#25 RRC
Are you aware of the new mission, vision and values recently developed by ACGME?
Yes, sort of.
What impact, if any, does their new mission, vision, values have on you and your associates?
None. They’re just words and they didn’t ask me to contribute to them.
In general, what can the ACGME do to make your life easier?
They could have fewer regulations and reduce the burden of paperwork. The competency movement is principle for life-long learners. But the way these rules are written is that it’s generated a huge amount of paperwork but hasn’t substantially changed training programs.
The rules of the residency should be simplified. They’re too complicated right now. They should not apply universal templates to all programs. They’re all unique. They should focus on rehabilitating problem programs. I’m at a hospital where we have high quality programs and I think the ACGME didn’t fix anything because nothing was broken.
Are you familiar with the governance structure and the board?
Minimally.
Do you presently know how new members of the board of the ACGME are appointed?
Not really.
Do we have the right appointing organizations? (To the board? To the RRCs?) Should others be appointing? Who?
I don’t have an opinion about that. My sense is that there is a lot of inbreeding and I think we need to have more outsiders.
Who should appoint members to the RRC’s?
I think we have the right groups.
What recommendations would you offer to strengthen the governance of ACGME?
I haven’t been on the RRCs but I don’t think there has been much direct communication with the ACGME board. I think they need to have a forum for discussion before they make big changes. That would be better than putting things out on their website for comments. I doubt anyone really does that. The communication is not very good.
Have you heard of the portfolio program?
Yes.
Do you have an opinion on how to make that process better?
I have the same opinion. If it’s not broke, don’t fix it. Looking at our board pass rates, I just don’t see a need to radically change our system, unless it simplified things.
What would make the board more inclusive?
It would be great to have some representation of the program directors.
How about the executive committee?
Don’t know anything about it.
Do you have an opinion about whether patients should be involved in the RRCs?
If there is a pattern of problems, including complaints by patients, then there should be a way to resolve them. But on the RRC, no, I don’t think that’s a good idea. But if there are repeated complaints, then the trainees should be counseled and disciplined.
Is there something you would change in the relationship between ACGME and the RRCs?
The ACGME needs to be an arbiter among the RRCs when there are overlapping skill sets, especially if there are controversial topics or to make sure they’re not out of bounds. The tone should be set by the ACGME that a prime goal is to simplify the requirements.
How should the ACGME deal with consistency? What is the line between standardization and allowing for uniqueness?
I don’t know where the institutional requirements come from. I don’t’ see why there has to be consistency among RRCs, except to make sure that the institution has adequate resources. The specialties are so different, it’s just not important as a goal.
Should the RRCs do more collaborating between them?
They should collaborate when there is overlap, like in neurosurgery and radiology where they need to make sure the requirements are the same. It’s reasonable for RRCs to comment on revisions on other subspecialties.
How can we make sure that there is adequate representation from the RRCs in the halls of the ACGME?
I think they already do that. Anytime the ACGME is contemplating a change in the regulations that affect the RRCs, there needs to be a lot of communication. The leaderships should come to the RRC and get some feedback.
What about the voice of residents being heard?
Since we have a resident member on each RRC I think that’s enough. I don’t know what else could be done.
What would you say is the greatest strength of the ACGME?
They have a lot of power and are able to make regulations that affect the quality of training programs and guarantee a minimum of training in the program. They have the federal government behind them. They have a well-developed and mature organization given their relationship with the RRCs.
If you were going to send a message to the Board of ACGME about what should be changed in the governance structure, what would that be?
They should focus on simplifying the regulations. The rules are overburdensome. They should reevaluate their goals and objectives and their list of competencies. They need to be tailored for each of the specialties. The regulations are very costly and often yield a negative or only a slightly positive. We need to get rid of the 80 hour work week rule.
Why is the 80 hour work week not a good idea?
Most hospitals were having the residents a reasonable amount of time, though there a couple that were abusing the residents, so that’s where it came about. But instead of just remediating the problem places, it has now restricted the hospitals who were not abusing it. Having one rule that will fix and fit every program is just a bad idea. They could have worked harder to look at the programs that were abusing the system and remedied the problem there. Many of the residents are getting short changed on the number of procedures they can participate in. This has been a very costly decision. It puts an expense on the hospital to make up the difference.
Do you really believe there can be quality of care after working 24 hours straight?
Well, they’re supervised. Right now you don’t know how long your physician has been working. There are no regulations on them. I don’t think there are studies that prove after 80 hours that quality suffers. And the rule is too strict. They have to be out of the hospital, even if they want to stay for a lecture, they can’t.
If it’s true that the business model of the hospital is dependent on the residents, that seems out of balance.
You need physicians who are the first responders, but residents can start out the assessments. You need someone there, such as a PA, and I imagine there are many places when you don’t have physicians on the premises. Now all the residents are doing shift work, they don’t know the patients. If it was the same resident who admitted them, then they’d know the patient better.
#26Appointing Organization
Are you aware of the new mission, vision and values recently developed by ACGME?
Not intimately. I’ve not been directly involved in it.
What impact, if any, does their new mission, vision, values have on you and your associates?
It probably has a great deal. It is necessary for the RRC of surgery stay in synch with the ACGME.
In general, what can the ACGME do to make your life easier?
Not too much. They don’t have much impact on my life. The single biggest thing that would impact the board is having the ACGME work in concert with us. That’s happened well of late.
Is there anything that could make the life of the RRC?
Not really. Perhaps better views at times.
Are you familiar with the governance structure and the board?
Yes.
Do we have the right appointing organizations? (To the board? To the RRCs?) Should others be appointing? Who?
I think they’re appropriate organizations. I’m sure you could find others.
Who should appoint members to the RRC’s?
The era when the AMA was relevant is long past. They don’t have the kind of involvement with education or the specialties that make them an anachronism. The Association of Program Directors of Surgery probably would be better suited.
What recommendations would you offer to strengthen the governance of ACGME?
I’m not sure if the directions taken are going to be productive. The six competencies were arrived at about 12-14 years ago as a result of a meeting between the ACGME and the ABMS. It is an idealized concept for idealized medical practice. It was an attempt to find the multi-dimensional approach to medicine. They have now become the driver for how accreditation is assessed. Unfortunately, while it’s an ideal concept, the six competencies do not include some extraordinarily necessary competencies that are required. This is resulting in the imposition of requirements that are relatively unrealistic which failing to evaluate things that are crucially important. It’s led to a misdirection for the ACGME. It was done with the best of intentions but it’s the wrong target.
What are they requiring that are impossible to measure?
System-based competencies for example is an exercise in futility.
Do you as a specialty have requirements that are above and beyond the ACGME?
Sure. But the RRCs are mandated by the ACGME to adhere to certain templates. The program directors of the RRCs are constrained by those guidelines.
It seems to me that the difficulties are on the ground at the training level. This is not something the ACGME is confronted with. The feedback to them is probably pretty limited.
How can we make sure that there is adequate representation from the RRCs in the halls of the ACGME?
There are multiple levels of feedback that would be useful. I think the program directors are a rich source of feedback. I don’t think their opinions are solicited very often.
What would make the board more inclusive?
It’s fine.
What’s the optimal size for the board?
It seems good.
Is there anything that can be done to improve transparency?
I think anyone who inquires can find out anything about it. The mechanism of decision-making is reasonably available. That’s not the problem. It’s a real knowledge of the difficulties in training.
Is there something you would change in the relationship between ACGME and the RRCs?
The ACGME provides the structure and framework. The issue is not the structure but the exchange of information.
How should the ACGME deal with consistency?
I think they do already.
What is the line between what you standardize and where you allow uniqueness?
It depends on the institutional guidelines and the specialty guidelines. T
Should the RRCs do more collaborating between them?
A little but not a lot. There is a council that gets together 2 or 3 times a year and exchanges information. There can be joint programs that bridge across a couple of specialties. It really depends on the specialty.
What would you say is the greatest strength of the ACGME?
It provides objective evaluation of the teaching. It’s an honest organization which evaluates in as fair and objective a way as possible. That’s a huge plus. Training programs that are not subject to the ACGME are not up to the same quality.
Do you have an opinion whether it should be a competency vs. a representational board?
I don’t think it would be of any benefit. It would be hard to specify which competency would be more beneficial than another.
If you were going to send a message to the Board of ACGME about what should be changed in the governance structure, what would that be?
They need to have a total relook at the 6 competencies, recognizing they were theoretically derived and have not been subjected to a high quality evaluation in any framework. They have not been shown to bring about a higher level of care.
What would be an alternative?
There is not an alternative in the US, but the Canadians have something called Canmeds. We wrestle with this on the board all the time. I would test cognitive knowledge pretty strongly. The oral examinations are much less robust. They’re subject to more variability. If you ask about the relevance of these to medical practice, you will not see their impact on broad competence. What we really lacking is what we care about. An example is that you’d like your doctor to talk to you in a way you can understand and is an expert advisor to you. It’s as if this group got the stone tablets from on high and if you question them, you’re a heretic. These are not stone tablets. They were never subjected to validation. They were never looked at to see if they affect outcomes. There’s a feeling that this group has their heads in the clouds. Evaluating the competencies should be a constant iteration. It should be a living document that changes with the times. And we should test them.
I don’t know if educators would be any more comfortable with that kind of mentality. They’re not very easy with living flexible documents.
That surprises me. It’s been proven that teaching mathematics does not work the way we’ve been doing it for the last 20 years. You have to put it in context of something practical.
The way doctors are trained is so inefficient. The time wasting aspect of medical education is huge.
The Canadian government has awarded a grant for redesigning residency programs.
#27 Board Member
Are you aware of the new mission, vision and values recently developed by ACGME?
Pretty much.
What impact, if any, does their new mission, vision, values have on you and your associates?
As a retired person, very little. As a board member, quite a bit.
In general, what can the ACGME do to make your life easier?
They could improve the communication with reference to every organization and person and item they deal with. I think we underestimated how the 80-hour work week would impact everyone. We should have communicated about it a lot more and a lot earlier.
Are you familiar with the governance structure and the board?
Yes.
Do we have the right appointing organizations? (To the board? To the RRCs?) Should others be appointing? Who?
Yes. I don’t know all the details, but it seems to me they are all appropriately structured.
What would make the board more inclusive?
There are about 26 members and that’s more than enough to manage. If there is an organization that feels they need representation on the board, it’s their responsibility to make that contact.
What’s the optimal size for the board?
I wouldn’t want it any bigger. It’s probably an appropriately sized board.
Is there adequate representation on the executive committee?
Yes. You can always add a board member or two to the executive committee without deterring the work of that committee. It should be someone who is appropriately interested in the work that needs to be done.
Do you have an opinion whether it should be a competency vs. a representational board?
No. We have enough competency among the members. The executive committee ought to be a succinct grouping.
Do you have an opinion about the transparency?
Yes. I’m a strong believer in communication. Any action taken by the executive committee should be openly communicated to the full board.
Anything about transparency between the member organizations and the board?
Anything that improves communication is to be encouraged. And it needs to be a two-way street.
What recommendations would you offer to strengthen the governance of ACGME?
They need to improve all of their communication. It needs to be clear to everyone in the world they serve what they’re doing. Positive and negative feedback.
Is there something you would change in the relationship between ACGME and the RRCs?
The ACGME is the mothership for the RRCs. They RRCs only exist within the confines of the ACGME. There needs to be a review by the ACGME central staff of the function of each RRC and the RRCs need to understand that’s going to happen.
How should the ACGME deal with consistency?
Basic requirements need to be the same. But beyond that it needs to be specific to the specialty.
Should the RRCs do more collaborating between them?
I have no problems with that. It should be encouraged. They could collaborate on anything that seems to be of interest to them. David Leach has created a committee of RRC chairs and that seems the appropriate mechanism for them to do that.
How can we make sure that there is adequate representation from the RRCs in the halls of the ACGME?
Anything we can do to bring them into a positive role with the ACGME is to be encouraged. They are the workers. I have no problem in seeking their council and advice, but they should not interpret that even though they’re in the position to offer advice, it may not be adhered to.
What about the voice of residents?
Every RRC has a resident member and that should be where they speak out.
What about the voice of program directors?