Proceedings of the 25th National Conference: April 14, 2014 – Second Plenary Session, Part 3 (Herman)

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:

This section follows: Proceedings of the 25th National Conference: April 14, 2014 – Second Plenary Session, Part 2 (Hansen)

James Herman, MD, Penn State University/Hershey Medical School; Hershey, Pennsylvania
James Herman, MD, Penn State University/Hershey Medical School; Hershey, Pennsylvania

James Herman, MD, Milton S. Hershey Medical School, Hershey, Pennsylvania:

Good morning everybody. Having heard these two excellent presentations I thought that I would get a little bit more granular and tell you a story.

Stories are always interesting and this is a story from our world in Penn State, which I think brings a little bit of a real world application to the subject of training physicians what we’ve been hearing about.

I will talk about moving a residency program from a community hospital into an academic medical center in the midst of all these changes in accreditation policies.

Here’s the situation. We had a university-managed residency program based at a community hospital that is 12 miles away from our academic health center. It primarily served an underserved Latino population.

Over the years faculty members in our program were employed in two institutions – our academic health center and the community hospital. Thus, we had a mix of revenue sources for departmental faculty.

Troubles Surface at the Community Residency Program

Problems at Affiliated Community Residency
Problems at Affiliated Community Residency

The faculty members employed by the community hospital over time became overwhelmed by clinical work. Basically, they had no time for residency oversight or the residency curriculum.

Over the past five years, the community hospital’s financial situation became increasingly distressed. When we looked into it. the hospital owed our academic health center about 1.5 million dollars in back bills for our faculty time and for the residents’ time spent in patient care for which they were not paying us.

Faculty Unrest

There were significant numbers of faculty departures at the community hospital due to unhappiness and unrest, including the departure of our academically trained residency director who just gave up and left to become a medical director of a health plan.

For a number of years, we failed to attract residents from LCME schools. Our residents had below average “in service exam” results. Those are not exactly the results we would want for Penn State’s residency program in family medicine.

Initial Steps to Address Problems

Attempts at Resolution
Attempts at Resolution

Our interim solution begun about five years ago was to expand our program and to attempt to staff both the community hospital and the academic health center in patient services.

We began assigning residents to work at our academic health center. This was – believe it or not – the first time in 20 years that family medicine residents were actually rotating on an inpatient service at our university hospital.

The academic health center-based faculty members, because of all these departures at the community hospital, were shipped them out to the community hospital to work with the residents to keep the community residency program afloat.

But our faculty began to realize over time, that the administration and their employed faculty saw the residency as their own program and resented the fact that we were becoming more involved in what, according to the ACGME, was administratively our program

Certainly, we saw the residency as our own program that was a joint venture with the community hospital. There was a real difference in perception..

Moving the Residency to the Academic Medical Center

Moving community-based residency into Academic Center
Moving community-based residency into Academic Center

After about a year and a half of negotiating and making a case on my part to our dean, my boss, and others in our place, we decided to return the residency program to the academic health center – basically to remove it from the community hospital and to take it down to a level of eight residents in each of the three years of residency.

But this required rebuilding the family medicine graduate infrastructure at the academic health center.

We had to assign core faculty positions as defined by the ACGME and reassign faculty members’ efforts. Luckily, we have a large department, with over 80 faculty members and growing, so we were able to do this.

We had to redesign our evaluation system of the residents, and redesign the curriculum centering at the academic health center – all big tasks.

We had to take two of our 15 faculty practices and turn them into family medicine centers for our residents that would meet all of the requirements of the ACGME and the family medicine Residency Review Committee.

We had to transform our inpatient service, which had worked at the university hospital with attendings and midlevel APCs into a full-fledged teaching service, because the residents would now be seeing their patients at the university hospital.

This required, and still requires a large amount of faculty development about how to teach residents in a department where people are really used to teaching medical students only. We had to assign adequate precepting time at both of our family medicine centers to teach our residents in their continuity care.

Competencies and Milestones

Impact of New Accreditation Requirements
Impact of New Accreditation Requirements

All these changes were taking place in the realm of the new six competencies and the next accreditation system. As part of the next accreditation system all residencies have to set up a clinical competency committee to review our program semiannually and make decisions on milestone achievements.

We have to have a program evaluation committee. And we have to continue to follow at the same all of the rules of the LCME, because we are a medical school as well.  So, there were many regulatory matters to address while we were trying to make these changes in program infrastructure..

Many of our R2 and R3 residents had to change their family medicine center practice. Interestingly, there is the rule that residents have to do the last two years in continuity so we couldn’t really move the people who were going to be our upcoming third year residents out of the community hospital. They are at the community hospital until the end of June 2014.

Differing Institutional Cultures

IMPACT OF DIFFERING CULTURES
IMPACT OF DIFFERING CULTURES

Some of the R1s and R2s after a year of practice at the community hospital had to change their site of continuity practice, but those residents had become attached to the what I call the “homey feel” of the community hospital and to the styles of faculty members with whom they worked out there, that I would describe as parental and as letting the residents get away with a lot.

Those residents were moved under the academic health center-based faculty whom the residents perceived as less personally engaging (probably not true), but more demanding (probably true). In the ACGME annual survey the residents expressed some of their unhappiness due to the change.

Continuity of Care and Educational Quality Issues

Residency Education Quality Issues
Residency Education Quality Issues

We had to deal with keeping adequate continuity for our residents. We have had to look at every one of our rotations, several of which were in the community surrounding the community hospital.

We’ve had great luck in moving them back into divisions and departments in the academic health center.

You know the bane of most family medicine departments, finding OBGYN and pediatric clinical experiences is something that we’re working on now. I think we found solutions to both of these, and so I’m happy about that.

During all of these events, we were also talking about medical students. We have a new vice-dean for education who’s asking why every medical student should have every basic clerkship. If you come into medical school knowing you want to be a surgeon, why should you do a family medicine rotation? I have a difference of opinion with her about that.

Should we be focusing on years one and two or years three and four? We just had a provocative departmental review with three of our colleagues who came in and one of them made a comment on why we bother teaching history-taking and physical diagnosis in years one and two? What real affect does that have on a medical student’s decision making to go into primary care? Maybe, it was suggested, we should really be focusing on years three and four.

Recruitment Stategies of “Unopposed” Residencies

We live in an environment in South Central Pennsylvania where we have very many long standing, very high quality residency programs based in community hospitals that you all know about, who all advertise themselves as unopposed.

I don’t like that word “unopposed”. I don’t think that we’re “opposed” in our environment. I think we have plenty of business in our academic health center for everyone to do. But that doesn’t help keep other programs from marketing themselves to the students that they should only go to an unopposed program.

Our health system is now talking with some of these hospitals and we may have a world with mergers, joint ventures, all kinds of things. Who knows what’s coming in the future with regard to our “enemies” becoming our friends, because as someone said it’s easier to do this when you have a common enemy. And we have several of those in our environment.

Dawson’s “Leading Culture Change”

Christopher Dawson' "Leading Culture Change"
Christopher Dawson’ “Leading Culture Change”

I’ve been looking at this book, it’s called Leading Culture Change; by Christopher Dawson. I think it’s really fantastic, something that I’m taking away from all of this.

He defines five critical success factors for cultural change. And I really think moving this residency program in the midst of all of these activities is a cultural change.

Defining the level of urgency is the first step, then defining the new and legacy cultures. I think this is really a great terminology, to distinguish between your actual culture – what I am today – with the ideal culture that you envision, what you’d really like to be; the required culture.

What are the “non-negotiables” I think all these accreditation things have, are part of the required culture. And then the vision culture, What can we actually be in the future, and what can we get to?

First Steps for Successful Culture Change
First Steps for Successful Culture Change

Dawson says there are three things you have in continuing the five success factors.

You have to build a cultural change road map: you have to have an idea in your mind of where you’re going to go and how you’re going to get there

You have to translate the vision culture into behavior competencies and measurable events. (We could spend a whole hour talking about that,)

Then you define these competencies and make changes in your organizational design (This is what we’re in the midst of now,)

Additional Critical Factors
Additional Critical Factors

Then you develop executive authenticity,  The executive has ro really buy into the new culture, to model it, and show people in the institution that they’re walking the walk and talking the talk at the same time as the rest are.

And I love this from a chart in Dawson’s book. Premise one, loss produces a predictable cycle of reaction.

Our residents felt a sense of loss leaving the community hospital.Dawson says that iwell applied tools, methods and techniques can accelerate this predictable cycle.

Addressing Predictable Resistance
Addressing Predictable Resistance

It doesn’t make it go away, but if you manage it well, you can make this go more quickly.The cost of not applying these methods is very high. In other words, you can really run aground if you don’t pay attention to this and do something and really manage the change.

There are some people who are willing and able to make the cultural change. Those are your keepers. And then there are people who are willing, but unable. They have to either be developed or they have to leave. Then you have the unwilling and the unable, the hopeless, and they probably will leave one way or the other.

Then there are the unwilling and the able, who have to decide either to commit or leave. I kind of like this.

Believe it or not, we’ve had some people, including a resident who have left, because of, and I would have never predicted that; that a resident would be so upset about this that they would actually have tremendous difficulty and wind up leaving. I won’t say any more about that, but it was tough.

Stragies for Overcoming Resistance
Stragies for Overcoming Resistance

There are three causes of this resistance. It’s misunderstanding, in which you can educate.

There’s lack of competence which can be developed, or there’s just value difference, where people won’t go along with what you’re proposing and that has to be confronted.

People will either improve and change, or they won’t’ improve and then the hard fact is that sometimes, you have to separate from them.

Peter Garrett’s Model of Change

This is a model of change that one of my friends, an English fellow named Peter Garrett, has described.

Peter Garrett's Model for Commencing Change
Peter Garrett’s Model for Commencing Change

I won’t go into this in big detail. But basically you can see it has a spiral kind of feel to it.

What it says is to get any change done you have to first identify a small group of people who will buy into what you’re doing, and if you can get them to change, to change their mental models.

Then you can spread that out in a spiral to other people as you go along. This is the model that we’ve tried to use to go through this cultural change of residency.

This is a slide by the same person. If you look, the arrow in the middle says if you have a technical problem, almost like a thermostat, something that you just need a technical quick fix,

it’s a pretty linear process to figure out what you have to do.

Peter Garrett's Diagram (Dialogue Associates 2005)
Peter Garrett’s Diagram (Dialogue Associates 2005)

But if you have an adaptive problem and I would define that as one that involves changing people’s hearts and minds, real cultural change; what usually happens in organizations is what’s on the right. You try to find a fast and simple solution, and then you go downhill.

Then you have to go back uphill because you encounter resistance and have to rework everything. And then you finally go back downhill to get to a solution and that takes a lot of time and energy because it requires some angst.

On the left is this spiral model where you try to get people to talk it through and change their mental models and do this a little bit more slowly and get people to buy in. I found this to be helpful in culture change.

So I’ll close with some of the lessons I think I’ve learned, and we’ve learned through this whole episode, which obviously is still ongoing.

Overcoming resistance to change
Overcoming resistance to change

First, in a joint graduate medical education venture each partner tends to think of the program as its own program and acts accordingly. And when you’re designing programs you have to take a lot of care to ensure that they function in just the way it’s planned.

This is interesting for us. Maybe we haven’t learned what we should have learned, but we’re setting up a new residency program 100 miles away, in the town that houses the main campus of our university. This is again in a community hospital which has had no education, and no experience with education at all. It has never had residency education, it has never had medical student education and we’re setting up a joint venture residency program there.

We have to be very careful that we don’t make the same mistakes that we made 20 or 30 years ago setting up the one that we just moved back to the academic health center. And that’s tough. Our new residency program director there is meeting tonight with their board to try to set up some of these parameters.

And second making change, getting people to change in a way that sticks, really involves people to change their minds about what they believe in. So we’ve had to change people’s beliefs about where we should educate residents and what should be the requirements for residency education. That has not been easy.

But an organized approach to culture change can highlight the needed changes and allow a process to proceed, but it’s messy and it’s difficult because it involves changing many peoples mental models and many heads at the same time; faculty members, residents, administrators, all the partners that we work in, in education all while we’re trying to remain accredited and do a better job.

And resistance comes in many forms and it can really derail people and derail the process unless you’re really careful, and you manage it.

Thank you.

This section is followed by:: Proceedings of the 25th National Conference; April 14, 2014 (Second Plenary Session, LeRoy Questions and Comments).