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Providence OB/Gyn Education Newsletter

March 2012- June 2012- December 2012

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December 2012: Third Editionpdf

A Word From the Chair:
We are a High Reliability OB/GYN Department!

Robert Welch MD
Department Chair and Associate Program Director

Dr. Robert Welch Over the past several years, we have introduced and implemented a variety of initiatives to improve patient safety in a quality and cost effective manner. Such things as policies & procedures, pathways, time-outs, team-training, root-cause analysis and simulations fall under the umbrella of what is known as a High Reliability Organization (HRO). What are some other industries that have this status? If you think about it, there are several. The ones that come to my mind are airlines and aviation, the nuclear power industry, and even aircraft carriers, to name a few. These industries enjoy a tremendous safety record, yet when things do go wrong, they can be catastrophic.
So what things do we have in common with other HROs? We operate in an unforgiving social and political environment. If something goes terribly wrong, our patients suffer and we pay a terrible toll. Our technologies are somewhat risky and present the potential for error. Think of the multiple steps in giving a simple blood transfusion, or how imperfect the electronic fetal monitor may be in predicting newborn outcomes. The scale of possible consequences from errors precludes experimentation. We have to get it right every time and there is little room for variation. The "dose-is-the-dose"! To avoid failures, we use complex processes to manage complex technologies and complex work. That I.V. solution or medication has to be checked and double-checked to assure accuracy.
There are some other things we have in common with HROs. We have highly trained personnel who undergo continuous training. There are effective reward systems, frequent process audits, and continuous improvement efforts. There is an organization-wide sense of vulnerability. Our sense of responsibility and account-ability for reliability is widely distributed and there is widespread concern about misperception, misconception and misunderstanding. We are pessimistic about possible failures and that has caused us to build in redundancy and a variety of checks and counter checks.
These realizations have lead to what is known as "Collective Mindfulness". We have a culture of safety and we want anyone and everyone to speak-up if they believe that a safety issue is occurring. We are sensitive to operations and must follow our established processes in even the most insignificant circumstance. For example, that time-out, needle count, instrument count and other processes are incredibly important and cannot be discounted or skipped. We must have a reluctance to simplify. Simple process are good . . . simple explanations for why something went wrong are not. If a failure takes place we must delve deeply into reasons to assure that they cannot recur. We have to have a preoccupation with failure. When a near miss does occur, it is a symptom of a flaw in our process that has to be addressed to avoid a future catastrophe. And, we must give deference to expertise. The staff on the frontline often knows what is best for patients and they must be included in any solutions. Finally, there has to be resilience. Even the best units will have rare complications. Unit staff have to work together to find better solutions to avoid a similar event in the future. They must also consider the "second victim" who is that health care provider who fell into the scenario that allowed the problem to occur in the first place. These health care providers deserve sympathetic consideration and support . . . and an opportunity to contribute to a solution.
The difference between our HRO and others is that we take care of people. For example, if there is a glitch in the nuclear reactor, they shut it down and fix it. We don't have that luxury and patients can be hurt, even if it is only an unnecessary needle poke. What we do have in common with other HROs is hypercomplexity in what we do; tight coupling relying on multiple people to pull-off an event (think of the operating room); extreme hierarchical differentiation between and among our staff; multiple decision makers in a complex communication network involving unit staff, nursing, physicians, anesthesia; a high degree of accountability; need for frequent and immediate feedback; and compressed time constraints.
So now, perhaps you are beginning to understand the concept of an HRO and that you are part of an HRO! I suspect that some of you will begin to speak HRO language. I personally like the phrase "tight coupling" because it forces me to consider the complexity of operations we perform (e.g., cesareans, hysterectomies). We don't even consider it, but we are tightly coupled with the performance of the parking attendant, registrar, laboratory, unit staff, nurses, anesthesia, scrub techs, assistants, recovery room and post-operative floor, discharge planners, etc. When you sit back and contemplate the whole process, it is both very impressive . . . and very scary!
I hope that I have synthesized some of the activities you have been part of and helped you to understand their importance. In my next installment about HROs, I will bring this all back specifically to OB/GYN; the things we are currently doing, the things that are coming . . . I like to think that being a High Reliability Organization is a journey we have embarked on together. Conversely, some of you may just think that you are in "the twilight zone"!

Program Director's Corner
Feedback, The Lifeblood of Educational Excellence!

Robert Dodds, MD
Program Director

Dr. Robert Dodds
Feedback has been defined as "the practice of providing information to medical learners about their performance in clinical situations to guide their future performance". In this way, feedback is formative. It is designed to make our residents and students become competent.
Evaluation, as compared with feedback, is important but serves a different purpose. It is summative. In other words, it is a description of the abilities and performance of a practitioner done after-the-fact. This is a necessity for credentialing and accreditation. It is typically done with formalized testing (ie. Board exams) or performance evaluations by a direct clinical supervisor (ie. end of month or surgical skills evaluations). These evaluations provide important feedback to program leadership, but are of much less learning value to the residents/students. In fact, a large concern expressed by our residents at last years Retreat was a lack of usable feedback.
There is a theory that an "Adult learning model" exists in medical education. As we mature we develop the ability to direct our own learning to meet our own individual needs. A practical example would be an obstetrician learning how to do a better delivery, but not being too concerned about how to place a neural shunt. As you can imagine, the key component of such a model would be the ability to accurately self assess performance and therefore determine what learning is required. A recent systematic review found that this ability was lacking in many physicians, but seemed to be most pronounced in 2 groups: those judged to be the least competent, and those who are the most confident. Compounding this problem, most physicians believe their self assessment skills are above average....contrary to reality. While there are many potential reasons for this lack of insight, these physicians may not have had the feedback they needed as students to develop this skill.
Ideal feedback is that which leads to sustained improvement in clinical performance. This type of feedback is most strongly associated with 2 factors:
  1. The feedback was from an authoritative (respected) source, such as a clinical supervisor
  2. The process occurred over an extended period of time, generally at least 2 years.
Avoid value judgements about the inherent "goodness" or "badness" of the feedback. The only way to avoid similar mistakes in the future is to make the learner aware of those mistakes. The most effective feedback should:
  • occur with the teacher and trainee working as allies with common goals in a private location
  • be well-timed and expected
  • be based on first-hand data (observations)
  • be limited to behaviors that are remediable
  • be phrased in descriptive, nonjudgmental language
  • deal with specific performances, not generalizations
  • elicit the learner's thoughts and feelings, and deal with decisions and actions (not presumed intentions)
  • include suggestions for improvement
It is possible to do too much at one time, remember: OB/Gyn residency is 4 years, not one case. Try not to overwhelm the learner by focusing on the most important concepts first. It is a good idea to blunt negative criticism with positive observations. Try to make an effort to give a little feedback with each clinical encounter.
With a little effort, I believe we can continue to improve our Educational Environment.

Update with Ellen

Ellen Kleiman
Happy Holiday!

Nothing new is happening in the administrative offices currently, just swamped with interviews. I would just like to wish everyone a happy holiday!

Medical Student Review
Providence Educational Excellence

Paul Schnatz, MD
Clerkship Director

I thought you might be interested to know how medical students view the Ob/Gyn core clerkship at Providence. The short answer is that in general they feel it is a worthwhile and valuable clinical experience and they indicate that the quality of teaching is as good or better than any they have had during their five core clerkships at Providence.
There are several sources of outcome data that validate the above statements. As you know, we have students from three medical schools taking the core clerkship. For the past eighteen months more than half the students have been from American University of the Caribbean School of Medicine. We also have students from Wayne State University every clerkship and one student from Michigan State College of Osteopathic Medicine for the first four weeks of most eight week clerkships. The Michigan State students also spend 4 weeks with a preceptor doing office gyn − a rotation that has nothing to do with Providence. At the end of each eight week core clerkship and after four weeks for the Michigan State student, I give an oral examination that is designed to provide students with experience in taking oral examinations. I also conduct an exit interview at the same time. During the exit interview I ask about the quality and quantity of resident and attending teaching during the student's time in our department. I consistently hear that both attending physicians and residents take time to teach and answer questions − some more than others, but all to at least some extent. Students express their appreciation for the attention paid to them and nearly all indicate that they enjoyed the rotation. It is not uncommon to hear students indicate that when they started Ob/Gyn they had no interest in the specialty, but because of the positive experience they had they are now considering a residency in Ob/Gyn. They also comment on the positive relationships among residents and attending physicians.
At the end of the clerkship, we have all students complete a written and anonymous evaluation of the clerkship and there are several questions dealing with teaching and attitudes of attending physicians and residents toward students. Again, these comments are overwhelmingly positive and indicate that all of you are truly dedicated to providing a quality clinical education for students. This evaluation also generates comments about the clerkship organization, some positive and some negative. Many of the comments indicate student preference and our department organization prevents some of the changes students suggest from being implemented. Over the years, however, several of the student suggestions have been incorporated into the clerkship curriculum.
AUC also has students complete an on line anonymous evaluation of every core clerkship at every one of it’s twenty four sites in the United States. AUC shares these comments with individual sites and again the overwhelming number of comments are superlatives regarding the quality and quantity of teaching at Providence in Ob/Gyn and naming specific residents and attending physicians as good or outstanding teachers. These evaluations are generally done after students have received their grades and generally tend to be more critical of faculty than surveys done immediately at the end of a clerkship before grades are available. The fact that they are so positive indicates that as a department we are providing a good educational experience.
AUC shares the results of the NBME Clinical Subject Examinations with all of it's clinical sites. The NBME "shelf" Examinations are taken by all AUC students at the end of each core clerkship. As you know, they are also taken by U.S. medical students. The NBME results at AUC for students who took their core clerkship in Ob/Gyn at Providence are in the top one third of all students who took the Ob/Gyn exam at AUC.
Last, but not least, Providence Medical Education Department sponsors a teaching award. The resident and attending physician recipients are selected by all students who have been assigned to Providence for all core clerkships and by students who take elective clerkships at Providence. In the past two years both resident and attending physician recipients have been from the department of Ob/Gyn!
As you can see, there are several sources of data beside my own opinion that indicate you are doing a fine job as clinical teachers. You have my profound thanks for your successful efforts.

Notes from the New Chief

Harjeet Sekhon, MD

Dr. Sekhon I can't believe that we're already halfway through the year! The first year residents have made a seemingly smooth transition into the residency program, and the third year residents have each come into their own of a being a senior resident.
This year particularly in morning report, we have strived to create an environment that is conducive to learning, presenting the latest Practice Bulletins, Committee Opinions, and journal articles. It is imperative that we always practice evidence-based medicine, especially with new technology and advancements in medicine in this day and age. We are fortunate to have faculty from various backgrounds that can offer unique perspectives on medical management of different disease processes. It has been emphasized to the residents this year to truly take ownership of their patients to learn how to create their own unique style of practicing medicine. Our department continues to be recognized for excellence in medical student education, and I hope that we can continue to lead by example.
I wish you and your families a very happy holiday season and a prosperous new year!

Important Dates to Remember
Mark Your Calendars

Faculty Meetings:

  • Thursday December 20, 8-9 am Otlewski Conference Room
  • Thursday January 17, 8-9 am Otlewski Conference Room
  • Thursday February 21, 8-9 am Otlewski Conference Room
  • Thursday March 21, 8-9 am Otlewski Conference Room
  • Thursday April 18, 8-9 am Otlewski Conference Room
Note: Faculty meetings are telecast on GoToMeeting

CREOG In-Service Training Exam

Remember there will be no residents available for surgery this day
  • Friday January 25, All Day, Providence Southfield

Christmas and New Year's Vacation

Resident staff is reduced for the holidays. There will be a skeleton staff in Southfield and moonlighting coverage in Novi.
  • December 22-25: Christmas
  • December 29-January 1: New Years

Interviews

Recruitment season is upon us!
  • Nov through Jan: Interviews will take place Monday's and Friday's

CREOG/APGO Meeting

Education administration will be flying southwest to learn more about upcoming changes in medical education.

  • February 27-March 2 2013: Phoenix Arizona

Match Day 2013

  • Friday March 15, 2013

SEMCME Senior Mock Oral Exams

  • Wednesday March 20, 2013: Maruzek Center WSU

Providence Hospital Resident Research Day

  • Wednesday April 17, 2013: Fisher Auditorium

Resident Graduation, 2013
Save the date!

  • The Reserve: Graduation will be held the evening of Friday, June 7. It will be at The Reserve in Birmingham

Future Newsletters

If you have any comments or suggestions for future newsletters, please feel free to email Dr. Dodds. Also, if anyone is unaware, we do have a recruitment website. The address is: www.providenceobgynresidency.com
I wish everyone a happy holiday and look forward to the new year!

Other Editions: March 2012- June 2012- December 2012

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