43rd Walter J. Zeiter Lecture, 2011 The Pursuit of Excellence in Physiatric Education and Practice
2012; Wiley; Volume: 4; Issue: 10 Linguagem: Inglês
10.1016/j.pmrj.2012.08.009
ISSN1934-1563
Autores Tópico(s)Diversity and Career in Medicine
ResumoI want to thank our Academy for bestowing upon me the honor of delivering the Forty-Third Walter J. Zeiter Lecture. This lectureship is named after Dr. Zeiter, who is one of the founding fathers of physical medicine and rehabilitation (PM&R). He was executive director of the Society of Physical Therapy Physicians, which, during his leadership, was renamed the American Academy of Physical Medicine and Rehabilitation (AAPMR) in 1945. He was 1 of the 14 founding members of the American Board of Physical Medicine (ABPMR), which defined our field as an independent specialty within the medical community [1]. Thus, Dr. Zeiter was among the first to recognize the importance of the certification of PM&R expertise and competence. I am truly humbled and privileged by having this opportunity to share with you my thoughts and ruminations about a topic about which I am most passionate: our education and formation as physiatrists and their relevance to the current and future needs of our society. I will not try to convince you that what I will discuss is what training in PM&R should be. I will merely share with you my opinions and musings about the status quo and offer ideas that hopefully will start more conversation about how we can sustain and possibly even exceed excellence of physiatric training. And although this lectureship honors the legacy of Dr. Zeiter, I dedicate this presentation to my trainees, past and present, who have inspired and challenge me every single day to be a better educator, and whose training that I direct serves as a means by which I can pay homage to my own teachers. One thing that I learned early on was that change is constant. We already have witnessed the vicissitudes of health care coverage during the last decade but are still wondering how other looming changes, such as the creation of accountable-care organizations, and the institution of bundled payment and value-based performance, will affect the provision and reimbursement of postacute rehabilitation services, especially when the Patient Protection and Affordable Care Act takes full effect. Already, we are experiencing the ramifications of policy changes on GME and are expecting more to come within the next year. It is very unlikely that Congress will remove the cap on Medicare's GME support, initially put in place after a 1997 consensus statement by 6 major medical organizations declared that the United States was at risk for an oversupply of physicians [2]. Recently, some congressional Democrats advocated lifting the cap and expanding the number of Medicare-funded GME positions by 15%, but Congress did not agree [3]. In 2010, Medicare contributed $9.5 billion to teaching hospitals to support approximately 100,000 trainees through direct or indirect GME payment that is based on the number of residents a hospital employs [3]. Last year, the National Commission on Fiscal Responsibility and Reform, more popularly known as the Simpson-Bowles Commission, was charged with identifying policies to improve the fiscal situation in the medium term and to achieve fiscal sustainability during the long term. One of its major recommendations is to reduce Medicare's GME payments [4]. By decreasing indirect medical education payments by half, from 5.5% to 2.2%, a savings of as much as $60 billion during a 10-year period by the year 2020 can be realized. Next week, the bipartisan Joint Select Committee on Deficit Reduction, coined the "supercommittee," is expected to submit its recommendations to be acted upon by Congress before the end of this year. Depending on how Congress votes on the proposed budget cut by approximately $1.2 trillion during the next decade, GME funding is at risk of being sharply cut, along with reductions in defense and domestic spending. If Medicare reduces its support of GME, training programs will likely decrease the number of trainees and produce fewer practicing physicians in the future, which seems ironic because 1 of the likely outcomes of the Patient Protection and Affordable Care Act is a significant increase in the number of newly insured patients. Will we eventually have enough physicians to care for more patients? Recently the Accreditation Council of Graduate Medical Education (ACGME) surveyed the 680 Designated Institutional Officials that represented 8887 residency and fellowship programs to understand the potential impact of reduction on GME funding [5]. The respondents were asked to indicate how federal funding would affect their institutions' training programs in 3 scenarios: first, funding would remain the same; second, funding would be cut by 33%; and, third, funding would be cut by 50%. As expected, the respondents estimated a significant reduction of programs and training positions in the 2 latter cases. In the 50% reduction scenario, approximately 1749 residency and fellowship programs would be discontinued. This would translate to a reduction of more than 22,000 training positions. If this scenario were to materialize, in 2021, when more than 20,222 students are expected to enter medical schools accredited by the Liaison Committee on Medical Education, only 19,711 residency positions would be available. This discrepancy is further magnified when approximately 2500 osteopathic graduates and 7000 international medical graduates apply for the same residency positions. It is alarming that continuing to receive the existing GME support may be the best outcome medical educators can hope to achieve. Along with these other changes, there has also been a steady shift in the demographics of the United States. We are not only a bigger country, but we are also an aging population that will experience health issues ranging from cardiovascular problems to degenerative musculoskeletal conditions that will require medical and rehabilitative attention. Persons with disabilities are living longer, and their impairments may further deteriorate unless preventive measures are implemented. We are now more Hispanic and Asian. One-half of schoolchildren belong to minority groups [6]. We are less wedded to traditional families and more embracing of same-gender couples and several generations living under 1 roof. We are more aware of mixed racial identities. With this demographic shift come changes in values, belief systems, and priorities. Now more than ever, the need to master cultural competency is paramount. We are also dealing with a new breed of health care consumers. With the advent of the Internet and other technological advances, there has been an increased expectation of obtaining needs and wants in a shorter amount of time. Receiving low-cost, nonurgent health care services at a retail clinic is an attractive and low-cost alternative to traditional long waits in a physician's office [7]. Recently, Walmart declared it goal of becoming the largest provider of primary care service [8]. Consumer options have increased dramatically over the years, and in the background of a less-than-stellar economy, more emphasis has been placed on the value of purchases and services. Health care consumers are now value shoppers, willing to make trade-offs, like accepting smaller networks of doctors to save money on insurance premiums [9]. Over the years, we have witnessed remarkable advances in clinical care and research. Almost every day new discoveries about disease mechanisms and therapies are being reported. There has been a greater awareness of the need for evidence-based physiatric practice. Conventional rehabilitation interventions through therapeutic exercise and modalities have been complemented by the introduction of new technologies, and physiatrists are rapidly embracing them. Recent new mandates by the ACGME also should be noted. Limitations in duty hours were implemented several years ago amidst the growing concerns about medical errors and resident well-being [10]. Its intent is laudable, but the lack of convincing data demonstrating achievement of its chief goal of enhancing safer patient care has made it more prone to scrutiny by its critics [11, 12]. There are concerns that patient care may actually be compromised because of the potential for lapses in continuity of care as the result of the apparent "shift work" nature the duty hours that restriction has engendered. Concerns about the negative impact on training that appears to have become a series of scheduled episodic patient encounters, rather than a fluid experience, have also been set forth. Some lament the loss of the total immersion in patient care, so critical in the formation of a well-trained physician. The challenges brought forth by the implementation of the duty hours restriction has been valiantly met by many training programs but at a significant financial and human resources cost to training programs. Underlying all these real and anticipated changes in health care and educational policies, practice, and values, there remain constant realities that anchor our identities and aspirations as a medical specialty. Despite all the advancements in health care, people will still suffer from injuries and diseases that will lead to impairments and disabilities. They will demand the best care possible to restore quality of life and participation in the community. In the long term, they will need expert attention, and hopefully these individuals will entrust physiatrists to be the managers of their care. And, despite the cuts in reimbursement and resources, we will be expected to continue to provide high-quality, safe, timely, patient-centered, cost-effective, and efficient physiatric care. Patients deserve trusted experts and competent healers who are not only dependable and knowledgeable but also culturally competent, and trustworthy. Our patients will expect physiatrists to apply the scientific foundation of contemporary rehabilitation medicine and the other medical fields related to their disabling conditions, including technological advances, that can alleviate their pain and suffering and allow them to be able to do more for themselves and participate in society. Through training, we need to prepare the physiatrists of the future for this demanding role. In the background of these evolving events in our society, I challenge you to reflect on your own education and training, and how it has prepared you for your current careers. What components of our training are vital in ensuring future success as a competent and compassionate physiatrist? What should we do differently to ensure the relevance of our field to our society? As the needs and demands of our patients evolve, as legislative policies are enforced, as resources become more scarce, and as medical knowledge advances, clinical practice should also evolve and adapt. But before this evolution and adaptation in the clinical setting occurs, a transformation in the content and method of training needs to occur. Before any curricular revision, a needs assessment is necessary so that any modification will be meaningful and useful to practicing physiatrists. This underscores the importance of maintaining a strong link and open communication line between educators and practitioners and other stakeholders in the workplace, including patients and health care administrators. Currently there are more than 77 PM&R residency programs in the country with 1228 residents and fellows [13]. Each year, we graduate more than 400 trainees who move on to various jobs across the county. The majority, approximately 68%, will be working in a private practice setting or will be hospital employed, 9% will work at a Veterans Affairs or other military facility, and 13% will be in an academic-based practice [14]. Although we have this information regarding the practice settings, little is known about the actual needs of physiatrists in practice. This, coupled with the many changes I have discussed previously, beg us to ask the questions: Have we done enough to train physiatrists for what they need in their practices to safely and effectively care for patients? What additional skills do they need to remain valuable care providers? In my opinion, we have done an excellent job of educating physiatrists, which is why our specialty has experienced an impressive growth during the last few decades. For physiatric training to further develop, however, we need to expand the desired knowledge, skill, and attitudes that trainees must achieve by the completion of training. A good starting point is reframing these 3 learning domains in such a way that they are more descriptive and translatable to specific competencies. I am proposing that they be looked upon not as separate learning attributes but as intimately related competencies, loosely inspired by Bloom's taxonomy of learning domains (Table 1) [15]. Physiatric knowledge includes the recall or recognition of scientific and clinical facts and concepts in addition to the ability to integrate knowledge from multiple sources. In the new framework, which I shall label as cognitive competency, it should also highlight the acquisition of new knowledge in a specific context, such as deciding on the best treatment approach for a particular patient, who has his own set of beliefs and values, within a particular health care system that has its unique set of available resources. Physiatric skills are not limited to what procedures are done, but include how a task is performed. This domain is usually measured in terms of speed, precision, and techniques in execution. In the new framework, which I will call psychomotor competency, skills are not limited to procedures but also include mental and behavioral characteristics, such as system redesign. Attitude, or affective attributes that refer to emotions, values, and motivation, among others, is perhaps the most difficult to teach and evaluate among these 3 learning domains. In the new framework, physiatric attitude refers not only to professional demeanor and attitude toward work but as well as to interpersonal relationships with persons with disabilities, their caregivers, and members of the rehabilitation team. It also represents cultural competency and appreciation of priorities and values of other health care partners, including hospital executives and payors. Thus, I shall label it as a relational competency. Although these 3 classic learning domains are important, their integration into interlocking competencies that guide physiatric practice is even more vital. Furthermore, there needs to be an effective means of transferring of learning from the conference rooms to the nursing units and clinics into the real world, where physiatrists need to continuously demonstrate and practice these cognitive, psychomotor, and relational competencies. Alongside the acquisition of these competencies, self-reflection and assessment need to be emphasized. The desired end-product of self-reflection, of course, is life-long learning to achieve mastery beyond competence and to apply them to safe and effective patient care. We are already required to do so through the Maintenance of Certification requirement of the American Board of PM&R, and in which we are assisted by the efforts of both the board and the AAPM&R. As I have mentioned previously, I am convinced that the current PM&R residency curriculum, exemplified by the ACGME program requirements, is already excellent and sufficient to graduate residents who will demonstrate enough competence to enter practice without direct supervision. However, we should always strive to continuously improve physiatric instruction so that we may produce even more competent graduates on their way to achieving mastery of various skills and competencies. What we need is not a dramatic overhaul of the current physiatric curriculum but a re-focusing of priorities to more effectively implement the ACGME program requirements. By revisiting the curriculum in the context of the challenges to graduate medical education, we can just fine-tune the existing training infrastructure to supplement what may be perceived as underemphasized areas of training in clinical and nonclinical areas, such as medical administration, informatics, and new procedures and technology. Other potential enhancements in the training curriculum require more thought even before vetting by accrediting bodies, such as the ACGME. Within our own specialty, we will have an opportunity to revise our program requirements through the work of the ACGME Residency Review Committee for PM&R in the coming years. I am confident that the Residency and Fellowship Program Directors Council of the Association of Academic Physiatrists (AAP) will continue to be an active forum that provides thoughtful ideas whenever the RRC seeks its input. We need to refocus training to reflect the increased emphasis in outpatient care, but not at the expense of losing expertise in inpatient and consultative care. On the basis of a 2007 survey by the AAPMR [16], the top 3 areas of physiatric care, namely, electrodiagnosis, pain management, and orthopedic rehabilitation, are rendered mostly in outpatient settings, but much of physiatric training occurs at hospital-based settings largely because of funding. One clear opportunity is to restructure elements of the curriculum and methods of teaching to facilitate transfer of skills learned in academic centers and training hospitals to the private practice setting. This can be done through direct experience, such as incorporating more encounters in private offices, by linking the training efforts to the clinical activities of the faculty, and by providing more emphasis to practice management during a clinic rotation. No significant time investment will be needed to create an excellent teaching activity. During the clinic encounter, by going beyond teaching about the physiatric management of various conditions, the supervising faculty can incorporate instruction on appropriate documentation and billing, among other skills that residents will eventually be able to generalize in their future practices. Other changes that can be introduced include the provision of longitudinal experiences through multiple settings. For various reasons, many patients with severe impairments and disabilities no longer fulfill the Center for Medicare Services criteria for admission to an inpatient rehabilitation facility. An excellent illustration is that of a patient in a minimally conscious state after a severe traumatic brain injury who is admitted to a long-term acute care hospital instead of an inpatient rehabilitation facility. Unless a rotation in these facilities exists, residents and fellows will miss the first-hand experience of caring for the myriad complications that occur along the course of recovery. If a continuity clinic does not exist, trainees will miss the opportunity to learn about the delayed complications of severe brain injury and how to advocate for these individuals as they struggle to reintegrate into their social and community networks. Consequently, the learning experience becomes episodic. As the knowledge base in PM&R and related fields expands, there will be a lot more that future trainees will have to learn and assimilate. Physiatrists should remain curious and open to assessing and adopting novel therapies that can better help their patients. Gradually, this new knowledge and technical skill are being incorporated into the physiatric curriculum, but it appears that most of the instruction about new treatments and technology are provided by pharmaceutical or device industries, which, needless to say, have a financial interest in promoting their products. We need to find a way to deliver new knowledge and skills as they develop, in a fair and balanced manner. The AAPMR has led the way by providing its membership a rich catalog of educational resources through its many initiatives, such as Knowledge NOW. Concurrent with developments in therapeutics, we need to continue to build our research capacity by providing exposure and support for research training during residency and fellowship. Lack of funding and the relatively short time spent during training will not make it realistic to expect significant research output after only 3 or 4 years; but it can set the stage for possible future careers in research or, at the very least, can inculcate in trainees the "research-mindset" of curiosity, inquiry, and critical appraisal that will help guide clinical decision making. The AAP provides additional resources that encourage research among trainees and early career faculty. The practice of PM&R is involved not only in the management of functionally limiting conditions but also emphasizes prevention of complication of disability from secondary conditions. Thus, it is our specialty that needs to promote health and well-being of persons with disabilities and teach future physiatrists how to be effective "disability managers," especially with the emerging popularity of the concept of "medical home for persons with disabilities." We need to teach our trainees how to advocate for our specialty in the media and to consumers to more clearly define what we are and what we can do for our patients. But, given the already packed 3-year curriculum, how much of these innovations can still be reasonably incorporated into the physiatric curriculum? Is it reasonable to even consider lengthening the duration of training, with its financial implications, particularly in GME funding and delaying income generation to repay student loans? It may discourage talented medical students from pursuing a career in PM&R. Perhaps a more reasonable solution is to review the current curriculum and weed out the less meaningful training elements to make way for new and more useful content. Every so often, we have the opportunity to modify the curriculum content through the efforts of the ACGME residency review committee, which is given the task of reviewing and, if needed, revising the program requirements. Another consideration is designing a curriculum that goes beyond traditional clinical rotations in hospitals, because rotational experiences are not necessarily the equivalent of educational content. Learners learn in different ways and at different speeds. It is possible that a resident will have achieved the goals and objectives of a 2-month rotation in half the time. In that scenario, if the curriculum structure were more flexible, it would be in the best educational interest of the trainee to be assigned to another rotation with a new set of educational goals and objectives and in keeping with the progressive nature of training. Unfortunately this can be a logistical nightmare, not only from the point of view of coordinating the rotation schedules of several residents, but more so from the funding perspective, as resident salaries are tied to hospital operations and the number of work hours. Woefully, funding and scheduling restrict the implementation of what could have been a logical advancement of learning one competency to another at the next level of difficulty. To receive continued accreditation, training programs are bound to the program requirements set forth by residency review committee. This is true for all ACGME-accredited programs and is a means of standardizing the educational experiences to ensure the quality of training and safe and effective patient care. Perhaps this "quality control" is a reverberation of the Flexnerian legacy in medical education that accelerated reforms to raise the quality and standards of medical education in the early 20th century [17] and has become the norm. However, in true Flexnerian spirit, we should re-evaluate whether traditions and practices are worth holding onto, or whether we should design new curricula and pedagogies to usher in a new future for residency education. In recent years, some medical schools have introduced innovations to shift focus to the needs of the learners. Several schools here and abroad have implemented a combined baccalaureate/MD program that spans 7 to 8 years of total training [18]. I am proud to share with you that I am a product of such innovation, as I joined the Integrated Arts and Medicine Program of the University of the Philippines straight out of high school [19]. I will always treasure that experience, especially because my very first day in college was spent not in a classroom but at the bedside of a patient at the Philippine General Hospital medicine ward. After that patient encounter, we had a debriefing in which my preceptor told me, and I paraphrase, "… from now on, anything that you will learn and anything that you will do will be for that patient and the many others like her …" It was an advice difficult to digest for a 17-year-old student, but it was one of the most important principles that has guided me through my journey as a physician and educator. Perhaps residencies can follow these innovations. For example, the traditional 3 years of PM&R training can be compressed to about 2 years of learning core physiatric elements and another year of electives for pursuing interests in disciplines not usually part of the traditional curriculum, such as medical informatics, health care advocacy and administration, or rehabilitation engineering. This approach is more learner centered. It will also allow individual programs to play up their strengths in clinical or research areas. The closest curricular innovation that we have right now is the clinical investigator pathway [20], which extends residency training to 4 years, that is, 2 spent on clinical rotations, and the other 2 on research. This is a very attractive learner-centered approach to education but will be almost impossible to implement without appropriate funding support. Perhaps Medicare GME payment can be shared by the sponsoring hospital and training institution to support this endeavor. Implementing creative methods of educational delivery should be encouraged not just for novelty's sake but for increasing the effectiveness of teaching. Should education always depend on lectures or noon conferences? Should journal clubs always be presented in the same format? PM&R residencies are accountable for graduating trainees who are ready to enter practice without direct supervision. Rather than a global and subjective assessment of competence and readiness for independent practice, training programs should embrace near-future efforts to switch to competency-based evaluation. The ACGME has also embarked on the Next Accreditation System, which features the Milestones Project [21] that creates a framework of observable behaviors and attributes associated with progressive levels of development during residency training. It describes performance levels that residents are expected to demonstrate for skills, knowledge, and behaviors in the general competence domains. Thus, milestones will assist residency programs in planning improvements in the curriculum to create better learning opportunities for residents and for evaluating resident performance. To supplement a summative evaluation, the teacher should also provide feedback. In my opinion, feedback is more valuable and meaningful for the learner because it deals with a particular behavior. For it to be effective, however, feedback should be given during or right after the action takes place. Time-locking the feedback to a specific observed behavior makes it a useful formative, as opposed to summative, tool for performance improvement. Linking elements of resident's clinical performance with evaluation is a novel way of teaching practice management. For instance, a resident's rotation grade will partly depend on clinic efficiency, measured by the number of patients seen during a particular time or by correct coding judged against the appropriateness of documentation; on the occurrence of preventable medical errors or readmission to acute care attributable to preventable causes; active participation in continuous quality improvement (QI) activities, such as designing and implementing a project, and not just patient attending a QI meeting; and patient satisfaction survey. These are all unusual and controversial but, if you look at them more closely, more meaningful and useful for the careers that we are preparing residents for. Along with teaching the competencies of medical knowledge and patient care, we also need to teach the more abstract competencies that revolve around values and attitudes, including professionalism, compassion, and relational skills. These can be taught in classrooms, but not as effectively as through modeling after a mentor. In Greek mythology, Odysseus left his older friend Mentor in charge of the upbringing of his son, Telemachus, when he left for the Trojan War. The word mentor has been adopted in English as a term meaning someone who imparts wisdom and shares knowledge. A mentor lends expertise to less experienced protégés, to help them enhance education, advance careers, and build networks. In medicine, it is typically an older, more experienced physician, but that should not be the case. Mentorship from people other than physiatrists—researchers, hospital executives, among them—plays an important role in the transfer of knowledge and skills and the creation of future possibilities. Informally we have all encountered many nonmedical mentors long before we entered the field of medicine. They have taught us important lessons, shared ideas, and shaped our values that have nurtured our personal formation and guided our professional growth. At this point of my presentation, I want to take a few moments to acknowledge some important medical and nonmedical mentors. My high school English teacher, Mr. Emmanuel Leviste, who unleashed my creativity by encouraging me to challenge traditions and baseless practices, which, back then, was quite radical for a teacher in a Catholic high school. I want to ackno
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