenty-Fifth National Conference:
The designated lead questioner is Doctor Gary LeRoy, Wright State University Boonshoft School of Medicine, Dayton, Ohio [Dr LeRoy is a Senior Fellow of the National Conferences:]
Thank you very much. I’m Gary Leroy from Wright State University, Dayton, Ohio.That was right on point. It was so to the point that I have more than one question to ask.
I’m going to try to tie this question together with a book that I am currently reading. But first of all, I was going to ask are the slides going to be available? There are several good slides that you shared that everyone can use, with a lot of useful statistics.
However, I understand from Mr Burnett, the National Conference coordinator, that they will be part of the posted proceedings.
I’d like to start first with Doctor Herman. I recently was given a book by our medical students in our healer’s art program called If Disney Ran Your Hospital, authored by Fred Lee and published in 2004.
The first chapter talks about how “culture trumping strategy”, and I think that’s what you are getting at. If you can’t change the culture, then no matter what you do, you can’t change the strategies.
So you were fortunate to have lots of resources at Penn State that other schools may or may not have. How did you deal with the Penn State culture when you were attempting to make changes to a culture that has been the norm for decades?
After Dr Herman comments, I’d like to ask Dr Hansen how he persuades his clinical faculty to keep precepting his residents and students without providing them subsidies like the Caribbean schools are doing; and I’d like to ask Dr Allen whether adding so many expectations and milestones to the education process might make it even more difficult to recruit volunteer clinical faculty to supervise residents and students without pay.
James Herman, MD: Fred Lee was surely referring the famous quote to Peter Drucker, author of The Effective Executive, who said “Culture eats strategy for breakfast.”
I hate that quote. It’s one of my top 10 most hated quotes. I can’t tell you what all the other nine are off the top of my head. But I really disagree with that, and I’ve made quite a study of this.
I think culture can be changed. But it is a process of changing many people’s mental models at the same time. <em>That</em> requires an organized attention to process and to structure, and it requires time. It requires a lot of what I would effective dialogue.
That is not the same as discussion. You know that the word discussion has the same roots as percussion and concussion. Effective dialog where real meaning can be talked about, and meanings in people’s heads can be changed.
Do you ever sit with someone (or with yourself when you really in thought), when somebody says something to you that changes what you believe, because you’re really listening carefully.. You can actually hear the rocks in your head shifting.
Cultural change requires a lot of <em>effective dialogue</em> over time, Most people don’t understand how long it takes, nor what the right process is to get it done, nor do they have the energy or the resources to make it happen.
But I really think that cultural change can occur if you pay attention to the right things. That’s what we are trying to do here with the change in the residency’s home base..
Thomas Hansen, MD, In addressing medical student surpluses in the current environment – at least in my health care system – our focus is on patient care and residency education, so you know we do receive funding for educating residents in our system. That’s what I keep assuring my docs.
My biggest concern is that someone is just going to get to the point where they throw in the towel, because the expectations are just too high.
Meanwhile, ih the teaching hospital situation, there was a tsunami of medical students that were coming and with really no place to put them, with no financial incentive to do that, and with the new LCME milestones in place.
First of all, how do you get someone that you’re not paying to understand or care about milestones? And how do you train the evaluators who have no financial incentive to learn all these milestones that you admit take more time?
How do you even know when the evaluator has reached his or her milestone of learning how to do that effectively? It is apparent how very subjective these supposedly objective measures can be..
Each year I have the opportunity to ask the departments and the physicians to answer my question: how many students can you educate in your system? Then they give me a number, and I let the medical schools know whether we can continue to accept students at the current level or, unfortunately, that we have to decrease. So that’s how I’m handling it within my system.
I do think, though, that we are evolving into a free market economy where “supply and demand” matters. The demand has gone up for teachers of medical students, while the supply has gone down. I believe that medical schools have got to look at how we reimburse those who are willing to teach. The DO and the Caribbean schools have been doing this successfully.
It’s time that the allopathic schools start looking at where tuition dollars are used. They may not necessarily need to go to the President’s Office, or to campus enhancement. Tuition dollars really need to go to those who are educating the students.
Suzanne Allen, MD: The milestones question is a great one.
I have been asked by numerous faculty program directors and department chairs who all are trying to figure out how to make this work within their own setting.
During the alpha and beta testing of the milestones the average time to evaluate each resident within these clinical competency committees was 30 to about 80 minutes.
The effectiveness of the results were dependent upon how well the evaluator knew the resident, Was the resident in difficulty or was the resident doing well?
There was a wide range of times. Let’s say you are a residency program with 18 residents, six in each year. If you have to evaluate twice a year, and, say, it takes you an hour to evaluate each resident; that’s a long day of trying to get through all those residents. How are you going to do that twice a year?
The milestones are set up not to be their own independent evaluation tool but to base the milestones on the evaluations you’ve done of the resident over the previous six months, along with, say, the training service exams, their conference attendance, presentations, numbers of patients seen in clinic and any other data you would wish to include.
You would take that information, have a discussion among the faculty about where that resident is along that continuum of the milestones. You would then provide feedback to the resident. You would also inquire of the program: Are we training our resident so they’re becoming competent in lifelong learning? Are we training our residents so that they’re becoming competent in systems based practice? Any such kind of feedback into the system should help enable it to continue to improve;
Residency programs are planning much different ways about how they’re going address milestones. Some programs are identifying them as just one of the things that a residency program is required to do, and they’re carving out time to do it. This process would mostly be using faculty half-days already set aside for administrative time, meaning that this is just another administrative duty. That administrative half-day is now to be spent on milestones or assessment of residents.
Other programs are actually offering incentives for faculty to participate in clinical competency committees. Nobody wants to do it because they say it’s too much work. It gets back to where the money is; which of course many of our programs don’t have the finances to be able to do that.
I hope with time this will become just one more thing that we do, We’ll actually be much more efficient in how we do our milestones and assessments, but I think it’s going to take us a number of years to get there.
I also think, at least within family medicine, we will be sharing “best practices”, so that we all have that faculty development that we need and we all become efficient at what we’re doing.
Dr Clasen (moderator):Thank you all for these great presentations. We will take a short break and return for our tribute to the late Doctor G. Gayle Stephens.
This section is followed by: Proceedings of the 25th National Conference, April 14, 2014: the 24th G. Gayle Stephens Lecture (Flinders)