Lessons from #CORDaa16 – Day 2

Things I learned yesterday at CORD Academic Assembly (CORDaa16):

1. “If you’re not at the table, you may be on the menu” (Atul Grover, AAMC). Medical Education Finance is Tricky.  Health care finance and medical education

   

   finance are ever changing and it is imperative that we, as physicians, get involved.  Academic hospitals make up 5% of institutions though they provide approximately 25% of care in the US (that percentage goes up for Medicaid care) and yet Medicare does not adjust risk or reimbursement for the sicker and more complex patients seen at academic centers.  Also, it turns out that residency applicants outstrip the number of PGY1 spots available each year.

2. Physician suicide is a big problem.  Dr. Wally Carter, a legend in Emergency Medicine education who is currently working with ACGME on physician wellness and resiliency, made the point that we’re losing the equivalent of 3-3.5 medical school classes every year to suicide.  Burnout is rampant, though it seems that a subset of physicians are susceptible while others are not even when exposed to the same stressors.  We know that burnout is multifactorial, and that there are also factors that seem to be protective of suicide.
   

   Carter: factors assoc with/contributing to resident #burnout. #cordaa16 pic.twitter.com/nKJbxGp8Np

   — David Marcus (@EMIMDoc) March 7, 2016

   Carter: Suicide protective factors. #cordaa16 pic.twitter.com/XyFuK6FwAh

   — David Marcus (@EMIMDoc) March 7, 2016

   Unfortunately, there are no proven tools to help us guide our friends and colleagues who are struggling with burnout, depression and suicidal ideation.  ACGME and other organizations are working on this.  In the mean time we have to be vigilant and supportive and refer colleagues to professional counseling when needed.  Residency programs need to work on developing wellness and mentorship curricula, address factors that contribute to burnout, an reduce stigma around and barriers to mental health services.

3. Medical student documentation in the EHR probably does not increase legal liability (Wittels and Patel).  It is imperative that medical students learn how to document appropriately during their time in medical school.  None of us want to start teaching  new resident documentation from scratch.  The AAMC has recognized this and included documentation as a requirement within their “Core Entrustable Professional Activities for Entering Residency” (EPA #5).   Since EHR’s are ubiquitous it only stands to reason that students should learn how to use them.  That said, they do not necessarily need to write in the patient’s chart.  Theoretically students could have a parallel chart.  Many facilities, however, do permit and encourage student documentation in the chart as this increases their sense of ownership/involvement and permits greater incorporation into the clinical team.  According to the speakers there is no literature to suggest any increased legal risk on behalf of the faculty or institution.  They did find one opinion paper that explained that students are not seen as “experts” in the eyes of the law and thus would not carry as much weight as the physicians themselves.
4. Student (and residents?) sometimes sue their schools (Jackson).  This session specifically reviewed case law around students dismissed from their schools for various reasons and then subsequently sued.  Important lessons:
   1. All students must be afforded a transparent, consistent, due process (regarding institutional disciplinary action).
   2. It is critical to avoid “capricious” decisions and apply policies equally.
   3. When remediation or disciplinary procedures are triggered it is important that faculty help guide students through the appeals process as well.  Students must receive an “initial notice of deficiency”
   4. The student handbook, policies and procedures, course syllabi, and departmental policies are all considered part of a contract between the student and the program.  It is important that these documents are provided to, and made available to, students.
   5. Student performance, formative evaluation meeting, issues that come up during training, and any remediation meetings should be documented throughout.
5. Standard Letter of Evaluation (SLOE) – there is a new eSLOE in the works.  As implied by the “e” SLOE submissions this year will be done online, though the content will remain mostly unchanged. Follow the SLOE homepage and CORD website for updates.
6. Getting medical education work published (Heitz, Bhatia, Biese)
   1. Since you’re doing the work of developing, implementing and evaluating new curricula you might as well get the word out, get academic/promotions credit out of it, and try to publish it.
   2. Several outlets focus on academic products, especially MeEdPortal.
   3. This article (“Harvest the Low-Hanging Fruit: Strategies for Submitting Educational Innovations for Publication”) from JGME outlines a process for developing educational projects for publication and includes a very useful table that lists a number of education specific features from leading journals including JMGE, Academic Medicine and others. A must read.