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Redesigning Medical Education in Internal Medicine: Adapting to the Changing Landscape of 21st Century Medical Practice
SPECIAL FEATURE
Improving U.S. Healthcare Symposium Feature Editors: Drs. John R. Feussner, Eugene Oddone & Eugene Rich
Redesigning Medical Education in Internal Medicine: Adapting to the Changing Landscape of 21st Century Medical Practice Deborah J. DeWaay, MD, E. Benjamin Clyburn, MD, Donald W. Brady, MD and Jeffrey G. Wong, MD Key Indexing Terms: Medical education; Residency training; Internal medicine. [Am J Med Sci 2016;351(1):77–83.]
INTRODUCTION
P
racticing internal medicine in the 21st century has changed. Novel scientific discoveries, diagnostic technologies and therapeutic interventions have evolved rapidly. At the same time, external forces have altered the interactions between internists, their patients and the new healthcare delivery systems incorporating those interactions in ways unforeseen a decade ago. Although most institutions strive to keep the scientific aspects of their curricula current, teaching learners to use this new science effectively in present and future healthcare environments is addressed less commonly. Adopting new models of education can be difficult. Educational change occurs slowly within the confines of the extant system, but the shifting landscape demands rapid change, and many “traditional” medical teachers find themselves on unfamiliar terrain. In the last 10 years, the Society of General Internal Medicine (SGIM), the American College of Physicians (ACP), and the Alliance for Academic Internal Medicine (AAIM) have all published position papers on redesigning Internal Medicine training.1-3 The medical education community is recognizing the necessity for learners to demonstrate objectively their ability to care for patients, a so-called “competencybased model” for training and education. Likewise, educational regulatory bodies have deemed that physicians should demonstrate competence for certification. Traditional clinical training, however, inserts learners into established patient care experiences in a fashion that minimally disrupts the system. This current “systemcentered” clinical structure limits the role learners can play and makes assessing their competence a struggle for educators. Thus, an endless loop is created; learners cannot fully participate until they are competent, yet they cannot easily be declared “competent” because there are limited arenas in which they can fully participate. Education is not given as top priority in this “system-centered” structure and adjustments that may be needed to satisfy any new educational requirements are also done in a way that is minimally disruptive for the system. Thus, our learners are having training in a clinical system that is not necessarily designed for education.
There are crippling problems with the modern day healthcare system that require superior physicians to be apart of the solutions needed to create a solvent system. Internal medicine training must evolve to become proactive and evidence based, opposed to reactive and systems-centered, with respect to educational curricular design, implementation, assessment and evaluation to produce physicians that are leaders, innovators and system changers. The framework created by the Commission on Education of Health Professionals for the 21st century should be adopted. In this framework, patient-centered care is taken at a systems level. The needs of patients dictate the qualities and services the educational system and healthcare system must provide. This fundamental change would alter our culture from one where the educational system and healthcare system are in competition to one where they are both patient centered.4 This article identifies 3 systematic changes that we believe must occur in internal medicine training if we are to create produce physicians that are leaders, innovators and system changers within a patient centered system: 1) The educational system in the 21st century should be a proactive, pedagogically sound and deliberately competency-based system that trains learners to be not only experts in the pathophysiological aspects of a disease but also effective members of interprofessional teams that are responsive to the needs of individual patients, their families and the communities in which they live. 2) Training a cadre of master educators who are skilled in a broad range of mentorship, teaching and evaluation techniques to be able to teach all aspects of physician development may be one successful strategy for supporting a robust and deliberate competency-based educational system. 3) The funding of medical education, at both the Undergraduate Medical Education (UME) and the Graduate Medical Education (GME) levels, must be better understood and reconfigured for transparency, accountability and long-term sustainability to fund the increased supervision and observation
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necessary to support a competency-based educational system. Each of the following sections analyzes the stated problem and speculates on potential solutions to consider for solving the problem (Table).
Competency-Based Training Through Team-Based Patient, Family and Community-Centered Experiences For most of the 20th century, medical students were taught in what some have described as a “Flexnerian” fashion. Influenced by Abraham Flexner's review of medicals schools in 1910, medical school
curricular structure became appropriately science focused. Early learning in medical school focused upon the factual basic science disciplines, for example, anatomy, biochemistry, histology, physiology, immunology and microbiology. Learning what was normal then evolved into learning “abnormal” and a diseaseoriented focus emerged. The student's learning was often categorized through an “organ systems” approach where an ability to list and describe the different potential pathologies, an organ might develop, was greatly rewarded. After learning “all” of basic science normality and abnormality, the students then entered the clinical medicine of the inpatient wards, operating rooms, emergency departments and outpatient.5
TABLE. Summary of proposed changes needed to Internal Medicine Education in the 21st century Competency-based training through team-based patient, family and community-centered experiences
Implementation, assessment and evaluation of identified competencies, milestones and entrustable professional activities Asynchronous learning possibilities Accelerated programs shortening the length of training Increased exposure to ambulatory medicine with team-based care Undergraduate Medical Education (UME) Immerse learners in the patientcentered medical home Early experiences patient centered care Collaboration with other health professional colleges to teach team skills
Master teachers
Will dedicate their careers to education and patient care Will be measured on their ability to advance educational curriculum Will hold key education roles within their institution Will be experts in a broad range of mentorship, teaching and evaluation techniques within the competency-based model Development of teaching academies to promote the streamlining of UME and GME faculty development UME Specific and ongoing faculty development in UME Experts in mentoring students Resident teaching academies to improve student teaching
Budget
GME Will receive specific and ongoing faculty development in GME Experts in mentoring residents
Educational value units (EVUs) to faculty Funding of appropriate faculty development Taxes on clinical care to support education The Academic Health Center or practice plan should weight clinical care in the teaching setting above clinical relative value units Philanthropic efforts for education UME Transparency of funds from the student tuition and state dollars
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Graduate Medical Education (GME) Identify rotations based on training needs for competency Increase and enhance ambulatory training Interdisciplinary residency activities to teach team skills
GME Transparency of funds from Medicare and state dollars Indirect medical education allocation should go to GME training programs Assign support to medical educators to allow for direct observation
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In late 20th and early 21st century medical education, students have progressed through clinical clerkships based primarily upon the length of time spent in any rotation. Summative evaluations given at the end of a “time block” are more often determined by the convenience of the calendar than by the learner's demonstration of competence. The underlying assumption has been that, if a student spends a certain amount of time on a service, they will learn the skills they need from that rotation. Indeed, this model of education carries over to the GME sphere of residencies and fellowships; the length of time spent in training is the independent variable. This time-limited synchronous learning is convenient for the schedule of the medical school or residency program, but does little to guarantee that any given learner has achieved their educational goals. Competency-based educational models identify the competencies necessary to meet the needs of patients and health systems. Curriculum is designed based on the desired outcomes. Public stakeholders have increasing expectations of physicians.6 Designing a competency-based program should begin with identification of the knowledge, skills and attitudes physicians must have to meet the needs of the healthcare system and the public. Subsequently, competencies can be articulated. Trainees are then assessed based on their achievement of these competencies through the use of milestones and Entrustable Professional Activities (EPAs).4 EPAs represent the routine professional life activities of physicians based on their specialty.7 Rigorous assessment and evaluation of learners achieving EPAs have been proposed as a method of determining if learners are proficient in the competencies. GME has been organized around the concepts of the Accreditation Council for Graduate Medical Education (ACGME) 6 core competencies (professionalism, patient care, medical knowledge, interpersonal skills and communication, systems-based practice and practice-based learning and improvement) for more than a decade.6 More recently, curricular milestones, reporting milestones and EPAs have been identified for Internal Medicine residency training.8,9 EPAs, on the GME level, can then be implemented to allow observation of the milestones, or developmental steps, necessary to practice. The Liaison Committee on Medical Education (LCME) mandates that all undergraduate programs have a set of institutional learning objectives that are the guiding force behind an institution's entire curriculum. The LCME has also recommended that these institutional learning objectives are organized by competencies that are similar to those in GME. The Association of American Medical Colleges (AAMC) is currently piloting a set of 13 EPAs that students must be proficient at upon graduation.10 Organizing internal medicine training under these rubrics will enable programs to effect most of the changes proposed in the position papers from SGIM, ACP and AAIM.1-3 The key step will be transitioning from
the identification of these competencies, milestones and EPAs to meaningful implementation of them. In addition, making clinical assignments-based assessment of competency, instead of service needs, facilitates training in team-based settings, enhanced ambulatory care and can allow for more flexibility for trainees with respect to time needed to achieve mastery of skills. At minimum, competency-based education will require 3 important things. First, that the definition and description of the competencies expected for the learners are explicit, objective and meaningful, and not merely just checklists of tasks completed or patient problems seen. Second, that those evaluating the learner's progress must be well versed, at all educational levels, on assessing the wide range of clinical and professional competence through observation, formal evaluative techniques and fostering introspective self-assessment. Third, academic medical centers (AMCs) should continue to research the effectiveness of new systemic changes. Educational research has evolved to become a type of translational science. The goal of this research is to demonstrate that educational curricular changes contribute to physician competence and ultimately improved patient outcomes.11 As these major changes are made to implement a truly competency-based system, educational research is needed to ensure that the changes that are being made are effective and are a sound investment. The transition to competency-based training also allows educators to emphasize the skills and domains of competency necessary for practice in the current and future environment, such as the need for physicians to be members of a highly effective healthcare team. Previously, medical education emphasized that each student must develop “independence” to become a sole provider of patient care. The ideal that an optimally trained physician is “all knowledgeable” within her discipline and minimally relies on others for the care of her patients is no longer tenable. In today's world, practitioners must be effective members of interprofessional patient care teams which have been shown to result in better patient outcomes than if physicians try to “do it alone.” Practitioners in the future must be trained to maximize the effectiveness of the healthcare team through mobilizing resources and leveraging the expertise and skills of the other team members.2,3 Training learners to develop these leadership and interprofessional skills require a cultural shift in how the educational system works. We believe that these skills must be taught and evaluated in interprofessional models of care. Emphasizing systems-based practice and assigning learners to specific clinical experiences to assess team leadership will help ensure that learners are prepared for this reality. In addition, education in a truly competency-based educational model should be independent of time allowing learners to progress at their own speed and advancing as competency is demonstrated. It can allow those
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who demonstrate competency to finish programs in less time, enabling them to become independent practitioners sooner, and potentially use fewer educational resources. Importantly, it does not penalize those learners who ultimately will become excellent physicians but who require more time than allotted under the constraints of the traditional system. We believe that in the 21st century, the demonstration of competence should be the independent variable determining progression and not the amount of time spent in any particular activity. Even if overall training is not shortened, trainees should be free to customize their training and progress through training as they demonstrate competency. With regards to GME specifically, most internal medicine residents finish their training at or near the 6month maximum amount of critical care training, but elective time is often limited. It is difficult to argue that this is not driven by the service needs of the sponsoring institutions. In a truly competency-based system, Program Directors can demonstrate to institutions that their residents have achieved competency in one area and are lacking in another. This should allow for rotations based predominantly on the educational needs of the resident and the program, rather than the service needs of the hospital. Some programs have created accelerated “fast-track” programs, such as for rural medicine. These programs simply shorten the number of requirements needed to graduate, as opposed to having the learner achieve competence in an accelerated fashion. The “extra” rotations are removed from medical school in order for students to start their residencies early. In other words, they remain time based.12 At the UME level, a truly competency-based program would give students increasing flexibility with their schedule. The competition for residency positions has become increasingly fierce. In the 2015 match, 41,334 applicants competed for 27,293 positions.13 If student were assessed based upon their competency, there would be the potential to have increased time for research and other activities that would make them more competitive within the match. In addition, the flexibility would allow students to tailor their training and spend more time working on their areas of weakness. However, evolving to a competency-based education system creates new challenges. In a time flexible system, how much extra time is sufficient? How fast is too fast? What if one competency lags all others? What additional resources are needed to adequately “measure” competency? The educational system has finite resources, and the overall comparative cost of the current time-based system versus a truly competencybased system is not well defined. How could such a system be conducted in an environment that runs on set schedules and calendar operations? Educational research is needed in the best way to create a system where learners can be asynchronous. The necessity of assessing trainees across all domains of internal medicine will force adequate
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experience in all settings and across competencies. This clearly will lead to an increased emphasis on the quantity and quality of ambulatory training. This is crucial as most care is delivered in the outpatient setting, and the majority of internal medicine training occurs in the hospital. The ACP, SGIM and AAIM all agree that there needs to be increased ambulatory training for learners.1-3 Programs should establish outpatient experiences in effective models such as the patient-centered medical home (PCMH) to both improve recruitment and retention of primary care physicians and give robust education in a representative interprofessional environment.1 The PCMH model allows for evaluation of learners at all levels across competencies and EPAs. A truly competency-based training program also allows for the evaluation of learners' skills in quality improvement, patient safety and cost-conscious care. The learners' commitment to professionalism and lifelong learning can be directly observed by faculty. Lastly, PCMH experiences provide medical students with early experiences that give them an understanding of the healthcare system from the point of view of the patient and their family. Programs at the GME and UME should create immersion programs which boost learner confidence and build teamwork skills. Kwiatkowski et al14 found the incorporation of an emergency medical technician curriculum including immersion experiences early in medical school, gave students meaningful clinical experiences that increased their self-reported level of confidence in the performance of patient care skills early in their medical education.
The Use of Master Educators to Assess Competence and Excellence Learning programs must use direct observation, narrative feedback and educational alliances to elevate their competency-based systems from reductive to robust. A competency-based educational system uses milestones to monitor and measure the progress of the learner.6,15 In order for medical education to be competency-based instead of time and system-centered, learners must meet set of criteria for advancement through direct observation accompanied by constructive feedback and continual improvement. The use of constructive feedback can transform a checklist of learner goals into a robust competency-based curriculum.15 Furthermore, learners may thrive through “educational alliances” between teachers and students that provide a formal structure for robust longitudinal feedback that improves performance.16 These alliances may be a way to bring the competency-based system to life for learners and faculty. A potential drawback to a competency-based model is a tendency toward a minimum passing standard instead of demands for excellence. Competency-based systems require teachers who are adept evaluators of THE AMERICAN JOURNAL VOLUME 351
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learner performance. Such teachers can discern reliably between failure to achieve competence and achievement of competency or mastery. They also should be skilled providers of effective feedback, and have the ability to conduct appropriate assessments. Clinician educators rarely have formal training in education, therefore, additional and extensive faculty development to create master educators is necessary.17,18 One strategy could be to train 2 specific types of master educators. The first type, the “referees,” would be well versed in evaluation and feedback. “Referees” would be trained for feedback and evaluation. They would assess the learner's progress along the path toward competency and provide robust narrative feedback to help the learner improve. A second type of educator, the “coach or mentor,” would be trained to create “educational alliances” with students.16 Coach or mentors would help the learner to process the feedback, encourage lifelong learning, reflection and introspection. In today's fast-paced system that has tended to push learners to the periphery, deliberate creation of a coach or mentoring relationship is critical. The coach or mentor works with the learner to create action plans for addressing areas of deficiency and creates accountability for following through on the plan. It is, of course, possible for a particular skilled individual to serve in both roles but separating the 2 concepts seems important. We believe that creating master educators in this fashion could provide new ideas to the educational system, result in quality improvement projects for defining effective educational change, and could result in perpetual growth and continuous improvement. Although there is the potential for an increase in the total educational cost of training these master educators, training educators who can work across the continuum of UME and GME can optimize resources to better assure the effectiveness of the competencybased curriculum. To create a system that will develop and support the training of master teachers, we recommend that AMCs) create academies of medical education. Over 60 centers currently have developed these academies.19 The 2 main purposes of these academies are to elevate the teaching skills of all faculty members and support and promote clinician educators in their academic activities to advance curriculum development, medical education and educational research.19 There are 7 steps that have been outlined in the literature to guide AMCs in the creation of these academies. First, the AMC must rally support for the academy and build a consensus around the concept that education must be prioritized on the same level as the research and clinical enterprise. Second, all educational activities must be systematically recorded in educational portfolios for each master teacher to appropriately quantify the amount of work that has been completed. Third, the educational activities must be
aligned with the priorities of the department and the institution. Fourth, teaching performance must be measured and the quality must be monitored. Fifth, master teachers should be given appropriate feedback to improve their performance and curriculum. Sixth, the strengths, weaknesses, threats and opportunities to the educational programs should be analyzed and quality improvement must take place. The AMC should assess promotion pathways, incentives for excellent teaching and the compensation structure to encourage excellent teaching.19 Resident education academies should also be created and modeled after the faculty academies. These academies serve several purposes. First, they are a key resource for developing the teaching of residents. Second, they have a structure that can be used to coach residents to be better teachers. Third, they would improve resident skills so that when they graduate and become faculty they would already have baseline education in competency-based methodology.20
Transparent Funding for Medical Education There is an increasing urgency to clarify the funding for medical education. The current system is not sustainable. Although there would always be a talent pool that would be attracted to medicine because of scientific curiosity and the desire to ease human suffering, the current system that asks students to incur huge debt will negatively impact recruitment of the best talent. The cost of medical education is increasing at an alarming rate. The tuition at medical schools now averages $34,540 for state schools and $53,714 for private schools, and the average debt of a graduating medical student now stands at $176,348.21 Additionally, the general public helps fund medical education through paying taxes (for state-subsidized schools) and through Centers for Medicare and Medicaid Services (CMS) funding for GME. All told, large amounts of money are being spent on medical education at both the graduate and the undergraduate level, yet very few schools state that they have “enough money” to support education. Why is there such a large disconnect between what is being purported to be given for medical education compared to what is being spent? The funds flow accountability at most AMCs is not very transparent. Medical school deans and hospital administrators are responsible for multiple missions, and they usually have considerable flexibility on where their budget's monies are actually spent. In fact, the Indirect Medical Education payments for GME do not solely target the education mission but also operating costs associated with being a teaching hospital, such as standby capacity, highly specialized training and services, and the complexity of cases often seen more frequently at AMCs. At the UME level, as most medical education programs involve medical students in experiential activities that minimally disrupt normal operations, the money devoted to “fund
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education” has a myriad of potential justifications for its distribution. Despite the educational dollars given to hospitals and medical colleges, few academic physicians would report that they were “paid to teach.” In addition, while residency program directors would have a budget for expenditures, such as administrative costs, recruitment and salaries, there is little if any money for curriculum development or faculty development unless the institution has grant funding, a large endowment or philanthropic revenue sources. Medical educators who oversee programs at the undergraduate and graduate levels are given budgets from the dean's office or their department with little understanding of the amount of money coming into the institution compared to how much is actually dispensed for their program. This financial state of medical education begs the question, where is the money? Meanwhile programs at all levels are under increasing pressure to develop comprehensive, competencybased programs that address a holistic approach to medicine. No longer must these programs just teach basic science and clinical patient care as discussed previously. They must also train physicians who can lead interprofessional teams—a content area that was not previously emphasized—in a competency-based format that inherently requires increased direct observation and faculty time. To frame this challenge, programs are being asked to significantly reformulate their educational focus with fewer funds then were previously allocated for maintaining the status quo. In the year 2000, The AAMC published a position paper articulating the need for “mission-based” management in AMCs via several different activities.22 First, faculty efforts for clinical activities should be measured. Second, the institution should decide on a metric for this effort such as a revenue value unit.22 Third, benchmarks should be established to compare faculty performances.22 Finally, an analysis of the extra factors that could affect the interpretation of the data and an analysis of faculty contributions to the clinical mission not captured by metrics should be performed.22 We would contend that this mission-based management should be expanded even further in a more specific and transparent way to the educational mission. When allocating funds, it is difficult to accurately assign value to the educational mission.23-25 More often, funds are primarily distributed based on clinical productivity and the teaching of medical students and residents can negatively impact such productivity. This negative impact may be especially detrimental to primary care faculty, whose sole method for generating clinical productivity is through seeing and billing high volumes of patients. These primary care physicians also tend to perform a large percentage of the teaching at AMCs.26 One method for attempting to quantify educational effort is the educational value unit (EVU). In an EVU system, educational activities, such as lectures, small
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group teaching, physical diagnosis teaching, morning report participation, and conference lecturer are quantified in some explicit fashion. Moreover, time required of educators who are also administering educational programs is also quantified. In such a system, the EVU and the clinical relative value unit can be compared and accounted for when making funding allocations. The Medical University of South Carolina successfully created such a system.26 The divisions within the Department had 40% of their budget allocation dependent upon how many EVUs their faculty produced. The effect was that there was increased participation in educational activity in a budget neutral fashion.26 GME in the Unites States receives support of around 15 billion dollars per year from the federal government, but many question the need for continuing this funding level.27 For those involved in medical education, the time is right to demand transparency and accountability for those GME dollars earmarked for medical education. We contend those dollars must be more clearly linked to efforts directly related to training physicians and should not be comingled with the larger AMC's budget. Sponsoring institutions should receive those dollars and be transparent on how those dollars are supporting the specific goals of the training programs, training the physicians needed for the ever-evolving 21st century healthcare system. With this transparency comes accountability. Institutions and programs have an obligation for creating “high value” education. This change would require medical educators to be good shepherds of these educational dollars and being “cost-conscious” on how educational dollars are used.
Summary The framework created by the Commission on Education of Health Professionals for the 21st century should be adopted to alter our culture from one where the educational system and healthcare system are in competition to one where they are both patient centered.4 Learners must be trained to be experts in the pathophysiological aspects of a disease and effective members of interprofessional teams that are responsive to the needs of individual patients, their families and the communities in which they live. This training can be accomplished through a competency-based training system that uses milestones and EPAs to assess and evaluate learners. Asynchronous learning opportunities may be a way of either accelerating training or personalizing learning within a set timeframe. Increased exposure to ambulatory medicine in a team-based patient care environment will be key to adequately assessing learners in all of the competencies. This competencybased training will require a cadre of master educators who are skilled in a broad range of mentorship, teaching and evaluation techniques to be able to teach all aspects of physician development. To create and sustain this educational workforce, academies of medical education THE AMERICAN JOURNAL VOLUME 351
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will be necessary. These academies will provide a center for faculty development, educational research and innovation. The funding of medical education, at both the UME and the GME levels, must be better understood and reconfigured for transparency, accountability and long-term sustainability to fund the increased supervision and observation necessary to support a competency-based educational system. Our culture must realize that the investment in these resources is not to fund education for education sake, but to invest in the creation of physicians who are leaders with the attributes necessary to continue the evolution toward a patient-centered healthcare system.
REFERENCES 1. Holmboe E, Bowen J, Green M, et al. Reforming internal medicine residency training: a report from the Society of General Internal Medicine's task force for residency reform. JGIM 2005;20:1165–72. 2. Weinberger S, Smith L, Collier V. Redesigning training for internal medicine. Ann Intern Med 2006;144:1–8. 3. Meyers F, Weinberger S, Fitzgibbons J, et al. Redesigning residency training in internal medicine: the consensus report of the Alliance for Internal Medicine Education redesign taskforce. Acad Med 2007;82: 1211–9. 4. Frenk J, Chen L, Bhutta Z, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923–55. 5. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. The Carnegie Foundation for the Advancement of Teaching, New York, NY, USA, 1910. 6. Nasca T, Philibert I, Brigham T, et al. The next GME accreditation system—rationale and benefits. N Engl J Med 2012;366:1051–6. 7. Ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med 2007;82:542–7. 8. Green M, Aagaard E, Caverzagie K, et al. Charting the road to competence: developmental milestones for internal medicine residency training. J Grad Med Educ 2009;1:5–20. 9. Caverzagie K, Cooney TG, Hemmer P, et al. The development of entrustable professional activities for internal medicine residency training: a report from the Education Redesign Committee of the Alliance for Academic Internal Medicine. Acad Med 2015;90:479–84. 10. Core Entrustable Professional Activities, Curriculum Developers Guide. Association of American Medical Colleges, 2014. 〈www.aamc.org〉. 11. McGaghie W. Medical education research as translational science. Sci Transl Med 2010;2:1–3. 12. Stageman J, Bowman R, Harrison J. An Accelerated rural training program. J Am Board Fam Med 2003;16:124–30.
13. National Resident Matching Program, Results and Data. 2015 Main Residency Match®. National Resident Matching Program, Washington, DC, 2015. 14. Kwiatkowski T, Rennie W, Fornari A, et al. Medical students as EMTs: skill building, confidence and professional formation. Med Educ Online 2014;19:1–7. 15. Tekian A, Hodges BD, Roberts TE, et al. Assessing competencies using milestones along the way. Med Teach 2015;37:399–402. 16. Telio S, Ajjawi R, Regehr G. The Educational Alliance as a framework for reconceptualizing feedback in medical education. Acad Med 2015;90: 609–14. 17. Geraci S, Babbott S, Hollander H, et al. AAIM report on master teachers and clinician educators part 1: needs and skills. Amer J Med 2010;123:769–73. 18. Geraci S, Kovach R, Babbott S, et al. AAIM report on master teachers and clinician educators part 2: faculty development and training. Amer J Med 2010;123:869–72. 19. Berman J, Aizer J, Bass A, et al. Creating an academy of medical educators: how and where to start. Hosp Spec Surg 2012;8:165–8. 20. Moza R, Villafranco N, Upadhya D, et al. Academy of resident educators: a framework for development of future clinician-educators. J Grad Med Educ 2015;7:294–5. 21. Medical Student Education: Debt, Costs, and Loan Repayment Fact Card 2014. https://www.aamc.org/download/152968/data/debtfactcard. pdf. Accessed July 6, 2015. 22. D'Alessandri Albertsen P, Atkinson B, Dickler R, et al. Measuring contributions to the clinical mission of medical schools and teaching hospitals. Acad Med 2000;75:1232–7. 23. Watson R, Romrell L. Mission-based budgeting: removing a graveyard. Acad Med 1999;74:627–40. 24. Nutter D, Bond J, Coller B, et al. Measuring faculty effort and contributions in medical education. Acad Med 2000;75:199–207. 25. Mallon W, Jones R. How do medical schools use measurement systems to track faculty activity and productivity in teaching? Acad Med 2002;77: 115–23. 26. Clyburn E, Wood C, Moran W, et al. Valuing the education mission: implementing an educational value units system. Am J Med 2011;124: 567–72. 27. Berwick D, Wilensky GR, Alexander B, et al. Graduate Medical Education that meets the nation's health needs. Inst Med 2014; 1–4. www.iom.edu/GME. Accessed June 7, 2015.
From the Department of Medicine (DJD, EBC), Medical University of South Carolina, Charleston, SC; Office of Graduate Medical Education (DWB), Vanderbilt University, Medical School, Nashville, TN; Department of Internal Medicine (JGW), Penn State Milton S. Hershey College of Medicine, University Park Regional Campus, State College, PA. Submitted July 6, 2015; accepted October 12, 2015. The authors have no financial or other conflicts of interest to disclose. Correspondence: Deborah J. DeWaay, MD, Medical University of South Carolina, 96 Jonathan Lucas St, MSC 623, Charleston, SC 29425. (E-mail: [email protected]).
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Improving U.S. Healthcare Symposium Feature Editors: Drs. John R. Feussner, Eugene Oddone & Eugene Rich
Redesigning Medical Education in Internal Medicine: Adapting to the Changing Landscape of 21st Century Medical Practice Deborah J. DeWaay, MD, E. Benjamin Clyburn, MD, Donald W. Brady, MD and Jeffrey G. Wong, MD Key Indexing Terms: Medical education; Residency training; Internal medicine. [Am J Med Sci 2016;351(1):77–83.]
INTRODUCTION
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racticing internal medicine in the 21st century has changed. Novel scientific discoveries, diagnostic technologies and therapeutic interventions have evolved rapidly. At the same time, external forces have altered the interactions between internists, their patients and the new healthcare delivery systems incorporating those interactions in ways unforeseen a decade ago. Although most institutions strive to keep the scientific aspects of their curricula current, teaching learners to use this new science effectively in present and future healthcare environments is addressed less commonly. Adopting new models of education can be difficult. Educational change occurs slowly within the confines of the extant system, but the shifting landscape demands rapid change, and many “traditional” medical teachers find themselves on unfamiliar terrain. In the last 10 years, the Society of General Internal Medicine (SGIM), the American College of Physicians (ACP), and the Alliance for Academic Internal Medicine (AAIM) have all published position papers on redesigning Internal Medicine training.1-3 The medical education community is recognizing the necessity for learners to demonstrate objectively their ability to care for patients, a so-called “competencybased model” for training and education. Likewise, educational regulatory bodies have deemed that physicians should demonstrate competence for certification. Traditional clinical training, however, inserts learners into established patient care experiences in a fashion that minimally disrupts the system. This current “systemcentered” clinical structure limits the role learners can play and makes assessing their competence a struggle for educators. Thus, an endless loop is created; learners cannot fully participate until they are competent, yet they cannot easily be declared “competent” because there are limited arenas in which they can fully participate. Education is not given as top priority in this “system-centered” structure and adjustments that may be needed to satisfy any new educational requirements are also done in a way that is minimally disruptive for the system. Thus, our learners are having training in a clinical system that is not necessarily designed for education.
There are crippling problems with the modern day healthcare system that require superior physicians to be apart of the solutions needed to create a solvent system. Internal medicine training must evolve to become proactive and evidence based, opposed to reactive and systems-centered, with respect to educational curricular design, implementation, assessment and evaluation to produce physicians that are leaders, innovators and system changers. The framework created by the Commission on Education of Health Professionals for the 21st century should be adopted. In this framework, patient-centered care is taken at a systems level. The needs of patients dictate the qualities and services the educational system and healthcare system must provide. This fundamental change would alter our culture from one where the educational system and healthcare system are in competition to one where they are both patient centered.4 This article identifies 3 systematic changes that we believe must occur in internal medicine training if we are to create produce physicians that are leaders, innovators and system changers within a patient centered system: 1) The educational system in the 21st century should be a proactive, pedagogically sound and deliberately competency-based system that trains learners to be not only experts in the pathophysiological aspects of a disease but also effective members of interprofessional teams that are responsive to the needs of individual patients, their families and the communities in which they live. 2) Training a cadre of master educators who are skilled in a broad range of mentorship, teaching and evaluation techniques to be able to teach all aspects of physician development may be one successful strategy for supporting a robust and deliberate competency-based educational system. 3) The funding of medical education, at both the Undergraduate Medical Education (UME) and the Graduate Medical Education (GME) levels, must be better understood and reconfigured for transparency, accountability and long-term sustainability to fund the increased supervision and observation
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necessary to support a competency-based educational system. Each of the following sections analyzes the stated problem and speculates on potential solutions to consider for solving the problem (Table).
Competency-Based Training Through Team-Based Patient, Family and Community-Centered Experiences For most of the 20th century, medical students were taught in what some have described as a “Flexnerian” fashion. Influenced by Abraham Flexner's review of medicals schools in 1910, medical school
curricular structure became appropriately science focused. Early learning in medical school focused upon the factual basic science disciplines, for example, anatomy, biochemistry, histology, physiology, immunology and microbiology. Learning what was normal then evolved into learning “abnormal” and a diseaseoriented focus emerged. The student's learning was often categorized through an “organ systems” approach where an ability to list and describe the different potential pathologies, an organ might develop, was greatly rewarded. After learning “all” of basic science normality and abnormality, the students then entered the clinical medicine of the inpatient wards, operating rooms, emergency departments and outpatient.5
TABLE. Summary of proposed changes needed to Internal Medicine Education in the 21st century Competency-based training through team-based patient, family and community-centered experiences
Implementation, assessment and evaluation of identified competencies, milestones and entrustable professional activities Asynchronous learning possibilities Accelerated programs shortening the length of training Increased exposure to ambulatory medicine with team-based care Undergraduate Medical Education (UME) Immerse learners in the patientcentered medical home Early experiences patient centered care Collaboration with other health professional colleges to teach team skills
Master teachers
Will dedicate their careers to education and patient care Will be measured on their ability to advance educational curriculum Will hold key education roles within their institution Will be experts in a broad range of mentorship, teaching and evaluation techniques within the competency-based model Development of teaching academies to promote the streamlining of UME and GME faculty development UME Specific and ongoing faculty development in UME Experts in mentoring students Resident teaching academies to improve student teaching
Budget
GME Will receive specific and ongoing faculty development in GME Experts in mentoring residents
Educational value units (EVUs) to faculty Funding of appropriate faculty development Taxes on clinical care to support education The Academic Health Center or practice plan should weight clinical care in the teaching setting above clinical relative value units Philanthropic efforts for education UME Transparency of funds from the student tuition and state dollars
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Graduate Medical Education (GME) Identify rotations based on training needs for competency Increase and enhance ambulatory training Interdisciplinary residency activities to teach team skills
GME Transparency of funds from Medicare and state dollars Indirect medical education allocation should go to GME training programs Assign support to medical educators to allow for direct observation
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In late 20th and early 21st century medical education, students have progressed through clinical clerkships based primarily upon the length of time spent in any rotation. Summative evaluations given at the end of a “time block” are more often determined by the convenience of the calendar than by the learner's demonstration of competence. The underlying assumption has been that, if a student spends a certain amount of time on a service, they will learn the skills they need from that rotation. Indeed, this model of education carries over to the GME sphere of residencies and fellowships; the length of time spent in training is the independent variable. This time-limited synchronous learning is convenient for the schedule of the medical school or residency program, but does little to guarantee that any given learner has achieved their educational goals. Competency-based educational models identify the competencies necessary to meet the needs of patients and health systems. Curriculum is designed based on the desired outcomes. Public stakeholders have increasing expectations of physicians.6 Designing a competency-based program should begin with identification of the knowledge, skills and attitudes physicians must have to meet the needs of the healthcare system and the public. Subsequently, competencies can be articulated. Trainees are then assessed based on their achievement of these competencies through the use of milestones and Entrustable Professional Activities (EPAs).4 EPAs represent the routine professional life activities of physicians based on their specialty.7 Rigorous assessment and evaluation of learners achieving EPAs have been proposed as a method of determining if learners are proficient in the competencies. GME has been organized around the concepts of the Accreditation Council for Graduate Medical Education (ACGME) 6 core competencies (professionalism, patient care, medical knowledge, interpersonal skills and communication, systems-based practice and practice-based learning and improvement) for more than a decade.6 More recently, curricular milestones, reporting milestones and EPAs have been identified for Internal Medicine residency training.8,9 EPAs, on the GME level, can then be implemented to allow observation of the milestones, or developmental steps, necessary to practice. The Liaison Committee on Medical Education (LCME) mandates that all undergraduate programs have a set of institutional learning objectives that are the guiding force behind an institution's entire curriculum. The LCME has also recommended that these institutional learning objectives are organized by competencies that are similar to those in GME. The Association of American Medical Colleges (AAMC) is currently piloting a set of 13 EPAs that students must be proficient at upon graduation.10 Organizing internal medicine training under these rubrics will enable programs to effect most of the changes proposed in the position papers from SGIM, ACP and AAIM.1-3 The key step will be transitioning from
the identification of these competencies, milestones and EPAs to meaningful implementation of them. In addition, making clinical assignments-based assessment of competency, instead of service needs, facilitates training in team-based settings, enhanced ambulatory care and can allow for more flexibility for trainees with respect to time needed to achieve mastery of skills. At minimum, competency-based education will require 3 important things. First, that the definition and description of the competencies expected for the learners are explicit, objective and meaningful, and not merely just checklists of tasks completed or patient problems seen. Second, that those evaluating the learner's progress must be well versed, at all educational levels, on assessing the wide range of clinical and professional competence through observation, formal evaluative techniques and fostering introspective self-assessment. Third, academic medical centers (AMCs) should continue to research the effectiveness of new systemic changes. Educational research has evolved to become a type of translational science. The goal of this research is to demonstrate that educational curricular changes contribute to physician competence and ultimately improved patient outcomes.11 As these major changes are made to implement a truly competency-based system, educational research is needed to ensure that the changes that are being made are effective and are a sound investment. The transition to competency-based training also allows educators to emphasize the skills and domains of competency necessary for practice in the current and future environment, such as the need for physicians to be members of a highly effective healthcare team. Previously, medical education emphasized that each student must develop “independence” to become a sole provider of patient care. The ideal that an optimally trained physician is “all knowledgeable” within her discipline and minimally relies on others for the care of her patients is no longer tenable. In today's world, practitioners must be effective members of interprofessional patient care teams which have been shown to result in better patient outcomes than if physicians try to “do it alone.” Practitioners in the future must be trained to maximize the effectiveness of the healthcare team through mobilizing resources and leveraging the expertise and skills of the other team members.2,3 Training learners to develop these leadership and interprofessional skills require a cultural shift in how the educational system works. We believe that these skills must be taught and evaluated in interprofessional models of care. Emphasizing systems-based practice and assigning learners to specific clinical experiences to assess team leadership will help ensure that learners are prepared for this reality. In addition, education in a truly competency-based educational model should be independent of time allowing learners to progress at their own speed and advancing as competency is demonstrated. It can allow those
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who demonstrate competency to finish programs in less time, enabling them to become independent practitioners sooner, and potentially use fewer educational resources. Importantly, it does not penalize those learners who ultimately will become excellent physicians but who require more time than allotted under the constraints of the traditional system. We believe that in the 21st century, the demonstration of competence should be the independent variable determining progression and not the amount of time spent in any particular activity. Even if overall training is not shortened, trainees should be free to customize their training and progress through training as they demonstrate competency. With regards to GME specifically, most internal medicine residents finish their training at or near the 6month maximum amount of critical care training, but elective time is often limited. It is difficult to argue that this is not driven by the service needs of the sponsoring institutions. In a truly competency-based system, Program Directors can demonstrate to institutions that their residents have achieved competency in one area and are lacking in another. This should allow for rotations based predominantly on the educational needs of the resident and the program, rather than the service needs of the hospital. Some programs have created accelerated “fast-track” programs, such as for rural medicine. These programs simply shorten the number of requirements needed to graduate, as opposed to having the learner achieve competence in an accelerated fashion. The “extra” rotations are removed from medical school in order for students to start their residencies early. In other words, they remain time based.12 At the UME level, a truly competency-based program would give students increasing flexibility with their schedule. The competition for residency positions has become increasingly fierce. In the 2015 match, 41,334 applicants competed for 27,293 positions.13 If student were assessed based upon their competency, there would be the potential to have increased time for research and other activities that would make them more competitive within the match. In addition, the flexibility would allow students to tailor their training and spend more time working on their areas of weakness. However, evolving to a competency-based education system creates new challenges. In a time flexible system, how much extra time is sufficient? How fast is too fast? What if one competency lags all others? What additional resources are needed to adequately “measure” competency? The educational system has finite resources, and the overall comparative cost of the current time-based system versus a truly competencybased system is not well defined. How could such a system be conducted in an environment that runs on set schedules and calendar operations? Educational research is needed in the best way to create a system where learners can be asynchronous. The necessity of assessing trainees across all domains of internal medicine will force adequate
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experience in all settings and across competencies. This clearly will lead to an increased emphasis on the quantity and quality of ambulatory training. This is crucial as most care is delivered in the outpatient setting, and the majority of internal medicine training occurs in the hospital. The ACP, SGIM and AAIM all agree that there needs to be increased ambulatory training for learners.1-3 Programs should establish outpatient experiences in effective models such as the patient-centered medical home (PCMH) to both improve recruitment and retention of primary care physicians and give robust education in a representative interprofessional environment.1 The PCMH model allows for evaluation of learners at all levels across competencies and EPAs. A truly competency-based training program also allows for the evaluation of learners' skills in quality improvement, patient safety and cost-conscious care. The learners' commitment to professionalism and lifelong learning can be directly observed by faculty. Lastly, PCMH experiences provide medical students with early experiences that give them an understanding of the healthcare system from the point of view of the patient and their family. Programs at the GME and UME should create immersion programs which boost learner confidence and build teamwork skills. Kwiatkowski et al14 found the incorporation of an emergency medical technician curriculum including immersion experiences early in medical school, gave students meaningful clinical experiences that increased their self-reported level of confidence in the performance of patient care skills early in their medical education.
The Use of Master Educators to Assess Competence and Excellence Learning programs must use direct observation, narrative feedback and educational alliances to elevate their competency-based systems from reductive to robust. A competency-based educational system uses milestones to monitor and measure the progress of the learner.6,15 In order for medical education to be competency-based instead of time and system-centered, learners must meet set of criteria for advancement through direct observation accompanied by constructive feedback and continual improvement. The use of constructive feedback can transform a checklist of learner goals into a robust competency-based curriculum.15 Furthermore, learners may thrive through “educational alliances” between teachers and students that provide a formal structure for robust longitudinal feedback that improves performance.16 These alliances may be a way to bring the competency-based system to life for learners and faculty. A potential drawback to a competency-based model is a tendency toward a minimum passing standard instead of demands for excellence. Competency-based systems require teachers who are adept evaluators of THE AMERICAN JOURNAL VOLUME 351
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learner performance. Such teachers can discern reliably between failure to achieve competence and achievement of competency or mastery. They also should be skilled providers of effective feedback, and have the ability to conduct appropriate assessments. Clinician educators rarely have formal training in education, therefore, additional and extensive faculty development to create master educators is necessary.17,18 One strategy could be to train 2 specific types of master educators. The first type, the “referees,” would be well versed in evaluation and feedback. “Referees” would be trained for feedback and evaluation. They would assess the learner's progress along the path toward competency and provide robust narrative feedback to help the learner improve. A second type of educator, the “coach or mentor,” would be trained to create “educational alliances” with students.16 Coach or mentors would help the learner to process the feedback, encourage lifelong learning, reflection and introspection. In today's fast-paced system that has tended to push learners to the periphery, deliberate creation of a coach or mentoring relationship is critical. The coach or mentor works with the learner to create action plans for addressing areas of deficiency and creates accountability for following through on the plan. It is, of course, possible for a particular skilled individual to serve in both roles but separating the 2 concepts seems important. We believe that creating master educators in this fashion could provide new ideas to the educational system, result in quality improvement projects for defining effective educational change, and could result in perpetual growth and continuous improvement. Although there is the potential for an increase in the total educational cost of training these master educators, training educators who can work across the continuum of UME and GME can optimize resources to better assure the effectiveness of the competencybased curriculum. To create a system that will develop and support the training of master teachers, we recommend that AMCs) create academies of medical education. Over 60 centers currently have developed these academies.19 The 2 main purposes of these academies are to elevate the teaching skills of all faculty members and support and promote clinician educators in their academic activities to advance curriculum development, medical education and educational research.19 There are 7 steps that have been outlined in the literature to guide AMCs in the creation of these academies. First, the AMC must rally support for the academy and build a consensus around the concept that education must be prioritized on the same level as the research and clinical enterprise. Second, all educational activities must be systematically recorded in educational portfolios for each master teacher to appropriately quantify the amount of work that has been completed. Third, the educational activities must be
aligned with the priorities of the department and the institution. Fourth, teaching performance must be measured and the quality must be monitored. Fifth, master teachers should be given appropriate feedback to improve their performance and curriculum. Sixth, the strengths, weaknesses, threats and opportunities to the educational programs should be analyzed and quality improvement must take place. The AMC should assess promotion pathways, incentives for excellent teaching and the compensation structure to encourage excellent teaching.19 Resident education academies should also be created and modeled after the faculty academies. These academies serve several purposes. First, they are a key resource for developing the teaching of residents. Second, they have a structure that can be used to coach residents to be better teachers. Third, they would improve resident skills so that when they graduate and become faculty they would already have baseline education in competency-based methodology.20
Transparent Funding for Medical Education There is an increasing urgency to clarify the funding for medical education. The current system is not sustainable. Although there would always be a talent pool that would be attracted to medicine because of scientific curiosity and the desire to ease human suffering, the current system that asks students to incur huge debt will negatively impact recruitment of the best talent. The cost of medical education is increasing at an alarming rate. The tuition at medical schools now averages $34,540 for state schools and $53,714 for private schools, and the average debt of a graduating medical student now stands at $176,348.21 Additionally, the general public helps fund medical education through paying taxes (for state-subsidized schools) and through Centers for Medicare and Medicaid Services (CMS) funding for GME. All told, large amounts of money are being spent on medical education at both the graduate and the undergraduate level, yet very few schools state that they have “enough money” to support education. Why is there such a large disconnect between what is being purported to be given for medical education compared to what is being spent? The funds flow accountability at most AMCs is not very transparent. Medical school deans and hospital administrators are responsible for multiple missions, and they usually have considerable flexibility on where their budget's monies are actually spent. In fact, the Indirect Medical Education payments for GME do not solely target the education mission but also operating costs associated with being a teaching hospital, such as standby capacity, highly specialized training and services, and the complexity of cases often seen more frequently at AMCs. At the UME level, as most medical education programs involve medical students in experiential activities that minimally disrupt normal operations, the money devoted to “fund
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education” has a myriad of potential justifications for its distribution. Despite the educational dollars given to hospitals and medical colleges, few academic physicians would report that they were “paid to teach.” In addition, while residency program directors would have a budget for expenditures, such as administrative costs, recruitment and salaries, there is little if any money for curriculum development or faculty development unless the institution has grant funding, a large endowment or philanthropic revenue sources. Medical educators who oversee programs at the undergraduate and graduate levels are given budgets from the dean's office or their department with little understanding of the amount of money coming into the institution compared to how much is actually dispensed for their program. This financial state of medical education begs the question, where is the money? Meanwhile programs at all levels are under increasing pressure to develop comprehensive, competencybased programs that address a holistic approach to medicine. No longer must these programs just teach basic science and clinical patient care as discussed previously. They must also train physicians who can lead interprofessional teams—a content area that was not previously emphasized—in a competency-based format that inherently requires increased direct observation and faculty time. To frame this challenge, programs are being asked to significantly reformulate their educational focus with fewer funds then were previously allocated for maintaining the status quo. In the year 2000, The AAMC published a position paper articulating the need for “mission-based” management in AMCs via several different activities.22 First, faculty efforts for clinical activities should be measured. Second, the institution should decide on a metric for this effort such as a revenue value unit.22 Third, benchmarks should be established to compare faculty performances.22 Finally, an analysis of the extra factors that could affect the interpretation of the data and an analysis of faculty contributions to the clinical mission not captured by metrics should be performed.22 We would contend that this mission-based management should be expanded even further in a more specific and transparent way to the educational mission. When allocating funds, it is difficult to accurately assign value to the educational mission.23-25 More often, funds are primarily distributed based on clinical productivity and the teaching of medical students and residents can negatively impact such productivity. This negative impact may be especially detrimental to primary care faculty, whose sole method for generating clinical productivity is through seeing and billing high volumes of patients. These primary care physicians also tend to perform a large percentage of the teaching at AMCs.26 One method for attempting to quantify educational effort is the educational value unit (EVU). In an EVU system, educational activities, such as lectures, small
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group teaching, physical diagnosis teaching, morning report participation, and conference lecturer are quantified in some explicit fashion. Moreover, time required of educators who are also administering educational programs is also quantified. In such a system, the EVU and the clinical relative value unit can be compared and accounted for when making funding allocations. The Medical University of South Carolina successfully created such a system.26 The divisions within the Department had 40% of their budget allocation dependent upon how many EVUs their faculty produced. The effect was that there was increased participation in educational activity in a budget neutral fashion.26 GME in the Unites States receives support of around 15 billion dollars per year from the federal government, but many question the need for continuing this funding level.27 For those involved in medical education, the time is right to demand transparency and accountability for those GME dollars earmarked for medical education. We contend those dollars must be more clearly linked to efforts directly related to training physicians and should not be comingled with the larger AMC's budget. Sponsoring institutions should receive those dollars and be transparent on how those dollars are supporting the specific goals of the training programs, training the physicians needed for the ever-evolving 21st century healthcare system. With this transparency comes accountability. Institutions and programs have an obligation for creating “high value” education. This change would require medical educators to be good shepherds of these educational dollars and being “cost-conscious” on how educational dollars are used.
Summary The framework created by the Commission on Education of Health Professionals for the 21st century should be adopted to alter our culture from one where the educational system and healthcare system are in competition to one where they are both patient centered.4 Learners must be trained to be experts in the pathophysiological aspects of a disease and effective members of interprofessional teams that are responsive to the needs of individual patients, their families and the communities in which they live. This training can be accomplished through a competency-based training system that uses milestones and EPAs to assess and evaluate learners. Asynchronous learning opportunities may be a way of either accelerating training or personalizing learning within a set timeframe. Increased exposure to ambulatory medicine in a team-based patient care environment will be key to adequately assessing learners in all of the competencies. This competencybased training will require a cadre of master educators who are skilled in a broad range of mentorship, teaching and evaluation techniques to be able to teach all aspects of physician development. To create and sustain this educational workforce, academies of medical education THE AMERICAN JOURNAL VOLUME 351
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will be necessary. These academies will provide a center for faculty development, educational research and innovation. The funding of medical education, at both the UME and the GME levels, must be better understood and reconfigured for transparency, accountability and long-term sustainability to fund the increased supervision and observation necessary to support a competency-based educational system. Our culture must realize that the investment in these resources is not to fund education for education sake, but to invest in the creation of physicians who are leaders with the attributes necessary to continue the evolution toward a patient-centered healthcare system.
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13. National Resident Matching Program, Results and Data. 2015 Main Residency Match®. National Resident Matching Program, Washington, DC, 2015. 14. Kwiatkowski T, Rennie W, Fornari A, et al. Medical students as EMTs: skill building, confidence and professional formation. Med Educ Online 2014;19:1–7. 15. Tekian A, Hodges BD, Roberts TE, et al. Assessing competencies using milestones along the way. Med Teach 2015;37:399–402. 16. Telio S, Ajjawi R, Regehr G. The Educational Alliance as a framework for reconceptualizing feedback in medical education. Acad Med 2015;90: 609–14. 17. Geraci S, Babbott S, Hollander H, et al. AAIM report on master teachers and clinician educators part 1: needs and skills. Amer J Med 2010;123:769–73. 18. Geraci S, Kovach R, Babbott S, et al. AAIM report on master teachers and clinician educators part 2: faculty development and training. Amer J Med 2010;123:869–72. 19. Berman J, Aizer J, Bass A, et al. Creating an academy of medical educators: how and where to start. Hosp Spec Surg 2012;8:165–8. 20. Moza R, Villafranco N, Upadhya D, et al. Academy of resident educators: a framework for development of future clinician-educators. J Grad Med Educ 2015;7:294–5. 21. Medical Student Education: Debt, Costs, and Loan Repayment Fact Card 2014. https://www.aamc.org/download/152968/data/debtfactcard. pdf. Accessed July 6, 2015. 22. D'Alessandri Albertsen P, Atkinson B, Dickler R, et al. Measuring contributions to the clinical mission of medical schools and teaching hospitals. Acad Med 2000;75:1232–7. 23. Watson R, Romrell L. Mission-based budgeting: removing a graveyard. Acad Med 1999;74:627–40. 24. Nutter D, Bond J, Coller B, et al. Measuring faculty effort and contributions in medical education. Acad Med 2000;75:199–207. 25. Mallon W, Jones R. How do medical schools use measurement systems to track faculty activity and productivity in teaching? Acad Med 2002;77: 115–23. 26. Clyburn E, Wood C, Moran W, et al. Valuing the education mission: implementing an educational value units system. Am J Med 2011;124: 567–72. 27. Berwick D, Wilensky GR, Alexander B, et al. Graduate Medical Education that meets the nation's health needs. Inst Med 2014; 1–4. www.iom.edu/GME. Accessed June 7, 2015.
From the Department of Medicine (DJD, EBC), Medical University of South Carolina, Charleston, SC; Office of Graduate Medical Education (DWB), Vanderbilt University, Medical School, Nashville, TN; Department of Internal Medicine (JGW), Penn State Milton S. Hershey College of Medicine, University Park Regional Campus, State College, PA. Submitted July 6, 2015; accepted October 12, 2015. The authors have no financial or other conflicts of interest to disclose. Correspondence: Deborah J. DeWaay, MD, Medical University of South Carolina, 96 Jonathan Lucas St, MSC 623, Charleston, SC 29425. (E-mail: [email protected]).
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