Simulation: An Inclined Plane in the NAS

©2015 Accreditation Council for Graduate Medical Education (ACGME)

Simulation: An Inclined Plane in the NAS

John R. Potts, III, MD, FACS Senior Vice President, Surgical Accreditation

ACGME

Consortium of ACS-Accredited Education Institutes 8th Annual Meeting

Chicago 14 March 2015


Disclosures

• In recovery • DIO • Program director in surgery • Practicing general surgeon

• I believe that surgical training in the United States is the best in the world

• No financial disclosure • In this talk, I do not represent ACGME


Outline

• NAS • Inclined plane • Hypothesis • Requirements for simulation • Potts triangle • Roles for simulation in NAS: Milestones • Other roles for simulation


NAS Background

• GME is a public trust

• ACGME accountable to the public


NAS Background

• Patients & payers expect doctors to be:

• Health information technology literate

• Able to use HIT to improve care

• Sensitive to cost-effective care

• Involve patients in their own care


NAS Background

• Public expects GME to produce doctors who:

• Possess these skills, and

• Requisite clinical and professional attributes


NAS Background

MedPAC

COGME

Robert Wood Johnson Foundation

Macy Foundation Institute of Medicine


• Help produce physicians for 21st century

• Accredit programs based on outcomes

• Provide public accountability for outcomes

• Reduce administrative burden of accreditation

Next Accreditation System: Goals


The Next Accreditation System Continuous

observations

Identify opportunities for

improvement

Program makes

improvement(s)

Assess program

improvement(s)

Promote Innovation


Outline



Inclined Plane

Definition: A flat supporting surface tilted at an angle, with one end higher than the other, used as an aid for raising or lowering a load.


Inclined Plane • Moving an object up an inclined plane

requires less force than lifting it straight up, at a cost of an increase in the distance moved.

Fw MA = Fi

MA = Mechanical Advantage Fw = Gravitational force of the load object (weight) Fi = Force exerted on the object, parallel to the plane, to move it up the plane.


• Probably used building: • Stonehenge • Egyptian pyramids

• Sloping roads and causeways by Romans • During the Renaissance the inclined plane

was classed with the other simple machines (lever, wheel, pulley, wedge, and screw)

• 1856 Simon Stevin (Flemish) derived the mechanical advantage of the inclined plane

Inclined Plane


Outline



Hypothesis

Simulation is a tool that can be used to “smooth” the path over many of the obstacles to: learning, assessment and, ultimately, to desired outcomes for GME programs.


Outline



Obstetrics & Gynecology

II.D.3. There must be space and equipment for the educational program, including meeting rooms and classrooms with audiovisual and other educational aids, simulation capabilities, and office space for staff members. (Core)

IV.A.3.b) [Regularly scheduled didactic] sessions should consist of patient rounds, case conferences, simulation training, journal clubs, and protected time for educational activities covering all aspects of obstetrics and gynecology, including basic sciences pertinent to the specialty. (Detail)

Simulation in PRs


Otolaryngology

IV.A.3.b).(3).(a) [Didactics in] Anatomy should include the study and dissection of anatomic specimens, including the temporal bone, and procedural skills laboratories, along with appropriate lectures and other formal sessions. (Detail)

Simulation in PRs


Surgery

II.D.2. Resources must include simulation and skills laboratories. These facilities must address acquisition and maintenance of skills with a competency-based method of evaluation. (Core)

Simulation in PRs


Thoracic Surgery

V.C.2.d).(2).(a) Programs must use the results of assessments to provide program improvement (e.g., quality of the didactic and clinical curriculum, and the use of educational tools such as skills labs and other activities) (Detail)

Simulation in PRs


Simulation in Surgical PRs Simulation Skills Lab

Colorectal Surgery - - Neurological Surgery - - Obstetrics & Gynecology ++ - Ophthalmology - - Orthopedic Surgery - - Otolaryngology - + Plastic Surgery - - Surgery + + Thoracic Surgery - + Urology - -


Anesthesiology FAQs


Emergency Medicine FAQs


Outline



High Tech Simulation


The Value Equation

Benefit Value = Cost


Inclined Plane & Value Equation

PPPPPPPPPPPPPP


PPPPPPPPPPPPPP

© Potts

Cost-Utilization Triangle of Simulation

Component Cost

Component Utility

Basic Surgical Skills

Specialty Surgical Skills

Advanced Specialty Surgical Skills

Advanced Subspecialty Surgical Skills

Innovative & Experimental Surgical Skills


Outline



General Surgery Milestones


Creation of Milestones

ABMS

Milestones

RRC PD Group Academy Residents


Clinical Competency Committee

Clinical Competency Committee

Assessment of Milestones

Peer Evaluations

Nursing and Ancillary

Personnel Evaluations

OSCE

Operative Performance

Rating Scales

Mock Orals

ITE

End of Rotation

Evaluations

Self Evaluations Case

Logs

Sim Lab

Student Evaluations

Patient / Family

Evaluations

Clinic Work Place

Evaluations


Miller’s1 Pyramid of Clinical Competence

Knows MCQ, Oral Examinations

Knows How MCQ, Oral Examinations, Standardized Patients

Shows How Clinical Observation, Simulation, Standardized Patients, Mini CEX

Clinical Observations, Multi-Source Feedback, Teamwork Evaluation, Operative (Procedural) Skill Evaluation, Mini CEX

van der Vleuten, CPM, Schuwirth, LWT. Assessing professional competence: from Methods to Programmes. Medical Education 2005; 39: 309–317

1Miller, GE. Assessment of Clinical Skills/Competence/Performance. Academic Medicine (Supplement) 1990. 65. (S63-S67)

Does


General Surgery Milestones


Outline



Other Roles for Simulation • Non-technical

• Patient history • Physical examination • Breaking bad news • “On call calls” • Obtaining informed consent • Checklist event • Identifying / confronting impaired physician • Patient safety event


Other Roles for Simulation

• Technical • Surgical origami • Knot board • Endoscopy • Laparoscopy • Robotics


Other Roles for Simulation

• Could become an ACGME requirement • Could become an ABS requirement • Could be used for credit for rare, high

stakes procedures (as in EM)


Inclined Plane

• A flat supporting surface tilted at an angle, with one end higher than the other, used as an aid for raising or lowering a load.

• Moving an object up an inclined plane requires less force than lifting it straight up, at a cost of an increase in the distance moved.

• The mechanical advantage of an inclined plane, the factor by which the force is reduced is equal to the ratio of the length of the sloped surface to the height that it spans.

• Due to conservation of energy, the same amount of mechanical energy (work) is required to lift a given object by a given vertical distance, disregarding losses from friction but the inclined plane allows the same work to


• 3rd century BC Archimedean simple machines: Lever, pulley and screw

• 1st century AD Heron of Alexandria listed the classic five simple machines that “can set a load in motion”: Lever, windlass, pulley, wedge and screw

• It wasn't until the Renaissance that the inclined plane was classed with the other simple machines

• 1856 Simon Stevin (Flemish) derived the mechanical advantage of the inclined plane

Inclined Plane


Component Utility

Component Cost



Principles of Surgery





Component Utility

Component Cost








Potts


Component Utilility

Component Cost








Potts


Inclined Plane

Definition: A flat supporting surface tilted at an angle, with one end higher than the other, used as an aid for raising or lowering a load.



PPPPPPPPPPPPPP


Inclined Plane

PPPPPPPPPPPPPP


Data Reviewed Annually by RC • Annual ADS Update

• Program Characteristics – Structure and resources • Program Changes – PD / core faculty / residents • Scholarly Activity – Faculty and residents • Response to active citations • Omission of data

• Board Pass Rate • Resident Survey • Faculty Survey • Clinical Experience – Case logs • Semi-Annual Resident Evaluation and Feedback

• Milestones

?


Inclined Plane • Moving an object up an inclined plane

requires less force than lifting it straight up, at a cost of an increase in the distance moved.

• The mechanical advantage of an inclined plane, the factor by which the force is reduced is equal to the ratio of the length of the sloped surface to the height that it spans.


MA = Mechanical Advantage Fw = Gravitational force of the load object (weight) Fi = Force exerted on the object, parallel to the plane, to move it up the plane.

Fw MA = Fi

Inclined Plane


Hypothesis

Simulation is a tool that can be used to “smooth” the path over many of the obstacles to learning, assessment and, ultimately, to desired outcomes for GME programs.

Simulation: An Inclined Plane in the NAS

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