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February 4-8, 2015 Hyatt Regency Mission BaySan Diego, California

2015 OPSC Annual Convention

syllabus

WEDNESDAY

* California Pain / End-of-Life Care | ^ California Radiology/X-Ray

Osteopathic Physicians& Surgeons of California

2015 H StreetSacramento, CA 95811

www.opsc.org

Phone: (916) 822-5246Fax: (916) 822-5247

Presentations included in this Syllabus are current as of publication date. Presentations modified after submission for publication

will be posted on the 2015 Annual Convention and Exposition web siteas they are provided to OPSC.

PLEASE NOTE: This PDF Syllabus contains bookmarks and hyperlinks on the Table of Contents for ease of navigation. Click on the presentation title or page number to jump to the appropriate page. There are fillable notes forms for each presentation. If you take notes, BE SURE TO SAVE YOUR WORK BEFORE CLOSING THE FILE!

At the request of our presenters the PDFs have security freatures to disallow content extraction or manipula-tion of the slides.

WEDNESDAY, FEBRUARY 4, 2015Total Health Makeover ............................................................................................................................. 7Presented by Marilu Henner

Robotics in Neurosurgery ........................................................................................................................11Presented by Dan Miulli, DO, FACOS

Professionalism: The Relationship with State Medical Boards and Their Disciplinary Function .....................34Presented by Joseph Zammuto, DO

ACGME-AOA Continuous Board Certification ..............................................................................................76Presented by David Connett, DO, FACOFP, dist

THURSDAY, FEBRUARY 5, 2015Pulmonary Nodules^ .............................................................................................................................137Presented by Abraham Pera, DO, FAOCR

Point of Care Ultrasound in Emergency Departments and Outpatient Settings^ ........................................196Presented by Robert Husband, DO

Cannabinoids: More than Marijuana - What you need to know and were never taught in medical school ....200Presented by Jeff Lapoint, DO

Trigeminal Neuralgia^ ...........................................................................................................................204Presented by Dan Miulli, DO, FACOS

Covered California: 2015 Update ............................................................................................................252Presented by Alesia Wagner, DO, FACOFP

CONTINUED NEXT PAGE...

http://www.opsc.org

THURSDAY, CONTINUED

The Shoulder: 2 View or Not 2 View* .......................................................................................................294Presented by Alexandra Myers, DO

Introduction to ICD-10: A Guide for Providers ..........................................................................................323Presented by Deb Kuehn, CPC, CMRS

FRIDAY, FEBRUARY 6, 2015Caring for Our Homeless Veterans ..........................................................................................................357Presented by Hieu Hoang, DO, MPH

Practice Development in the Changing Healthcare Environment .............................................................361Presented by Tom Horowitz, DO

Opioid Addiction and Buprenorphine Use* ..............................................................................................394Presented by Mark Eastman, DO

Legal Medicine Hot Topics ......................................................................................................................419Presented by David Canton, DO, MPH, JD

Changing Employment: Making the Most Out of an Unfortunate Situation ...............................................457Presented by Alesia Wagner, DO, FACOFP

Concierge Medicine: To Live or Die in Private Practice ..............................................................................477Presented by Randall West, DO, FAAFP

General Introduction to Biofeedback .....................................................................................................489Presented by Frank DeGregorio

* California Pain / End-of-Life Care | ^ California Radiology/X-Ray CONTINUED NEXT PAGE...

FRIDAY, CONTINUED

Difficulties in Diagnosing Melanoma: How Dermoscopy Can Help .............................................................493Presented by Ashfaq Marghoob, MD

Stone Disease^ .....................................................................................................................................497Presented by John Grimaldi, DO

Erectile Dysfunction for the Internist .....................................................................................................521Presented by John Grimaldi, DO

SATURDAY, FEBRUARY 7, 2015Osteopathic Approaches to Chronic Pain* ...............................................................................................545Presented by Brian Loveless, DO

The Power of Self-Healing .....................................................................................................................567Presented by Fabrizio Mancini, DC, FICC, FACC

Osteopathic Considerations in Infections of the Respiratory Tract ............................................................612Presented by Melissa Pearce, DO, C-NMM/OMM

Inflammation or Infection…?* .............................................................................................................735Presented by Steve Lee, DO and Mario Perez, DO, AAHIVS

Clinical Research ...................................................................................................................................739Presented by Joel Barra, BSBM, CCRP

When Do I Need a Geriatric Consult? .......................................................................................................743Presented by Sunil Singhania, DO

Uncovering the Non-Opiate Candidate Patient* ......................................................................................771Presented by Lisa Pitino, DO

* California Pain / End-of-Life Care | ^ California Radiology/X-Ray CONTINUED NEXT PAGE...

SATURDAY, CONTINUED

Managing the Problem Opioid Patient * .................................................................................................838Presented by Wade Wong, DO, FACR, FAOCR

SUNDAY, FEBRUARY 8, 2015Therapeutic Lifestyle Changes: The New Standard? ............................................................................... 1026Presented by Ken Browning, DO

Coding and Documenting in Managed Care .......................................................................................... 1088Presented by Nupur Kumar, DO, MPH

The Modern Practice: Or how to make it easier on you… and your staff .................................................. 1118Presented by Jim Lee, DO, AAHIVS

Primary Care of the HIV Patient ........................................................................................................... 1147Presented by Jim Lee, DO, AAHIVS

High Altitude Medicine at the Top of the World ..................................................................................... 1177Presented by Jo Ann C.Pullen, MD

* California Pain / End-of-Life Care | ^ California Radiology/X-Ray

wednesday,February 4, 2015

WEDNESDAY, FEBRUARY 4, 2015: 1:30pm - 2:30pm

Total Health MakeoverPresented by Marilu Henner

OPSC’s 54th Annual Convention and Exposition Syllabus 8

PRESENTATIONLearning Objectives andSelf ASSESSMENT questions

LEARNING OBJECTIVES SELF ASSESSMENT QUESTIONSSelf assessment questions not available at time ofpublication.

Learning objectives not available at time ofpublication.


WEDNESDAY, FEBRUARY 4, 2015: 1:30pm - 2:30pm ..................................................................................................................................... Total Health Makeover | Presented by Marilu Henner

Presentation not available at time of publication. RETURN TO TABLE OF CONTENTS


WEDNESDAY, FEBRUARY 4, 2015: 1:30pm - 2:30pm ..................................................................................................................................... Total Health Makeover | Presented by Marilu Henner

RETURN TO TABLE OF CONTENTSPresentation not available at time of publication.


Robotics in NeurosurgeryPresented by Dan Miulli, DO, FACOS



LEARNING OBJECTIVES SELF ASSESSMENT QUESTIONSSelf assessment questions not available at time ofpublication.

1. Describe reasoning for use of robotics in Neurosurgery 2. Determine risks factors for using robotics in Neurosurgery

3. Describe how communication about robotics in Neurosurgery improves the physician patient relationship and experience


WEDNESDAY, FEBRUARY 4, 2015: 2:30pm - 3:30pm ......................................................................................................................... Robotics in Neurosurgery | Presented by Dan Miulli, DO, FACOS

Robotics in Neurosurgery

Dan Miulli, DO, FACOS Arrowhead Neurosurgery



Disclosure I have: • No Commercial Interest or support • No Financial relationships with outside individuals or

companies including individual benefits by receiving a salary, royalty intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected

• No Conflict of Interest



Objective

• Describe reasoning for use of robotics in Neurosurgery

• Determine risks factors for using robotics in Neurosurgery

• Describe how communication about robotics in Neurosurgery improves the physician patient relationship and experience



Cultural Barriers

• Language Barrier could led to delay – availability of translators crucial

• Personal Beliefs creating treatment issues – concern regarding medications & treatments – necessitates detailed explanations

• Ethno cultural Beliefs that delay treatment – concern regarding procedures at certain ages



Robotics

• Improve patient outcomes

• Improve patient experience

• Improve healthcare costs

• Brain transplants



Limits

• 1980’s • Microscope,

magnification, light, movement

• Fixed reference – stereotactic frame



Stereotaxis • A surgical technique using

imaging to precisely locate in 3D an anatomical site to which a surgical instrument is directed

• Minimally invasive surgical intervention using 3D coordinate system to locate small targets inside the body and to perform on them some action – 1st in 1908 at University College

London Hospital – Sir Victor Horsley, neurosurgeon,

and Robert H. Clarke, a physiologist – Cartesian (three-orthogonal axis)

system



Improve Imaging

• CT Scan • MRI



Neurobot

• Telecontrol through endoscope



Mazur

• soda can sized SpineAssist Robot was the first FDA approved robotic system for spinal surgery



Control



Telesurgical



DaVinci Robot



Surgical Time



Costs



ERROR RATE



IMPROVEMENTS



OUTCOMES



RETURN TO TABLE OF CONTENTS


Professionalism: The Relationship with State Medical Boards and Their Disciplinary FunctionPresented by Joseph Zammuto, DO



LEARNING OBJECTIVES SELF ASSESSMENT QUESTIONS1. Describe the composition and responsibility of the board

2. Describe the licensing and disciplinary process

3. Identify ways to avoid attention from the board

4. Provide resources for additional information on future changes

1. What is the OMBC composition? a. 10 DOs and 10 Public b. 4 DOs and 2 Public c. 5 DOs and 4 Public

2. How was the OMBC established? a. Statute b. Lottery c. Initiative

3. What year was the OMBC established? a. 1921 b. 1922 c. 1923

4. Who does the OMBC protect? a. Nurses b. Doctors c. Patients

5. Which is not a Physician Competency? a. Patient Care b. Medical Knowledge c. Practice-based learning and improvement d. Interpersonal and communication skills e. Professionalism f. Systems-based practice g. ICD-10

6. Which is not unprofessional conduct? a. Professional misconduct b. Substandard care c. Inappropriate prescribing

d. False advertising e. Discharging a patient from your practice

7. What is the greatest source of complaints? a. Anonymous b. Family member c. Patient d. Malpractice e. Other


WEDNESDAY, FEBRUARY 4, 2015: 4:00pm - 5:00pm ................ Professionalism: The Relationship with State Medical Boards and Their Disciplinary Function | Presented by Joseph Zammuto, DO

Professionalism: The relationship with state medical boards and

their disciplinary function

The Osteopathic Medical Board of California

Current and New activities for the Future.



Goals/Objectives

• Describe composition and responsibility of the board

• Describe the licensing and disciplinary processes

• Identify ways to avoid attention from the board

• Provide resources for additional information



OSTEOPATHIC MEDICAL BOARD OF CALIFORNIA

• Board composition– Nine members– Three Year Length of term– OSTEOPATHIC PHYSICIANS regulated by

the board– FIVE Physicians/FOUR Public members– Gubernatorial appointment



OSTEOPATHIC MEDICAL BOARD OF CALIFORNIA

• The Board was not established by statute, rather by an Initiative Act.

• Established by Osteopathic Initiative Act of 1922

• * Amended by the State electorate in 1962• Mission of the board is to protect the

public.• Duties & responsibilities of the board



Teaching on medical licensure and regulation

Source: 2007 LCME Annual Medical School Questionnaire

126 LCME-accredited medical schools

Number of US Medical Schools Teaching on Medical licensure/regulation

Included in required course Included in elective course

70 19

Good News: 71% of medical schools report teaching on the topic of medical licensure and regulation



Teaching on medical licensure and regulation

Source: 2007 AAMC Medical School Graduation Questionnaire

Question# 11; 12,512 respondents

Do you believe that the time devoted to your instruction in the following area was inadequate, appropriate or excessive?

Medical licensure/regulation

Inadequate Appropriate Excessive

61.4% 38.3% 0.3%

Bad News: Most medical students feel inadequately informed on issues relative to medical licensure and regulation



Licensure Evaluate applicants’ fitness to practice

— Medical education and training— Examination of cognitive and clinical skills necessary for the independent

practice of medicine— Character— Prior disciplinary action

Regulation Establish standards for physician licensure and practice

Discipline Take appropriate action against individual physicians’ licenses for

unprofessional, incompetent or unlawful practice of medicine

State Medical Boardsa triad of functions for public protection



Professionalism


Question# 16: Indicate whether you agree or disagree with the following statement about your preparedness for beginning a residency training program; 12,524 respondents

“I understand the ethical and professional values that are expected of the profession.”

Strongly Agree Agree No Opinion Disagree Strongly Disagree 56.2% 41.1% 2.4% 0.2% 0.1%

Graduating medical students are confident in their understanding of the tenets of the medical profession



Physician Competencies(Source: ACGME/ABMS)

1. Patient Care2. Medical Knowledge3. Practice-based learning and improvement4. Interpersonal and communication skills5. Professionalism6. System-based practice



Definitions

• Medical practice (defined)• Unprofessional conduct (defined)

– Professional misconduct– Substandard care– Inappropriate prescribing– False advertising– Etc.



Statistical Data

• Licensees: 15,000• Number of complaints: 700• 4.6%



Disciplinary Process

Complaint

Investigate CloseContinue Investigation

Warning

Resolve by ConsentSummary Suspension

Investigation Committee

Consent Parameters

Decision

Hearing

Optional Appeal: Administrative Review Board



Disciplinary Process

Complaint received

Investigation/review

Dismissal Charges filed/Formal complaint process

Dismissal Board action



Complaint Process

• Outline of the Board’s complaint process



History of Complaints

10000

12000

14000

16000

18000

20000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

0

100

200

300

400

500

600

700

800

900

1000

Licensees

Complaints



Sources of Complaints

24, 3%108, 13%

339, 41%101, 12%

257, 31% AnonymousFamily MemberPatientMalpracticeOther



Complaint categories

Other jurisdiction 39 1.8%Incomp. / Unethical 706 33.3Unprofessional 700 33.0Illness 56 2.6Non-jurisdictional 20 0.9Medical records 99 5.0Addiction 34 1.6Prescribing 287 13.5Sexual misconduct 35 1 6



Case Studies



Impaired Physicians Program (IPP)

• Contracted Vendor: Maximus, Inc.(800) 522 9198 Phone• Osteopathic Medical Board, Diversion

Evaluation Committee(3) three licensed D.O.’s

• California Code of Regulation; Title 16, Division 16, Article 12.5, Sections 1660,1660.2,1660.4,,1661,1661.2,1661.4,1662



Medical board goal

“Rehabilitate, when possible, persons who are impaired or who practice medicine unethically or below minimal standards of care, and prohibit persons who have not been rehabilitated from practicing medicine.”

Source: State Medical Board of Ohio



0

5

10

15

20

25

30

35

40

45

50

2002 2003 2004 2005 2006 2007

Impairment Actions

Impairment Action



0

5

10

15

20

25

30

35

Negligence /IncompetenceFraud

Impairment

Other

InappropriateprescribingSexual misconduct

Records

Violation of P/O

Final Disciplinary Actions by Type of Misconduct in 2007

Source: State medical board of ___.

As

% o

f all

final

dis

cipl

inar

y ac

tions



Compliance Monitoring

• Over 40 licensees currently monitored by the Board (On Probation)

• Currently 16 Participants in Diversion program. Primarily impairment cases

• Usually monitored for a minimum of 5 years for diversion participants.



Reporting Requirements

• Reference Business and Professions Code 800 for Reporting Requirements.

• http://leginfo.legislature.ca.gov/faces/codesdisplayText.xhtml?lawCode=BPC&division=2.&title=&part=&chapter=1.&article=11.



Serious Misconduct

• Negligence/Incompetence• Impairment• Sexual abuse• Fraud• Inappropriate prescribing



The Investigation

• Medical Records– Medical Coordinator review

• Interview• Background Checks• Expert Opinions• Closed• Investigation Committee



Investigation Committee

Possible recommendations1. Closure2. Further investigation3. Administrative warning4. Impairment review5. Hearing6. Summary suspensionConsent Parameters



Board Hearings• Hearing committee of 9• Administrative law judge• Court reporter• Attorneys• Parties• Witnesses/evidence

• Not bound by strict evidentiary rules

• Standard of proof:– Identify preponderance, clear

and convincing or other

ACTORS

PROCESS



Board Decisions

• Censure and reprimand• Suspension (actual/stayed)• Probation (monitoring)• Limitation of license• Revocation• Monetary fine• Education/Training • Community Services• Dismissal



Administrative Review Board

• Established by…• Review board composition Board has

medical Consultant who reviews complaints. If further review necessary, case sent to specialty expert.

• Expert Reviewers under contract with Board.

• Process: Refer to Osteopathic Medical Board’s Complaint Process.



Physician Participation

• Board chair, board staff (if applicable)• Board members• Adjudicatory committees• Medical coordinators• Expert consultants• Administrative warning• Physician monitoring/supervision



Specialties at Risk

• Internal Medicine• Family / General Practice• Psychiatry• OB / GYN

Source: ___ board. Based upon disciplinary sanctions taken for sexual violations, 1997-2007



Communications

Graduating medical students are confident in their ability to communicate effectively


Question# 16: Indicate the degree of preparedness for entering a residency training program. 12,527 respondents

“I have the communication skills necessary to interact with patients and health professionals.”

Strongly Agree Agree No Opinion Disagree Strongly Disagree

60.6% 36.6% 2.3% 0.3% 0.1%



National Data: Board Actions by Type, 1991-2006

336 39

9 626

584

584

611 73

975

373

166

764

7 706

640 76

379

170

9

3767

3838

3944

4015 41

69 4590

5502

5344

4867

280

4 2

971

308

1 3

571

381

3 3

821

372

8

0

1000

2000

3000

4000

5000

6000

7000

1991

: 3,14

0

1992

: 3,37

0

1993

: 3,70

7

1994

: 4,15

5

1995

: 4,39

7

1996

: 4,43

2

1997

: 4,46

7

1998

: 4,52

0

1999

: 4,56

9

2000

: 4,61

1

2001

: 4,66

2

2002

: 487

5

2003

: 523

0

2004

: 626

5

2005

: 613

5

2006

: 557

6

Non-Prejudicial Prejudicial

Total Actions

Source: Federation of State Medical Boards



1024.7974.2

929.1

697.5

514.1

316.4236.1

25

125

225

325

425

525

625

725

825

925

1025

Unprofessional Conduct NegligenceSubstance Abuse Controlled Substance ViolationsFraud Sexual MisconductFailure to Maintain Adequate Medical Records

National Data: Basis for Board Actions against Physicians, 1997-2006

Neg

ligen

ce

Unp

rofe

ssio

nal C

ondu

ct

Subs

tanc

e Abu

se

Con

trol

led

Subs

tanc

e V

iola

tions

Frau

d

Sexu

al

Mis

cond

uct

Failu

re to

Mai

ntai

n A

dequ

ate

med

ical

Rec

ords

Source: Federation of State Medical Boards



How Often Do Physicians Get Disciplined by State Licensing Boards?

~750,000 licensed physicians in the U.S.

2,250 physicians disciplined annually (0.3%) – over a ten year period



Grounds for Discipline

Grounds for action, including…• Standard of care violations• Inappropriate prescribing• Breaching professional ethics

Source: Identify relevant statute/code



Source: Teherani A, Hodgson C, Banach M, Papadakis M. “Domains of Unprofessional Behavior During Medical School Associated with Future Disciplinary Action by a State Medical Board.” Academic Medicine 2005; 80(10):S17-S20

Behavioral domains associated with subsequent discipline by a state medical broad

• Poor reliability and responsibility

• Lack of self-improvement and adaptability

• Poor initiative and motivation



For further information

• Board website: www.ombc.ca.gov• Board phone numbers:

phone 916 928 8390; fax 916 928 8392• Email contact: [email protected]• Board’s physical address: 1300 National Drive, Suite 150 Sacramento, CA 95834-1991

* California Pain / End-of-Life Care


ACGME-AOA Continuous Board CertificationPresented by David Connett, DO, FACOFP, dist



LEARNING OBJECTIVES SELF ASSESSMENT QUESTIONS1. Understand the factors leading to the ACGME Single Unified Pathway

2. Understand the number of applicants applying to ACGME from offshore medical schools, AOA schools, IS MD Medical Schools and Foreign Medical Graduates

3. Understand the current number of PGY 1 AOA and AC GME positions available for residencies in the United States

4. Understand the current issues with Maintenance of Certification with ABMS

5. Introduction to concept of Continuous Certification/Recertification

1. The major factor in curtailing the growth of graduate medical education is: a. CMS capping residencies b. Medical staff concerns with malpractice or productivity c. Hospital administration concerns with financials d. ACGME lack of programs for GME growth

2. The total number of PGY 1 of Combined AOA and ACGME Residency positions in the United States a. 20,000 b. 33,000 c. 50,000 d. 90,000

3. The projected number of graduates from LCME (MD) Schools in the United States in 2013 were: a. 20,000 b. 30,000 c. 50,000 d. 91,000

4. The projected number of graduates from COCA (DO) Schools in the United States in 2013 were: a. 6900 b. 10,000 c. 15,000 d. 20,000

5. According to AAMC (Association of American Medical Colleges Table 40) the number of LCME Medical applications applying to ACGME programs a. 20,055 b. 34,705 c. 35,467 d. 56,532 e. 91,999

6. According to AAMC (Association of American Medical Colleges Table 40) the number of US Caribbean Medical Schools applications applying to ACGME programs a. 20,055 b. 34,705 c. 35,467 d. 56,532 e. 91,999

7. According to AAMC (Association of American Medical Colleges Table 40) the number of combined foreign medical graduates and Caribbean applicants applying the unused 5000 ACGME PGY 1 positions a. 20,055 b. 34,705 c. 35,467 d. 56,532 e. 91,999

8. 50% of all residencies in the United States are in what time zone? a. Pacific/Arizona b. Mountain c. Central d. Eastern

9. What percentage of osteopathic residents who graduate from ACGME programs take the DO/osteopathic boards? a. 20% b. 40% c. 60% d. 80%


WEDNESDAY, FEBRUARY 4, 2015: 5:00pm - 6:00pm ........................................................... ACGME-AOA Continuous Board Certification | Presented by David Connett, DO, FACOFP, dist

AOA-ACGME Single Unified Pathway-Continuous Medical

Education David A. Connett, DO, FACOFP

President – Osteopathic Physicians and Surgeons of California

Vice Dean – College of Osteopathic Medicine of the Pacific

1



Disclosures

• No financial disclosures

1/20/2015 2



Objectives 1. Understand the factors leading to the ACGME

Single Unified Pathway 2. Understand the number of applicants applying

to ACGME from offshore medical schools, AOA schools, IS MD Medical Schools and Foreign Medical Graduates

3. Understand the current number of PGY 1 AOA and ACGME positions available for residencies in the United states

4. Understand the current issues with Maintenance of Certification with ABMS

5. Introduction to concept of Continuous Certification/Recertification

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FACTORS LEADING TO THE DEVELOPMENT OF SINGLE UNIFIED ACCREDITATION SYSTEM

4



Self-Assessment Questions

• The major factor in curtailing the growth of graduate medical education is: – CMS capping residencies* – Medical staff concerns with malpractice or

productivity – Hospital administration concerns with financials – ACGME lack of programs for GME growth

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Residency Development Shortage

– Cooper Report 2007

6



Institute of Medicine Report GME Funding 2014

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Types of Residency “Match” for Osteopathic Medical Students

• Military - December • Urology – January • NMS/AOA Match - February • NRMP match and SOAP – March

– “All-In” Policy 2013 – Residency not Fellowship

• San Francisco Matching Program-Varies by Specialty

1/20/2015 8



Osteopathic Medical Students Residency Placement 2012

29%

12% 40%

12% 5%

2%

DO 2012 Residency Choice

AOA Internship ACGME Dual Govt, VA Uncertain

Source: http://www.aacom.org/data/classsurveys/Documents/2011-12_Graduating_Summary.pdf

9



Accreditation Counsel for Graduate Medical Education (ACGME)

• ACGME Board of Directors by 2015 – American Board of Medical Specialists – American Hospital Association – American Medical Association – Association of American Medical Colleges – Council of Medical Societies

• The Accreditation Council for Graduate Medical Education (ACGME) is

the body responsible for accrediting the majority of graduate medical training programs (i.e., internships, residencies, and fellowships, aka subspecialty residencies) for physicians in the United States. It is a nonprofit private council that evaluates and accredits medical residency and internship programs. The ACGME was founded in 1981 and was preceded by the Liaison Committee for Graduate Medical Education, which was established in 1972. The ACGME currently oversees the post-graduate education and training for all MD and the majority of DO physicians in the United States. (Wikipedia)

1/20/2015 10



ACGME Transition – Next Accreditation System (NAS)

• 1999 - introduced 6 domains of clinical competency – 1. Medical Knowledge – 2. Patient Care – 3. Professionalism – 4. Interpersonal Communication – 5. Practice-based Learning: personal – 6. System-based Practice: system

• 2009 restructuring begins based on educational outcomes in these competencies.

• July 2013 The result of this effort is the Next Accreditation System (NAS), scheduled for phased implementation beginning in 2015.

11



ACGME – Next Accreditation System

The aims of the NAS are threefold: 1. to enhance the ability of the peer-review system

to prepare physicians for practice in the 21st century,

2. to accelerate the ACGME’s movement toward accreditation on the basis of educational outcomes, and

3. to reduce the burden associated with the current structure and process-based approach.

12



November 2011 – ACGME Rule Change

13



2011 Next Accreditation System Implications for DO Grads in AOA GME

• Requiring an ACGME-accredited residency program as a prerequisite for clinical education for entry into an ACGME-accredited residency program – This would limit a DO who completed an AOA-accredited

internship from proceeding to an ACGME program unless they repeated their internship year in an ACGME-accredited residency program.) Five states currently have licensing requirements for AOA residency – MI, PA, WV, FL, OK

• Requiring an ACGME-accredited residency program (not an AOA Residency) as a prerequisite for clinical education for entry into an ACGME-accredited fellowship program. – Impact Areas (IM/Surgical Specialties, PC Fellowships) thought

to be only 8% of the osteopathic profession

14



2011 Unintended ACGME Program Effect

1. Exclusion of DO Students into some ACGME clerkship opportunities - VSAS

2. DO’s residency preceptors with AOA Boards could not participate in active teaching in ACGME programs to include DO residents

3. Selection bias began for DO’s into residencies

1/20/2015 15



1/20/2015 16




• The number of graduates from COCA (DO) Schools in the United States in 2013 were: – 5100* – 10,000 – 15,000 – 20,000

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• The number of graduates from LCME (MD) Schools in the United States in 2013 were: – 20,000* – 30,000 – 50,000 – 91,000

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• The total number of PGY 1 (1st year) of Combined AOA and ACGME Residency positions in the United States – 20,000 – 33,000* – 50,000 – 90,000

1/20/2015 19



DO/MD Graduates 2013

AOA ACGME

Number PGY 1 Residency Training Positions

2900 30,000

AOA DO LCME MD

Number Medical School Graduates 5154

20,055

Surplus PGY-1 Positions 0 7691 20




• 50% of all residencies in the United States are in what time zone? – Pacific/Arizona – Mountain – Central – Eastern*

1/20/2015 21




• According to AAMC (Association of American Medical Colleges Table 40) the number of combined Foreign Medical Graduates and Caribbean applicants applying the unused 7691 ACGME PGY 1 positions – 20,055 – 34,705 – 35,467 – 56,532 – 91,999*

1/20/2015 22



AAMC Table 40 2013

1/20/2015 23



AAMC Table 40 2013 ERAS Applicants for Remaining 7691 PGY-1 Position

1/20/2015 24



Residency Maldistribution

– Maldistribution of AOA and ACGME Residencies 50% of all Graduate Medical Education (GME) is in the eastern time zone; MD or DO

– Western University is the leader for either MD or DO schools in residency development

– 1100 AOA Approved Programs – DO exclusive programs

– 10,000 ACGME Approved Programs – DO’s eligible to apply

25



Anticipated Reality – 2015 & Beyond

Unified ACGME

Number of Programs 10,000 +

Number Total Residents 123,000+

Number of Total Specialties 135 + 2

26



October 24, 2012 Announcement • ACGME, AOA,

AACOM have entered into an agreement to pursue a Single Unified Accreditation System for GME programs in the USA beginning in July 2015

27



AOA-ACGME Specialty Societies Collaborated -2013

• Crosswalk of Residency Standards between AOA and ACGME programs began: – Family Medicine – Internal Medicine – Emergency Medicine – General Surgery – Orthopedic Surgery – Obstetrics and Gynecology – Transitional Year

1/20/2015 28



Summer 2013

• June 14 – ACGME announces “conclusion of negotiations for MOU” and awaits decision of AOA BOT/HOD, AACOM in July

• July 19 – AOA announcement …“unsuccessful in reaching MOU w ACGME for a unified GME accreditation system.

• July 23 – ACGME announces “…failure to form an ACGME accreditation system that includes AOA and AACOM is regrettable……ACGME will proceed with keeping its promise …to implement The NAS.

• July 30 – “Final” ACGME/AOA Joint Mtg

29



Fall 2013 • October 21, 2013

– ACGME has delayed implementation date of the revised Common Program Requirement until 2016

– Fellowship programs are allowed to select “exceptionally qualified applicants” who completed residency training in non-ACGME programs, including physicians who completed prior training in AOA-approved residency programs.

– Individual Residency Review Committees are allowed to grant exceptions at the fellowship level and not require prior that residency training have been completed in ACGME or Canadian programs.

• Winter/Spring 2014 – AOA will move toward a PBAS “PERFORMANCE BASED

ACCREDITATION SYSTEM” – implementation Summer 2014

30



February 2014 – MOU Approved

• “The Board of the American Osteopathic Association, the Board of the Accreditation Council for Graduate Medical Education (ACGME), and the Board of the American Association of Colleges of Osteopathic Medicine (AACOM) reached an agreement (Memorandum of Understanding) to work together to prepare future generations of physicians.”

1/20/2015 31



July 2014 AOA House of Delegates • When fully implemented

in July 2020, the new system will allow graduates of osteopathic and allopathic medical schools to complete their residency and/or fellowship education in ACGME-accredited programs and demonstrate achievement of common milestones and competencies.

1/20/2015 32



Memorandum of Understanding

• ACGME Board of Directors by 2015 – American Board of Medical Specialists – American Hospital Association – American Medical Association – Association of American Medical Colleges – Council of Medical Societies – American Osteopathic Association – American Association of Colleges of Osteopathic Medicine

• Equal Representation on the ACGME Board of Directors with bylaw change to allow AOA and AACOM by July 2015

1/20/2015 33



ACGME Board Composition • AOA

– Karen Nichols, DO – David Forstein, DO

• AACOM – Clint Adams, DO – Gary Slick, DO

• The other 5 organizations have 4 Board Members: – AMA – AHA – CMSS – ABMS – AAMC

• Public Director- 3 • Director at Large- 2 • Chair of the Council of

Review Committees Chair • Fed Gov Representatives

– VA – Bureau of Health

Workforce at the Health – Resources Service

Administration • Vice President DO

Pending

August 20, 2013 34



Memorandum of Understanding

• Residency Review Committees providing Residency oversight – Osteopathic “distinctive” programs – Osteopathic representation on all residencies DO’s

• AOA programs must apply over 5 years for full ACGME certification – automatically preliminary certification

• AOA Boarded Program Directors not guaranteed same status as ABMS Board Certified DO’s

1/20/2015 35



Proposed Timeline to July 2015

• Spring 2013 - Questions to be resolved – Certification for DO’s (AOA v ABMS) – Role for DIO/DME – OPTI structure as Institutional Sponsor – Number of Program Directors/program – All GME open to all Med school grads (LCME,

COCA, Int’l) – Observers at ACGME & AOA meetings

36



Further Negotiations • All current AOA GME programs will be deemed “pre-

accredited” by ACGME – must apply • AOA Credentials will be deemed on par with ACGME

– COMLEX = USMLE licensing exams for residency application • 70% of ACGME programs accept DO licensing exam • All DO’s eligible to take MD licensing exam USMLE

– AOA Certification = ABMS Certification • Currently not for Program Directors with AOA Boards • Negotiations with Individual Specialty Colleges

– AOA Training = ACGME for fellowship training provided AOA program pre-accredited by ACGME

• Single Match –not currently being discussed 37



ACGME-AOA NEXT STEPS AND CONCERNS

38



Concerns

• AOA Board Certification and AOA Membership • Maintenance of Licensure and Maintenance of

Certification • Osteopathic Physicians access to Surgical Specialties • Viability of Osteopathic Residencies

August 20, 2013 39




• When given a choice what percentage of osteopathic residents who graduate from a dual accredited ACGME/AOA program take the DO/osteopathic boards? – 20%* – 40% – 60% – 80%

1/20/2015 40



AOA vs. ABMS Board Certification • AOA Board Certification

– Currently in dual accredited programs both in family medicine and in internal medicine those graduates with the DO degree only 20% take the AOA boards.

– Over 60% of osteopathic student graduates take ACGME residencies - almost none take the AOA boards.

• Survey DO graduates in Dual Accredited Programs: – ABMS Boards

• Greater “value” regarding employment options and hospital privileges • 10 year re-certification versus 7 year re-certification

– DO Boards Participation • Potential for any academic career • Perceived loyalty to the profession • MD’s not invited • AOA Board certification = AOA membership – OPSC HOD



Board Certification - ABMS and AOA

• AOA Boards – Bureau of Osteopathic

Specialists – 18 Individual Boards but

all report to AOA

• Recertification 7 years • MD’s not eligible

• ABMS Boards – 24 Boards Individual

Companies

• Recertification up to 10 years – continuous of certification

• ABMS added (MOC) Maintenance of Certification

August 20, 2013 OPTI - West 42



AOA vs. ABMS Board Certification • ABMS Boards

– Significant dissatisfaction by current members – ABIM instituted significant changes to its MOC

process on January 1, 2014. The modifications apply to all physicians, including those who received life-time certification prior to 1990 (“grandparents”), and mandate completion of any MOC activity every two years, accumulation of 100 MOC “points” distributed between Part II and Part IV activities within five years, completion of patient survey and patient safety activities, and passing a secure examination every 10 years.



American College of Cardiology Response to MOC - President

• “it is important to share the results of a member survey commissioned by ACC and distributed through our state chapters in the spring of 2014. The survey was completed within four weeks by over 4,400 members (12 percent of the total solicited). Nearly 90 percent of respondents opposed the changes to MOC, citing, among multiple concerns, higher than expected costs. Nearly a third of respondents indicated that the changes will affect their future career plans and will likely accelerate career decisions such as early retirement, part-time work, or transition to non-clinical work.”



Association of American Physicians and Surgeons MOC Law Suit

AAPS Takes MOC to Court Jul 31, 2014

July 28, 2014 update: A Wall Street Journal Article of July 21, 2014 reports: "The ABMS also says it has arranged with some 32 major health systems, including the Mayo Clinic and M.D. Anderson Cancer Center, for their own in-house quality improvement projects to satisfy some MOC requirements for their doctors." This reported statement by Defendant ABMS is contrary to its position in this case, which is that hospitals are somehow acting independently of ABMS in imposing MOC requirements. Read more in the AAPS July 28 letter to the U.S. District Court: http://aapsonline.org/AAPSvABMS-july-28-2014-letter.pdf



ABMS Changes



Medical Knowledge Growth Exponential

• Medical knowledge today doubles every 1.8 years as of 2015.

• It is predicted that medical knowledge will double every 48 days by 2018.

• Current solution by ABMS method of Maintenance Of Certification does not keep up with the knowledge growth yet it has substantially increased the costs and burden of recertification.



Current AOA Boards

• Do not reflect Scope of Clinical Practice – Geriatrics under Family Medicine spend time with studying

Pediatrics and Obstetrics – Is not flexible for changes in practice such as urgent care or

administrative medicine

• Does not allow MD’s to be Board Certified

August 20, 2013 OPTI - West 48



Proposal - Alternate MOC

• AOA create an alternate pathway to Maintenance Of Certification which combines continuous certification with recertification.

• Those enrolled in the alternate pathway to MOC will maintain a lifetime certification provided they are compliant with the monthly certification modules.

• Customize Board Certification based on current practice of medicine – not scope of practice during residency training.



Adaptive Intelligent Learning Engine

• RealizeIt Software – • Disclosures – None Personally – WesternU Dental

Program • Developed in association with Stanford Medical

School with Western University School of Dentistry for Head and Neck Anatomy class

• Adaptive Intelligent Learning Engine – Personalizes Learning Experience – mapping the knowledge base of each user.




• Realize It Video If Time Permits




• Initially tests knowledge and based on your response, “maps” your knowledge through learning nodes




• Provides customized course material to assure compliance to maintain competency based on testing responses

• Provides a continuous “mapping of knowledge” throughout career



Continuous Board Certification

• “Node Concept” can subdivide knowledge requirements and customize for each physician’s practice – Gerontology – no node for pediatrics and obstetrics – Allopathic physicians- no node for osteopathic

manipulative medicine – Outpatient physicians – exclude hospitalist and intensivist

curriculum and assessment

• Provide continuous certification for those providers both MD and DO who never completed a residency



Continuous Board Certification • “Knowledge Mapping” of both physician and profession

– Provides evidence based analysis for continuing medical education for both state and national societies

– CME can provide on-site skills assessment – OSCE’s • Specialty Societies provide content for teaching with

potential interprofessional collaboration between specialties – Example - Diabetes modules by both internal medicine and

family medicine • Specialty Boards continue assessment integrated with

Adaptive Intelligent Learning Engine • Continuous update of knowledge-based curriculum with

the advances in medicine



Current Proposal - Benefits • Continuous certification with specific learning nodes

using the adaptive intelligent learning engine is not easier but more relevant to current practice pattern

• Repatriation of DO graduates from ACGME programs to become AOA board-certified

• New DO or MD graduates of new ACGME to have improved method of (AOA) board certification

• Opportunity for growth of the AOA profession by allowing allopathic physicians currently ABMS boarded to take continuous certification modules

• Theoretically would provide better patient safety/care due to the evolving real-time curriculum and assessment modules



Proposed Solutions

• AOA Develop Boards provide DO’s with Continuous Certification if participate Lifetime Board Certification

• AOA Develop new Boards with ability to Board

57

2015Fall Conference

September 11-13

Monterey Plaza Hotel400 Cannery Row

Monterey, CA 93940

www.opsc.org/event/FC15

2015Fall Conference

September 11-13


Monterey, CA 93940


2015Fall Conference

September 11-13


Monterey, CA 93940
