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Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.orgwww.entnet.org

Empowering otolaryngologist–head and neck surgeons to deliver the best patient care

Section for Residents and Fellows-in-Training (SRF)

PanelAllison G. Ordemann, PGY4, University of MississippiRobert Morrison, PGY5, University of MichiganFiyin Sokoya, PGY3, University of ColoradoMeghan N. Wilson, PGY7, Children’s Hospital of Philadelphia

Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org

Many thanks to…

Kara Davis, PGY4, University of PittsburghPeter M. Villa, PGY4, Washington University-St. LouisErynne Faucett, PGY5, University of ArizonaCaitlin McMullen, PGY6, University of Toronto



UpdatesSection for Residents and Fellows (SRF)AAO-HNS/F

Meghan N. Wilson, MD

Chair, AAO-HNS/F Section for Residents and Fellows


Why

should you encourage your trainees to get

involved?

SRF Updates


Engagement Burnout Reduction Knowledge of Policy Knowledge of need for Advocacy Networking Education Leadership Management Skills Recognition National Impact Shape the future of training Shape the future of our specialty Integrate local and national involvement Humanitarian opportunities Giving back Political knowledge Business Management skills

SRF Updates

SRF Leadership Committee Positions Clinical Practice Guidelines Core Grant reviewer Tasks forces Research opportunities Planning educational opportunities Future Academy leadership positions Representation to other otolaryngology

societies Advocate to other residents Gain communication skills Learn about what it takes to move our specialty

forward Hear great speakers Volunteerism Improve writing skills with articles, etc

Benefits to Residents/Fellows


Trainees who are more engaged with specialtyA voice from your programGreater understand needs for future impact in our specialty

Skills gained are brought back home Leadership, Management, Communication….

Increased scholarly activity (CORE reviewer, CPGs, Committee initiated research)

Professional fulfillmentBurnout reduction

SRF Updates

Benefits to YOU!


SRF Updates

The future of our profession depends on active, engaged and experienced trainees!


SRF Updates

Now What?


Encourage them to seek mentorsApply for an Academy Committee (Jan 1st)

Attend the Spring Leadership Forum (March 2016)

Free registration Travel Grants (AKA Resident Leadership Grants)

available: $350Apply for an appointed officer position (late winter) or run for an elected position at the Annual meting

So many more options!Email me: [email protected]

SRF Updates


Find a Mentor or MenteeEasy sign upResidents/Fellows can be mentors too!Access through ENTConnect site

SRF Updates


SRF Updates


SRF Updates

Resident Leadership Grants (RLG) will be available. We will let you know when to apply!


Women in Otolaryngology

Exemplary Senior Trainee AwardAnnual award Outstanding female senior resident

penultimate or final year of residency or fellow. Demonstrate excellence in at least one of following areas:

leadership, research, education, and/or mentoringApplication due: March 15, 2016See me or email for application information

New Award Opportunity



SRF SURVEYAMERICAN ACADEMY OF OTOLARYNGOLOGY – HEAD AND NECK SURGERY


Annual SurveyApproximately 40 questions – 10-15min to complete

Response rate

2016 is coming up….Please encourage and set aside time for this to be completed!!

SRF Survey

~30%


AlbanyBoston UniversityBuffaloEinsteinGeisingerLoyolaMaryland Mayo – RochesterNorthwestern

Missing Program Reps

NYURutgers UC IrvineUCSD UT HoustonUT San AntonioUniv WashigtonWisconsinWayne State


Meghan Wilson [email protected]

Thank You!

Peter Vila, MDSRF Vice Chair

Kara Davis, MDSRF Information Officer


Design• 45 Questions

• 4 Demographic• 8 Quality Improvement Training• 12 Rounding Practices• 21 Resident Education and Protected

Didactic Time

• Likert scale questions

• 87 Program Directors and 106 Program Coordinators

SRF-SUO Survey


Section for Residents and Fellows

SUO SurveyResponse rate: 24 Program Directors (28% response

rate)46 Residents (44) and Fellows (2)

Limitations: Contact information unattainable from 19

Program DirectorsIndirectly contacting residents via

Program Coordinators


Resident Education and Protected Didactic Time

“To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all”. –Sir William Osler


Does your program follow an organized didactic curriculum?

• 100% of Faculty and 89% of Trainees responded YES

• Faculty and chief residents determine curriculum

• Lecture series, M & M, Journal club, QI, Temporal bone lab, Reading schedule, Board Prep, Anatomy Lab


Faculty

Trainee

Faculty

Trainee

Faculty

Trainee

Faculty

Trainee

Faculty

Trainee

Faculty

Trainee

Jou

rna

l Clu

bR

ese

arc

hE

NT

facu

lty

None <1 per month 1-2 per month 3-4 per month >4 per month


Academy U Products & Text Books utilized in didactic curriculum

Home Study Course (73.5%)COCLIA ( 48%)Academy Q (31%)Clinical Practice Guidelines (30%)

Clinical fundamentals (8%)MOC courses (6%)COOL courses (2%)

Cummings (42%)Baileys (40%)

KJ Lee (4%)Pasha (2%)


Agreement statement – “Protected time for didactics is important for resident

education”

• The majority of residents and faculty strongly agreed with this statement

• Only 6% of residents and 4% of faculty disagreed


• “It should rarely take priority over clinical learning. It should be used to scaffold clinical concepts, and is not meant to replace time in the OR or wards.”

• “Time, know-how, and engagement is the issue. Staff need time to learn how to teach, to make educational offerings, and to deliver them. Residents need to be available in a critical mass to make it worth the time and effort. All this is in competition for work-week time with operating and work-hour restrictions.”


How many hours of protected time for didactics are residents given per week at

your institution?

0 1-2 3-4 5-60.0%

20.0%

40.0%

60.0%

80.0%

100.0%

2.2%

26.1%

63.0%

8.7%8.3%16.7%

58.3%

16.7%

Trainees Faculty

Hours per week


How many hours of protected time for didactics are residents given per week at

your institution?• “Monday mornings 7-8 am. Cases often start

at 7:30am, so chiefs usually leave to get the case started”

• “2 hours every Wednesday evening”

• “Monday mornings from 7 to 11 or 12”

• “MWF 7-8am conference. It is not resident free time, but instead lecture format. “


Agreement – “This is an adequate amount of protected time”

1 2 3 4 5 6 70.0%

20.0%

40.0%

60.0%

80.0%

100.0%

8.9% 13.3% 15.6% 17.8% 20.0%13.3% 11.1%

4.2% 8.3% 8.3%16.7%

8.3%

25.0% 29.2%

Strongly Disagree--------------Neutral----------------Strongly Agree

Trainees Faculty

44% Residents63% Faculty


How frequently do clinical duties such as rounding, OR, or clinic time interfere with

resident protected time?

1 2 3 4 5 6 70%

20%

40%

60%

80%

100%

7%

20% 24%

7%

26%

11% 7%17%

33%21%

4%13%

4% 8%

Never----------------------Neutral-----------------------------Always

Trainees Faculty

FACULTY


How frequently do clinical duties such as rounding, OR, or clinic time interfere with

resident protected time?

• Infrequently: 71% of faculty versus 51% of residents

• Frequently: 25% of faculty versus 44% of residents

OR most commonly cited reason for missing didactic time 1/3 residents and 1/5 of faculty Many citing need to do so for Key Indicator

cases

Consults & Clinic less likely


• “…approximately 1/3 of residents are absent due to clinical responsibilities.”

• “Affects seniors … about 50% of the time. ”

• “…about 75% of the residents at lectures.”

• “It is challenging to adequately protect didactic time for residents -- it is not attractive for many mid-level providers such as physician assistants and nurse practitioners to cover the pager during this time”


Agreement- “The amount of protected time given for didactics has a positive

correlation with resident in-service scores”

1 2 3 4 5 6 70%

20%

40%

60%

80%

100%

2%9% 13% 13%

28%17%

9%4%

29%

13% 17% 17%8% 3%

Strongly Disagree-----------Neutral------------------Strongly Agree

Trainees Faculty

54% resi-dents28% faculty


Agreement- “The didactic curriculum at your institution is outdated”

1 2 3 4 5 6 70%

20%

40%

60%

80%

100%

4%

24% 28%17% 17%

6% 0%

33% 33%21%

4% 4% 0% 4%

Strongly disagree----------Neutral------------------------Strongly agree

Trainees Faculty

56% residents88% faculty


• “I would like to see didactics based on a structured curriculum….practical didactics would be helpful for more utilization of our anatomy lab resources”

• “Would like more time for either independent learning or active learning curriculum (ie, COCLIA) rather than lectures”

• “The AAO has evolved to provide a wide variety of learning materials. Our program, unfortunately, has not evolved to adopt any of those materials in a formal way.”

• “Revamped to make more interactive and mock oral board format. “


What is the overall quality of the didactic curriculum at your institution?

1 2 3 4 5 6 70%

20%

40%

60%

80%

100%

0% 4%11%

17%

33% 33%

2%0% 4% 0% 0%

33% 33% 29%

Trainees Faculty

Poor---------------------Neutral----------------------------Ex-cellent

68% resi-dents96% faculty


Conclusions

Trainees and Faculty tended to agree, in the majority, on most statements

However, trainee responses were more skewed towards the need for more protected time and a up-to-date curriculum that maximizes the use of resources provided by both the AAO and their home institution

Faculty and Trainees disagreed on its usefulness in preparing the trainee for the in-service examination


Thoughts

How do we balance hands on clinical learning with didactic learning in a restricted time setting?

How do we individualize the curriculum to maximize the learning of all trainees?



Inpatient Rounding Practices at Otolaryngology-Head/Neck Residency Programs

Fiyin Sokoya MD

PGY-3

Department of Otolaryngology

University of Colorado


History

Bedside rounding started in the mid-17th century by Franciscus Sylvius

1886- Students were taken on ward rounds, given lectures, as well as anatomic and pathologic demonstrations by William Halsted.

Dr. Halsted was described as "inspiring and charismatic teacher”


History

In 1903, William Osler pioneered medical education reform by advocating bedside teaching by an attending physician1

“Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell and know by practice alone you can become expert.” –W. Osler


Evolution of Rounding Practices

In the 1960s, 75% of attending rounds occurred at the bedside

In the 1970s 16 to 20% 2

Bedside teaching rounds became the primary method of teaching students in the initial half of the 20th century


Evolution of Rounding Practices

Causes of decline include teacher apprehension, teacher/learners’ perceptions of patient preferences, logistics within the hospital setting3

85% of patients liked the case presentation discussion at the bedside,

95% of both students and housestaff felt more comfortable with discussion away from the patient4.


SUO-SRF Survey

Response rate: 24 Pragram Directors (28% response rate)46 Residents (44) and Fellows (2)

Limitations: 19 Program Directors contact information unattainableIndirectly contacting residents via Program Coordinators


On Bedside Rounding

Bedside

Hallway

Both

0% 10% 20% 30% 40% 50% 60% 70% 80%

71%

17%

13%

57%

37%

6%

How is Formal Inpatient Rounding Performed?

TrainessAttendings

% of Responses


On Bedside Rounding

<5 minutes 5 - 10 minutes 10 - 15 minutes0%

10%

20%

30%

40%

50%

60%

70%

80%

38%

58%

4%

73%

16%11%

How much time do you spend with each patient

AttendingsTrainees

% o

f res

pons

es


On Attending Participation

Once per week

More than once per week, but not every

day

Every day none depends on service

0%5%

10%15%20%25%30%35%40%45%50%

4%

50%

38%

4% 4%

17%

39%

20%24%

0%

Attending Participation in Inpatient Rounds

AttendingsTrainees

% o

f Res

pons

es



21%

75%

4%Attendings

15%

63%

21%

Trainees

Less is needed

We have the per-fect amount

More is needed

Is Frequency of Attending Participation Adequate?



• Our data suggests that trainees and attendings are comfortable with the level of attending participation in rounds

• Rotating pediatric ENT hospitalist model @ Boston Childrens Hospital5

• Improved inter-professional communication• Improved teaching experiences• Comparable RVUs


On Multidisciplinary Rounding

MD RN SLP RTs SW0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Relative Participation in Rounds

TraineesAttendings

Rela

tive

Parti

cipati

on



42%

33%

18%

7%9%

2% 2%

Trainees

39%

12%20%

10%

13% 9%

Attendings

None RNs SW RTPharmacists SLP Nutritionists

Who would you like to see participate more in inpatient rounding?



Communication failure among health care providers is one of the most frequently cited causes of preventable harm to patients6.

MDR improved efficiency, delivery of evidence-based care, and relationships with involved disciplines7

Adjusted average LOS decreased 0.5 (95% CI 0.1–0.8) days for patients with a target core measure diagnosis of either CHF, pneumonia, or AMI (p < .01 ) and by 0.6 (95% CI 0.5–0.7) days for all medicine DRGs (p < .001)7.


Summary

• Frequency of bedside rounding may have decreased in medicine overall, but is still a common practice in Otolaryngology

• Time spent with each patient could be increased, and will likely improve patient satisfaction and resident/student learning

• Even though trainees and attendings are comfortable with the level of attending participation, literature suggests that increased participation will likely improve patient satisfaction and resident learning

• Multidisciplinary rounding, though not well studied in ENT has been associated with improved patient outcomes, resident education, and length of stay in other specialties


References

1. Osler W. On the need of radical reform in our methods of teaching senior residents. Medical News.1903;82:49–53.

2. Reichsman F, Browning FE, Hinshaw JR. Observations of undergraduate clinical teaching in action.Academic Medicine. 1964;39:147–63.

3. LaCombe MA. On bedside teaching. Annals of Internal Medicine. 1997;126:217–20.

4. Wang-Cheng RM, Barnas GP, Sigmann P, Riendl PA, Young MJ. Bedside case presentations: Why patients like them but learners don't. Journal of General Internal Medicine. 1989;4:284–7.

5. Adil E, Xiao R, McGill T, Rahbar R, Cunningham M. A Chief of Service Rotation as an Alternative Approach to Pediatric Otolaryngology Inpatient Care. JAMA Otolaryngol Head Neck Surg.2014;140(9):809-814. doi:10.1001/jamaoto.2014.1325.

6. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23:294–300

7. O’Mahony S, Mazur E, Charney P, Wang Y, Fine J. Use of Multidisciplinary Rounds to Simultaneously Improve Quality Outcomes, Enhance Resident Education, and Shorten Length of Stay. Journal of General Internal Medicine. 2007;22(8):1073-1079. doi:10.1007/s11606-007-0225-1.



QUALITY IMPROVEMENT

Robert Morrison, MDUniversity of Michigan


Attitudes/Current State

PROGRAM DIRECTORS RESIDENTS/FELLOWS0

1

2

3

4

5

6

7

8

9

10

How important do you feel it is to have quality improvement

training in your residency pro-gram?

PROGRAM DI-RECTORS

RESIDENTS/FELLOWS

0

10

20

30

40

50

60

70

80

90

100

Is there a formal QI curriculum in your residency program?


How is QI taught at your institution?

Small Group Activi-ties

Self-Guided Projects

Faculty Guided Projects

Lectures

0 10 20 30 40 50 60 70 80 90 100

RESIDENTS/FELLOWS


QI Experiences

PROGRAM DIRECTORS

RESIDENTS/FELLOWS

0

10

20

30

40

50

60

70

80

90

100

Does your depart-ment have a formal monthly QI confer-

ence?

PROGRAM DIRECTORS

RESIDENTS/FELLOWS

0

10

20

30

40

50

60

70

80

90

100

Are residents required to complete a QI

project during their res-idency?

PROGRAM DIRECTORS

RESIDENTS/FELLOWS

0

10

20

30

40

50

60

70

80

90

100

Do residents at your program have the oppor-

tunity to participate in institution-wide quality

improvement?


Comments

Nearly every respondent recognized opportunities for quality improvement built into the M&M mechanism.

Formal curriculum is highly variable in structure.Resident respondents expressed desire for more

collaboration with faculty/institutional leadership. Feel QI work may be more “respected” and more likely to

produce change

Residents respondents recognized QI training as professional development training.

Several respondents emphasized institutional quality committee opportunities as value-added.


Thoughts/Discussion

How do you create QI work that is meaningful and impactful to patient care?

How do you develop faculty buy-in / leadership for QI work?

How do you share successes? Within your institution? Within otolaryngology?

What are the goals of a QI curriculum in Otolaryngology-Head & Neck Surgery Residency?

Practical Goals Professional Development Goals


Quality Improvement as “Professional Development”

Professional development refers to the acquisition of skills and knowledge, both for personal development and for career advancement.

-Dr. Wikipedia


Resident Professional Development

Regional / National

Institutional / Departmental

Education Policy Peer Review

GME CME Journal Review CORE Review

GuidelinesDevelopment

ACGME, AAO, SUO, etc

Health Policy Development


Resident Professional Development

Regional / National

Institutional / Departmental

EducationInterprofessional

CollaborationResearch

UMEGMECME

Simulation

Basic Science

Clinical

Quality Improvement

Patient Safety

Medical-Legal

Post-GraduateDegree

Public Health

InterprofessionalCollaboration

Quality Improvement

Patient Safety


Improving Resident Access to Interprofessional Collaboration

An example from my own institution… In 2012, UMHS generated initiative through the Office of

Clinical Affairs, endorsed by Office of GME. “To more fully leverage the unique front-line experiences of our

residents and further engage them in patient safety and quality improvement efforts across UMHS”

Resulted in formation of the House Officer Quality and Safety Council (HOQSC).

Goals: Increasing house officer representation on institutional

committees Increasing house officer access to institutional resources

for resident-generated initiatives


HOQSC Structure

OCA Representation: ~1-2 members

Faculty Mentors: ~2-3 per year

Resident Chairs: 2 per year

Resident Representatives: Goal >1 per department

“Guests” Administration Faculty Leads Institutional Resouces

2012 2013 2014 2015 20160

20

40

60

80

100

120 HOQSC Membership

*10% representation

Current Membership: 96


Review of Patient Safety

(“Incident”) Reports

Updates on Current HOQSC

Initiatives

Generation of Action Items

Updates from UMHHC

Committee Representatives

Current HOQSC Function


SCHOLARSHIP


“Professional Development” and the Resident

Closing thoughts: Quality Improvement done right requires physicians (and residents!) to assume

leadership roles (“to act as professionals”).

“Professional development” is not just knowledge development, but also developing skills to work with other professionals in the healthcare system.

Skills take practice!

Small initiatives or opportunities can grow beyond expectations if given the proper nourishment.

Provide the opportunities and the mechanism, and you will be surprised how much we (as residents) can accomplish.

Survey results show residents want to be advocates for positive, sustained change Survey results show residents want to be leaders


QUESTIONS?

empowering otolaryngologist–head and neck surgeons to deliver the best patient care empowering...

Documents

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