Systems-Based Practice 20 Years On: Navigating the System for Better Care.

ABSTRACT: Systems-based practice (SBP) was introduced as 1 of 6 core competencies in 1999 because of its recognized importance in the quality and safety of health care provided to patients. Nearly 25 years later, faculty and learners continue to struggle with understanding and implementing this essential competency, thus hindering the medical education community's ability to most effectively teach and learn this important competency.Milestones were first introduced in 2013 as one effort to support implementation of the general competencies. However, each specialty developed its milestones independently, leading to substantial heterogeneity in the narrative descriptions of competencies including SBP. The process to create Milestones 2.0, and more specifically, the Harmonized Milestones, took this experience into account and endeavored to create a shared language for SBP across all specialties and subspecialties. The 3 subcompetencies in SBP are now patient safety and quality improvement, systems navigation for patient-centered care (coordination of care, transitions of care, local population health), and physician's role in health care systems (components of the system, costs and resources, transitions to practice). Milestones 2.0 are also now supported by new supplemental guides that provide specific real-world examples to help learners and faculty put SBP into the context of the complex health care environment.While substantially more resources and tools are now available to aid faculty and to serve as a guide for residents and fellows, much work to effectively implement SBP remains. This commentary will explore the evolutionary history of SBP, the challenges facing implementation, and suggestions for how programs can use the new milestone resources for SBP. The academic medicine community must work together to advance this competency as an essential part of professional development.

Learner Assessment and Program Evaluation: Supporting Precision Education.

ABSTRACT: Precision education (PE) systematically leverages data and advanced analytics to inform educational interventions that, in turn, promote meaningful learner outcomes. PE does this by incorporating analytic results back into the education continuum through continuous feedback cycles. These data-informed sequences of planning, learning, assessing, and adjusting foster competence and adaptive expertise. PE cycles occur at individual (micro), program (meso), or system (macro) levels. This article focuses on program- and system-level PE.Data for PE come from a multitude of sources, including learner assessment and program evaluation. The authors describe the link between these data and the vital role evaluation plays in providing evidence of educational effectiveness. By including prior program evaluation research supporting this claim, the authors illustrate the link between training programs and patient outcomes. They also describe existing national reports providing feedback to programs and institutions, as well as 2 emerging, multiorganization program- and system-level PE efforts. The challenges encountered by those implementing PE and the continuing need to advance this work illuminate the necessity for increased cross-disciplinary collaborations and a national cross-organizational data-sharing effort.Finally, the authors propose practical approaches for funding a national initiative in PE as well as potential models for advancing the field of PE. Lessons learned from successes by others illustrate the promise of these recommendations.

The Association of Subspecialty and Sex with Industry Payments to Internal Medicine Physicians Who Recently Completed Training.

BACKGROUND: Financial relationships with drug and medical device companies may impact quality of care and academic research. However, little is known when and how these financial relationships develop among newly independent physicians who recently completed from residency or fellowship programs in internal medicine (IM). OBJECTIVE: To compare patterns of industry payments among IM graduates. DESIGN: Retrospective, observational cohort study. SUBJECTS: IM graduates from residency or fellowship programs between January 2015 and December 2019. MAIN MEASURES: We analyzed Open Payments reports made between July 2015 and June 2021 to recent graduates of U.S. Accreditation Council for Graduate Medical Education (ACGME)-accredited residency and fellowship programs in IM. The primary outcome was general payments accepted by these physicians, stratified by procedural (i.e., critical care medicine/pulmonary medicine, cardiac/cardiovascular disease, and gastroenterology) and non-procedural (i.e., infectious disease, general internal medicine, and other specialties) subspecialties. The secondary outcomes included general payments stratified by sex and age at residency or fellowship training completion. KEY RESULTS: There were 41,669 IM physicians with a median age of 33.0 years. In the first 3 years after completion, the proportion of physicians accepting any general payments was 72.6%, 91.9%, and 86.8% in Critical Care Medicine/Pulmonary Medicine, Cardiac/Cardiovascular Disease, and Gastroenterology, compared to 56.1%, 52.6%, and 52.3% in Infectious Disease, General Internal Medicine, and Other Specialties (p<0.0001). After adjusting for confounding variables, the procedural group showed an increased hazard ratio (HR) for accepting any general payments and at least $5000 of general payments compared to the non-procedural group. The HRs of accepting any general payments in the procedural subspecialty were 2.26 (95% CI, 2.11-2.42) and 2.83 (95% CI, 2.70-2.97) in female and male physicians, respectively (p-value < 0.0001). CONCLUSION: Industry financial relationships among newly independent physicians in IM exist immediately after completion of training and are influenced by subspecialty, sex, and age.

Transition to Residency: National Study of Factors Contributing to Variability in Learner Milestones Ratings in Emergency Medicine and Family Medicine.

PURPOSE: The developmental trajectory of learning during residency may be attributed to multiple factors, including variation in individual trainee performance, program-level factors, graduating medical school effects, and the learning environment. Understanding the relationship between medical school and learner performance during residency is important in prioritizing undergraduate curricular strategies and educational approaches for effective transition to residency and postgraduate training. This study explores factors contributing to longitudinal and developmental variability in resident Milestones ratings, focusing on variability due to graduating medical school, training program, and learners using national cohort data from emergency medicine (EM) and family medicine (FM). METHOD: Data from programs with residents entering training in July 2016 were used (EM: n=1,645 residents, 178 residency programs; FM: n=3,997 residents, 487 residency programs). Descriptive statistics were used to examine data trends. Cross-classified mixed-effects regression were used to decompose variance components in Milestones ratings. RESULTS: During postgraduate year (PGY)-1, graduating medical school accounted for 5% and 6% of the variability in Milestones ratings, decreasing to 2% and 5% by PGY-3 for EM and FM, respectively. Residency program accounted for substantial variability during PGY-1 (EM=70%, FM=53%) but decreased during PGY-3 (EM=62%, FM=44%), with greater variability across training period in patient care (PC), medical knowledge (MK), and systems-based practice (SBP). Learner variance increased significantly between PGY-1 (EM=23%, FM=34%) and PGY-3 (EM=34%, FM=44%), with greater variability in practice-based learning and improvement (PBLI), professionalism (PROF), and interpersonal communication skills (ICS). CONCLUSIONS: The greatest variance in Milestone ratings can be attributed to the residency program and to a lesser degree, learners, and medical school. The dynamic impact of program-level factors on learners shifts during the first year and across the duration of residency training, highlighting the influence of curricular, instructional, and programmatic factors on resident performance throughout residency.

Industry Payments Received by Residents During Training.

Importance: Those responsible for medical education-specialties, sponsoring institutions, and program directors (PD)-are independently associated with the professional identity formation of the trainees with respect to potential conflicts of interest. Objective: To identify the relative degree to which factors in the training environment are associated with resident acceptance of payments from pharmaceutical and medical device companies. Design, Setting, and Participants: Cross-sectional, retrospective study of residents enrolled in the 3 largest primary-care specialties (internal medicine [IM], family medicine [FM], obstetrics and gynecology [OBGYN]) and 3 largest surgical disciplines (general surgery [GS], orthopedic surgery, and urology) during academic year 2020 to 2021. All analyses were conducted January through August 2023. Exposures: Specialty, sponsoring institutions' ownership (nonprofit, for-profit, federal government, local government, or state government), and the number of payments PDs accepted. Main outcomes and measures: Modified Poisson regression assessed the relative risk of ownership, specialty, and PD behavior on residents' acceptance of industry payments as recorded in the Open Payments Program (OPP) database. Results: In total, there were 124 715 residents in all training programs during 2020 to 2021, 12% of whom received payments totaling $6.4 million. There were 65 992 residents in training during 2020 to 2021 in the 6 specialties evaluated in this study, with 4438 in orthopedics, 1779 in urology, 9177 in GS, 5819 in OBGYN, 14 493 in FM, and 30 286 in IM. OPP records $3.9 million in payments to the 8750 residents (13.4%) who received at least 1 industry payment. The record of all payments to residents in OPP totals $6.4 million. Compared with residents in federal sponsoring institutions, those affiliated with for-profit institutions were 3.50 (95% CI, 2.32-5.28) times more likely to accept industry payments, while those affiliated with nonprofit organizations were 2.00 (95% CI, 1.36-2.93) times more likely to accept payments. Compared with IM, residents in each of the following specialties have an elevated risk of accepting payments: orthopedics, 3.21 (95% CI, 2.73-3.77) times; urology, 2.95 (95% CI, 2.44-3.56) times; GS, 1.21 (95% CI, 1.00-1.45) times; OBGYN, 1.30 (95% CI, 1.05-1.62) times. The difference in the risk of accepting a payment between FM and IM residents was not statistically significant. The number of payments PDs accepted slightly elevated the risk of residents to accept a payment by 1.01 (95% CI, 1.01-1.01). Conclusions and relevance: In this cross-sectional, retrospective study, receipt of industry payments by residents was associated with specialty, institutional control, and PD behavior.

Efforts to Recruit Diverse Resident Complements in Family Medicine.

BACKGROUND AND OBJECTIVES: Family medicine is the most demographically diverse specialty in medicine today. Specialty associations and the Accreditation Council for Graduate Medical Education (ACGME) urge residency programs to engage in systematic efforts to recruit diverse resident complements. Using responses from program directors to the ACGME's mandatory annual update, we enumerate the efforts in resident recruiting. This allows us to compare these statements to the recommendations of two highly respected commissions: the Sullivan Commission on Diversity in the Healthcare Workforce and the Institute of Medicine's In the Nation's Compelling Interest: Ensuring Diversity of the Healthcare Workforce. METHODS: We compiled the annual updates from 689 family medicine programs and analyzed them using a qualitative method called template analysis. We then classified the efforts and compared them to the recommendations of the Sullivan Commission and Institute of Medicine (IOM). RESULTS: Nearly all (98%) of the programs completed the portion of the annual update inquiring about recruiting residents. The Sullivan Commission and IOM recommended 23 steps to diversify workforce recruiting. We found that programs engaged in all but one of these recommendations. Among the most frequently employed recommendations were doing holistic reviews and using data for planning. None mentioned engaging in public awareness campaigns. Programs also implemented eight strategies not suggested in either report, with staff training in nondiscrimination policies being among the most frequently mentioned. Among program efforts not included in the Sullivan Commission or IOM recommendations were extracurricular activities; appointing diversity, equity, and inclusion (DEI) committees or advocates; subinternship (Sub-I) experiences; recruiting at conferences; blind reviews; legal compliance; and merit criteria. In total, we found 31 interventions in use. CONCLUSIONS: The Sullivan Commission's guidance, IOM recommendations, and program-developed initiatives can be combined to create a comprehensive roster of diversity recruiting initiatives. Programs may use this authoritative resource for identifying their next steps in advancing their recruiting efforts.

Trainee Physician Milestone Ratings and Patient Complaints in Early Posttraining Practice.

Importance: Evaluation of trainees in graduate medical education training programs using Milestones has been in place since 2013. It is not known whether trainees who have lower ratings during the last year of training go on to have concerns related to interactions with patients in posttraining practice. Objective: To investigate the association between resident Milestone ratings and posttraining patient complaints. Design, Setting, and Participants: This retrospective cohort study included physicians who completed Accreditation Council for Graduate Medical Education (ACGME)-accredited programs between July 1, 2015, and June 30, 2019, and worked at a site that participated in the national Patient Advocacy Reporting System (PARS) program for at least 1 year. Milestone ratings from ACGME training programs and patient complaint data from PARS were collected. Data analysis was conducted from March 2022 to February 2023. Exposures: Lowest professionalism (P) and interpersonal and communication skills (ICS) Milestones ratings 6 months prior to the end of training. Main Outcomes and Measures: PARS year 1 index scores, based on recency and severity of complaints. Results: The cohort included 9340 physicians with median (IQR) age of 33 (31-35) years; 4516 (48.4%) were women physicians. Overall, 7001 (75.0%) had a PARS year 1 index score of 0, 2023 (21.7%) had a score of 1 to 20 (moderate), and 316 (3.4%) had a score of 21 or greater (high). Among physicians in the lowest Milestones group, 34 of 716 (4.7%) had high PARS year 1 index scores, while 105 of 3617 (2.9%) with Milestone ratings of 4.0 (proficient), had high PARS year 1 index scores. In a multivariable ordinal regression model, physicians in the 2 lowest Milestones rating groups (0-2.5 and 3.0-3.5) were statistically significantly more likely to have higher PARS year 1 index scores than the reference group with Milestones ratings of 4.0 (0-2.5 group: odds ratio, 1.2 [95% CI, 1.0-1.5]; 3.0-3.5 group: odds ratio, 1.2 [95% CI, 1.1-1.3]). Conclusions and Relevance: In this study, trainees with low Milestone ratings in P and ICS near the end of residency were at increased risk for patient complaints in their early posttraining independent physician practice. Trainees with lower Milestone ratings in P and ICS may need more support during graduate medical education training or in the early part of their posttraining practice career.

Trends in Industry Payments to Physicians in the First 6 Years After Graduate Medical Training.

Importance: Financial incentives and conflicts of interest may influence physician decision-making. It is important to understand financial interactions between the pharmaceutical and medical device industries and newly independent physicians who have recently completed their graduate medical education using a national transparency program. Objective: To identify trends in industry payments to recent graduates of Accreditation Council for Graduate Medical Education-accredited residency or fellowship programs in orthopedic surgery, neurosurgery, and internal medicine. Design, Setting, and Participants: This retrospective cohort study analyzed Open Payments reports of industry payments made between July 1, 2015, and June 30, 2021, to newly independent physicians from residency or fellowship programs in neurosurgery, orthopedic surgery, and internal medicine who graduated between January 1, 2015, and December 31, 2019. Exposures: Specialties (neurosurgery and orthopedic surgery, with internal medicine as a comparison group). Main Outcomes and Measures: Industry payments to newly independent physicians, including any general payments (noninvestment or nonresearch) and at least $5000 of general payments in aggregate value per year, which are considered significant financial conflicts of interest. The percentage of newly independent physicians accepting general payments during the first 6 years after graduation was analyzed by specialty and sex using cumulative incidence curves and hazard ratios (HRs) in univariable and multivariable analyses. Results: There were 45 745 recent graduates (28 137 men [62%]; median age at graduation, 33.0 [IQR, 31.0-35.0 years]) in neurosurgery (n = 595), orthopedic surgery (n = 3481), and internal medicine (n = 41 669). In the first 2 years of independent practice, 95% (n = 3297), 92% (n = 546), and 59% (n = 24 522) of newly independent physicians in orthopedic surgery, neurosurgery, and internal medicine, respectively, accepted any general payments. A higher percentage of the newly independent physicians in orthopedic surgery and neurosurgery accepted any general payments (orthopedic surgery vs internal medicine: HR, 5.36 [95% CI, 4.42-6.51] for women and 7.01 [95% CI, 6.35-7.73] for men; neurosurgery vs internal medicine: HR, 3.25 [95% CI, 2.24-4.72] for women and 4.08 [95% CI, 3.37-4.94] for men; P = .03). A higher percentage of male physicians compared with female physicians accepted any general payments (orthopedic surgery, 2884 of 3026 [95%] vs 413 of 455 [91%]; P < .001; neurosurgery, 466 of 502 [93%] vs 80 of 93 [86%]; P = .01; and internal medicine, 15 462 of 24 609 [63%] vs 9043 of 17 034 [53%]; P < .001) and at least $5000 of general payments (orthopedic surgery, 763 of 3026 [25%] vs 71 of 455 [16%]; P < .001; neurosurgery, 87 of 502 [17%] vs 5 of 93 [5%%]; P < .001; and internal medicine, 882 of 24 609 [4%] vs 210 of 17 034 [1%]; P < .001). Conclusions and Relevance: In this cohort study of newly independent physicians in orthopedic surgery, neurosurgery, and internal medicine, the financial relationship with potential conflicts of interest between newly independent physicians and industry began to develop soon after training programs and continued to expand in the early years of newly independent physician practice. Newly independent physicians in surgical specialties and male physicians accepted significantly higher industry payments. Further studies are needed to evaluate whether modifiable factors are associated with the future outcome of newly independent physicians accepting general payments.

Effects of COVID-19 on Residency and Fellowship Training: Results of a National Survey.

Background: The COVID-19 pandemic has affected every facet of American health care, including graduate medical education (GME). Prior studies show that COVID-19 resulted in reduced opportunities for elective surgeries, lower patient volumes, altered clinical rotations, increased reliance on telemedicine, and dependence on virtual didactic conferences. These studies, however, focused on individual specialties. Because the Accreditation Council for Graduate Medical Education (ACGME) routinely collects information from all programs it has an obligation to use these data to inform the profession about important trends affecting GME. Objective: To describe how the pandemic influenced resident training across all specialty programs in areas of clinical experiences, telemedicine, and extended trainings. Methods: The ACGME validated a questionnaire to supplement the Annual Update reporting requirements of all accredited programs. The questionnaire was tested to ensure easy interpretation of instructions, question wording, response options, and to assess respondent burden. The questionnaire was administered through the Accreditation Data System, which is a password-protected online environment for communication between the ACGME and ACGME-accredited programs. Results: We received a response rate of 99.6% (11 290 of 12 420). Emergency medicine, family medicine, internal medicine, and obstetrics and gynecology programs experienced the most significant impact. Most programs reported reduced opportunities for in-person didactics and ambulatory continuity rotations. Hospital-based programs on the "frontline" of COVID-19 care relied least on telemedicine. Family medicine and internal medicine programs accounted for the greatest number of extended trainings. Conclusions: COVID-19 has affected GME training, but its consequences are unevenly distributed across program types and regions of the country.

Reasons for Data-Prompted Site Visits: Field Staff Findings and Review Committee Decisions.

BACKGROUND: A major component of the ACGME's Next Accreditation System (NAS) is the annual review of key performance indicators by each review committee (RC) for all programs under its oversight. The RC may request a site visit that is data-prompted for either a full review of all common and specialty-specific program requirements or a focused review of specific concerns for programs identified as underperforming. OBJECTIVE: The aims of this study were to: (1) identify the reasons that RCs requested data-prompted site visits; (2) describe the findings by accreditation field representatives as reflected in their site visit reports; and (3) summarize the accreditation decisions of RCs that followed the data-prompted site visits (DPSVs). METHODS: RC letters to programs informing them of a DPSV, site visit reports, and RC letters with accreditation decisions were reviewed for all programs having DPSVs from 2015 to 2020. RESULTS: DPSVs were performed in 312 programs, including 59 hospital-based, 122 medical-based, and 131 surgery-based programs; 214 programs had a single DPSV, and 98 programs had repeat DPSV. The most frequent reason that RCs requested a DPSV was noncompliance on the annual ACGME Resident/Fellow Survey. Notification of a DPSV prompted a change in program director in 7% of programs in the single DPSVs group and 57% of programs in the repeat DPSVs group. Surgery-based programs in the single and repeat DPSVs groups were more likely to receive an unfavorable accreditation status. The majority of programs in the single DPSVs group (78%) and repeat DPSVs group (70%) had a status of continued accreditation as of March 2020. CONCLUSIONS: Noncompliance on the Resident/Fellow survey was the most frequent reason that RCs requested a DPSV. The majority of programs in the single and repeat DPSV groups achieved a favorable accreditation status.

Patterns of preconception, prenatal and postnatal care for diabetic women by obstetrician-gynecologists.

OBJECTIVE: To assess barriers to and quality of care received by diabetic pregnant women from obstetrician-gynecologists. STUDY DESIGN: A questionnaire was mailed to 1,000 representative practicing Fellows of the American College of Obstetricians and Gynecologists; 74 did not treat pregnant patients and 510 (55.1%) returned completed surveys. Respondents were divided into 3 groups: maternal-fetal medicine specialists, physicians with high minority/low insurance patient populations, and physicians with low minority/ high insurance patient populations. RESULTS: Reported preconception and prenatal care was generally consistent with guidelines. Regarding gestational diabetes mellitus patients the 3 physician groups differed in assessing postpartum glycemic status, counseling about lifestyle changes, and counseling patients to consult a doctor before their next pregnancy. Patient demographics and perceived barriers to care were similar between maternal-fetal medicine specialists and physicians with high minority/low insurance patient populations. These two physician groups were more likely to agree that lack of educational materials, arranging specialist referrals, patient compliance with recommendations, and patients' ability to afford healthful food were barriers to quality care. CONCLUSION: According to physician self-report, pregnant diabetic patients with access to an obstetrician receive quality care regardless of insurance status. Postpartum care is more variable. Physicians with high minority/low insurance patient populations may lack access to resources.

Measuring meaningful use.

To qualify for new federal funds intended to promote the widespread adoption and use of electronic health records, U.S. physician practices must meet the government's "meaningful use" benchmarks. Our analysis indicates that among physicians who have electronic health records, between 75-85 percent are already using functions that meet some of the proposed criteria for demonstrating meaningful use. But gaps remain. We provide a new analysis of baseline use of specific electronic health record functions among primary care physicians and medical and surgical specialists. The analysis can help researchers and policy makers measure more accurately the success of ongoing efforts to expand effective use of health information technology.