Program Director’s Corner – March 2022

A Commentary on the 2021 Endocrinology Subspecialty Exam ABIM Pass Rates

Greg Hong, MD, PhD
Associate Professor
Program Director, Endocrinology & Metabolism Fellowship
Pituitary Program, Division of Endocrinology, Department of Medicine
University of Virginia Health System

Program directors (PDs) across the nation read with alarm the recent publication of ABIM pass rates for the Endocrinology & Metabolism subspecialty exam (https://www.abim.org/Media/yeqiumdc/certification-pass-rates.pdf). Of note, the pass rate for 1st time test takers significantly decreased from a usual/typical range of 84-91% over 2017-2020 to a significant nadir of 74% for 2021. This represents the lowest pass rate in 2021 for any internal medicine subspecialty exam.

At this time the reasons behind the abrupt decline in pass rates remain unclear. There were no significant changes to the examination itself this year, although detailed analysis is ongoing at this time and may eventually yield more information. In the meantime we are left to speculate on many possibilities, 2 of which are described below:

1. COVID-19 significantly impacted the training experience (e.g. less endocrine patient volume during the height of the pandemic) or the education quality of fellowship (Zoom-based education potentially less effective due to less trainee engagement or higher trainee distractions).

2. This recent year simply represents an outlier in terms of trainee performance and a return to the mean will eventually occur. For example, a 7% drop in pass rate was noted between 2018-2019, followed by a 5% increase in pass rate in 2020. Furthermore, the ABIM extended Board Eligibility to 2021 for physicians opting not to test in 2020 due to COVID-19. As such, the pass rates for 2021 may not be perfectly comparable to prior years as a result as this group of test takers likely included those further removed from fellowship training than usual.

While #1 and #2 above are plausible theories, it should be noted that other medical subspecialties performed similarly in their pass rates compared to years past. It would seem unusual that the issues identified in #1 and #2 would selectively affect endocrinology fellowships, while not affecting other similarly outpatient based specialties (e.g. Rheumatology, which exhibited pass rates of 94%, 95%, and 93% over 2019, 2020, and 2021 respectively).

While we wait for further clarification from the ABIM on potential reasons for the pass rate decline, it seems prudent for endocrinology PDs everywhere to reevaluate what resources are in place to ensure adequate board preparation. Some potential strategies to consider are listed below:

1. Purchasing board review materials (ESAP & Endocrine Board Review books from Endocrine Society, ASAP from AACE) for the fellows early in the course of fellowship and encouraging ongoing study throughout the course of fellowship (at UVA I encourage our fellows to begin studying for the Endocrine Boards as soon as they are done with their ABIM internal medicine exam).

2. Ensuring that any structured didactics/lecture series covers the appropriate content material over the course of a fellow’s time in the program (a specific list of tested content for the ABIM exam can be found at https://www.abim.org/Media/wxbjt5o3/endocrinology-diabetes-metabolism.pdf

3. Using the ESAP-ITE exam performance as a prognostic indicator of future ABIM exam performance. Previous data (pre-2019) indicates that the ESAP-ITE score is the strongest predictor of future ABIM success (see Horton WB, et al, JES 2021). It is unclear whether this relationship still holds with the current iterations of the ESAP-ITE and ABIM exam. Regardless, poor performance on the ESAP-ITE can potentially identify fellows who would benefit from intervention and more intense board preparation than usual. At UVA we also devote several sessions each Spring to reviewing ITE performance with the fellows, including having content experts work through difficult questions (as judged by % of fellows answering correctly) with the fellows as a group.

4. Dedicating periodic case conferences to “high yield” board topics. At UVA we typically have a 1h clinical case conference weekly as a division where an interesting case is presented and a group discussion unfolds between faculty & fellows. At least once every 2 months we devote a discussion to a “high yield” board topic, often by using a board question as a discussion prompt for our faculty and fellows to share ideas on clinical pearls, test taking strategies, etc.

5. Consider funding additional board review options, e.g. in-person board review courses. While these can be costly, in certain cases it could be justified for select fellows who could use additional help.

I’m sure many of you have your own unique or innovative ideas on how to help our trainees succeed in their ABIM exam certification – let’s hear about them on the APDEM Facebook page or in a future PD corner!

Dr. Greg Hong is a member of the APDEM Membership Recruitment committee, co-chair of the APDEM Fellow Recruitment Subcommittee, and was recently nominated to APDEM’s Council for the 2022-2024 term. 

APDEM Facebook Group – If you are interested in joining the APDEM Facebook group, please search for ‘Association of Program Directors in Endocrinology, Diabetes and Metabolism’ in Facebook. You will be asked a series of questions, and then admitted once your membership in APDEM has been confirmed. If you have any questions about this group, please email David Lieb, Newsletter Committee Chair, at liebdc@evms.edu.

Program Director’s Corner – February 2022

Will “The Great Resignation” affect fellows coming out of training?

Dragana Lovre, MD, Associate Program Director, Endocrinology, Metabolism, and Diabetes Fellowship, Tulane University Health Sciences Center

The Great Resignation, also known as the Extraordinary Exodus, is an economic trend in which employees voluntarily resign from their jobs en masse, beginning in early 2021, for reasons associated with the COVID-19 pandemic.

Most of us are well aware and concerned that healthcare workers, facing increased job stress and burnout, are going to continue resigning as the pandemic prolongs. As the time of the year approaches when the PDs and any attending that knows a graduating endocrinology fellow is asking: “have you signed your contract yet?”, it is our duty as PDs/APDs to bring the topic and trends of “The Great Resignation” to the attention of our fellows and help them make a plan for the next career move.

Here is the bad news:

“The Great Resignation” phenomenon may affect the graduating fellows mainly due to 2 reason as described in an article in Harvard Business Review (Sept 2021) titled “Who Is Driving the Great Resignation?” by Ian Cook (1).

The two key trends in this recent COVID-19 driven phenomenon are:
1. Resignation rates are highest among mid-career employees.
2. Resignations are highest in the tech and health care industries.

The article mentions that employees between 30 and 45 years old have had the greatest increase in resignation rates, with an average increase of more than 20% between 2020 and 2021. Furthermore, 3.6% more health care employees quit their jobs this year than in the previous year.  Ian cook also explained how we’re also seeing higher resignations among women in the last 3 years and the 2020 spike was likely due to the pandemic. Women left their job to take care of their families. The opposite pattern took place for men.

Furthermore, according to a new study led by the American Medical Association and Mayo Foundation for Medical Education and Research (2), the health care industry is likely to see more staff turnover as workers experience burnout and resign. In the study by Sinsky et al., researchers surveyed 20,665 health care workers at 124 health systems between July 1, 2020, and Dec. 31, 2020, to examine the relationship between Covid-19-related stress and work intentions. Among the respondents, 44.84% were physicians, 21.41% were nurses and advanced practice providers, 11.83% were workers in other clinical roles, and 3.57% were administrators. Approximately 1 in 3 physicians, APPs, and nurses surveyed intend to reduce work hours. One in 5 physicians and 2 in 5 nurses intend to leave their practice altogether.

A new survey conducted in June and July 2021 by Jackson Physician Search in partnership with Medical Group Management Association (MGMA) (3) suggests that physician satisfaction with their current employer — reported at an average of 5.5 on a scale of 0 to 10 — is less about the impacts of the pandemic and more about disconnects that can be solved, at least in part, by better communication. Sixty eight percent of administrators and 61% of physicians confirm that physicians are experiencing burnout. Of those, 62% of physicians reported burnout as being caused by their current employer (versus being caused by the experience of being a physician), while only 14% of administrators recognized their role in physician burnout.
Now the good news:

Ian Cook, vice president of people analytics at Visier, explains that employers will have to take a data-driven approach to improve retention programs and plans and even developed tailored retention programs. Reducing burnout and improving a sense of feeling valued may allow health care organizations to better maintain their workforces post pandemic. Liking your place of work and feeling valued may help. Sinsky et al., found that “Feeling valued by one’s organization was protective of reducing hours (OR, 0.65; 95% CI, 0.59 to 0.72) and intending to leave (OR, 0.40; 95% CI, 0.36 to 0.45; all P<.01).” Additionally, most of the graduating endocrinology fellows are likely in the age group of that matches that of the greatest increase in resignation group mentioned above and most of the graduating endocrinology fellows are women which again would replace the women who left their job to take care of their families during the pandemic. Lastly, even if the field of endocrinology may not have issues with the number of physicians resigning, there is likely going to be an issue of lacking support staff which will affect the day-to-day practice of the future junior endocrinologists. One can hope that there will be programs to retain nurses and medical assistants too, especially since they are a crucial part of the team and require time to onboard and train.

Considering the information above, how do we implement this knowledge and resignation trends to advise our fellows and perhaps use for ourselves?
Here are several points to consider:
1. During the interviews, fellows should ask their potential future colleagues about how the resignation has affected the practice and what are the steps being taken to retain employees or hire new ones (physicians and support staff).
2. Similarly, during interviews, a question about raises and cuts should be approached.
3. Fellows should consider using their mentors’ network to help find a position they may have reliable information about.
4. Fellows may want to ask HR about the trends of hiring and resignation at the place they are considering for employment.
5. Fellows with student loans should be advised on researching employer that would qualify for Public Service Loan Forgiveness (non-profit and VA) and Education Debt Reduction Program (VA only)
6. Once hired, endocrinologists should communicated clearly and frequently with staff and administration to ensure reasonable work flow and job satisfaction in order to continue to improve employee retention.
7. Fellows should be encouraged to join national committees as well as groups on social media that connect them to other endocrinologists to stay up-to-date on national trends in our field and more importantly to advocate for positive changes.

a. https://hbr.org/2021/09/who-is-driving-the-great-resignation
b. Christine A. Sinsky, Roger L. Brown, Martin J. Stillman, Mark Linzer. COVID-Related Stress and Work Intentions in a Sample of US Health Care Workers, Mayo Clinic Proceedings: Innovations, Quality & Outcomes, Volume 5, Issue 6, 2021, Pages 1165-1173, ISSN 2542-4548,https://doi.org/10.1016/j.mayocpiqo.2021.08.007. (https://www.sciencedirect.com/science/article/pii/S2542454821001260)
c. https://www.prnewswire.com/news-releases/does-the-great-resignation-have-an-outsized-impact-on-the-business-of-healthcare-301407263.html

Dr. Dragana Lovre is a member of the APDEM Newsletter Committee.

Program Director’s Corner – December 2021

Milestones 2.0 – They’re Here!

David C. Lieb, MD, Program Director, Endocrinology, Diabetes and Metabolism Fellowship, Eastern Virginia Medical School

It’s that time of year – everyone is in the holiday spirit, Spider-Man is swinging into theaters, and program directors across the country are working to complete their fellowship milestone evaluations. Milestones must be submitted through the ACGME Accreditation Data System (ADS) by January 14, 2022 – and this year is different. This year, it’s time for Milestones 2.0!

In full disclosure I was a member of the ACGME Endocrinology, Diabetes and Metabolism Milestones Work Group that helped to develop the new milestones. I’m proud of our work, and I hope that the changes that have been incorporated into the milestones are practical and helpful for program directors and Clinical Competency Committees (CCC) that are using them to evaluate their fellows’ progress. A link to the new Endocrine Milestones can be found here.

As per the ACGME, “the Milestones provide a framework for the assessment of the development of the fellow in key dimensions of the elements of physician competence in a…subspecialty”. The milestones are arranged into 5 levels – which are based upon the Dreyfus Five-Stage Developmental Model of Adult Skill Acquisition. The Dreyfus Model is all about how adults acquire skills – and fellows go through five stages, from novice, to competence, to proficiency, to expertise to mastery, on their road toward becoming the best endocrinologists they can be.

You can find a helpful 10-minute YouTube video here that explains the Dreyfus Model in some detail, with practical examples. It’s worth watching – and worth sharing with your fellows and faculty – especially those on your CCC. I’d recommend doing so prior to your CCC meeting, and before meeting with your fellows to review their Milestone progress. It’s important for both faculty and fellows to understand the framework upon which their evaluations are based – it makes them more useful. Fellows should understand their position as learners along a continuum, with developmental goals along their path. Faculty should realize that learners go through these stages – and evaluate, and teach, to each fellows’ current stage. Our role as program leaders is to help fellows move from stage to stage, and to help our faculty to recognize where each fellow is on their journey.

A nice review on the genesis of the original milestones, and the new milestones, can be found here. As this article explains, the initial milestones were limited by inconsistences and often utilized complicated, negative language. The new milestones were developed through focus groups and multiple interviews involving stakeholders (such as yourselves) – and we hope that Milestones 2.0 are more practical and more positive.

This page from the ACGME has resources that can help your CCC members, faculty and fellows to better understand, and more importantly, practically use the new milestones, for development and improvement. There are guidebooks for both fellows and for CCC members. I’d strongly recommend that you share these resources with your fellows and your CCC.

One of the most exciting resources is the new Supplemental Guide. The guide was created to provide examples for each of the milestones, that CCC members can use to assess their fellows. There are also recommended tools for assessment, with references and helpful information. I’d also strongly recommend sharing this guide with your CCC before your CCC milestone meeting. The goal is for your specific fellowship program, both faculty and fellows, to have a ‘shared mental model’ of the milestones. It also helps for fellows to have a more clear understanding of what is expect of them as they move through each developmental stage. Share the Supplemental Guide with them too – and use the examples as often as you can during rounds, in the clinic and during didactic.

Please don’t hesitate to reach out to me at liebdc@evms.edu with any questions or comments – the milestones are a central way for us to evaluate our fellows’ progress and development. I’m excited for this update and know that there will be more updates in the future. Your input is key. Let me know what you think!

Dr. David Lieb is chair of the APDEM Newsletter Committee. 

Program Director’s Corner – October 2021

Role of a Chief Fellow in Endocrinology Fellowship

Ruchi Gaba, MD, Associate Program Director and Eric Deal, MD, Chief Endocrine Fellow
Endocrinology, Metabolism, and Diabetes Fellowship, Baylor College of Medicine

Chief residents have traditionally played an important role in the educational, administrative, and clinical structure in residency programs – and over the last few years the trend of assigning a chief fellow has caught up in most fellowship programs. Their exact role, however, remains ambiguous, especially in the field of Endocrinology, Diabetes and Metabolism.  In this PD corner, I would like to share our experience of incorporation of a chief fellow as a vital addition to our fellowship program – from the standpoint of program leadership, as well as from the chief fellow’s standpoint, with a hope that it will help in providing guidance for programs considering incorporating chief fellows.

We appointed our first chief fellow in 2014, with a goal of helping the program (including administrative and academic aspects) to be more efficient. Rising first year fellows chose one of their own to serve as a strong liaison between themselves and the faculty. They wanted an individual that was easily approachable and that had good organizational skills. This fellow served as the chief fellow in their second year of training and was responsible for both first- and second-year fellows. Our faculty were excited that we would be able to streamline the functioning of the program better – but we were in for a surprise when we realized the role that this person played in our program that year was more and beyond.

Our chief fellows’ roles include:

The chief fellow also plays a critical role as a member of Program Evaluation Committee. They are able to give insight into the development and implementation of educational activities in the program from a trainee perspective. They give candid feedback on faculty development and highlight areas of potential noncompliance of ACGME protocols. The chief fellow has an opportunity to be a leader to their peers and gain experience about leadership roles in the endocrine division.

The chief fellow’s role has recently expanded to include supporting fellowship recruitment. They synchronize organizing and leading the happy hour for the interviewees during interview days so that they can meet with our current fellows and ask questions. In fact, one past year the chief helped in the interview process when we needed a back-up interviewer due to a last-minute cancellation by an assigned faculty due to unforeseen circumstances. Their unique perspective and assessment of the candidates was very valuable for that year’s rank order list, and we now try to include them in the interview process.

Very soon, the chief fellow will also be helping coordinate wellness events for endocrine fellows alongside the faculty and program leadership in addition to checking on co-fellows during busy rotations, while on-call or when going through personal issues, and offering resources and help.

As the ambassador of the fellowship program, the chief fellow has the responsibility of representing all of the fellows. The chief relays the perspectives, challenges and needs of the fellows to program leadership in a fair, respectful, and unbiased way- serving as a strong link between the fellows, faculty, and administration. The chief fellow coordinates and disseminates time-sensitive information pertaining to fellowship and divisional matters to the fellows.

So, every year in the last quarter (Feb- March) of their first year of training, all the first-year fellows vote and choose their chief fellow for the next year. We as program leadership recognize that the chief fellow spends valuable personal time on top of their clinical and educational responsibilities, and so we always try to show appreciation by allowing them to participate in a program-sponsored CME conference. Lately, since all conferences have been virtual due to COVID restrictions we have instead been providing them acknowledgement with a special award/ certificate at the graduation ceremony. It is of essence that we as program leadership provide not only acknowledgement but also back up and support in important decision-making processes so that we prepare future leaders.

To wrap up, I would love to share with you a testimonial from our current chief fellow – Dr Eric Deal.

“Deep in the grind of rigorous clinical duties, my life came to a halt pondering this question upon learning that I was elected as chief fellow by my peers. I was extremely honored to be chosen for the position. After reviewing the duties and seeking counsel from my predecessors, I emphatically accepted.

The responsibilities of a chief fellow will vary between programs, but certain administrative and communication duties are universal. Scheduling is a pesky but crucial duty. The chief fellow is responsible for making and maintaining schedules for call, clinics, jeopardy, and vacation. This requires that I am available and responsive for jeopardy needs and schedule change requests. In a coordinating role, I communicate updates and deadlines from leadership or our institution to my co-fellows. I also respond to day-to-day requests from our fellows, such as granting access to patient lists or explaining how to order dynamic testing.

Perhaps the most impactful role of the chief fellow is to act as a liaison between fellows and program leadership. Information is constantly cycling between fellows and leadership, with the chief fellow acting as a conduit and relative filter. As an elected and trusted advocate, the chief fellow is in a privileged position to maintain a pulse on the fellows’ experiences. The chief can anticipate and proactively communicate potential issues to leadership. This is particularly important in a program of our size where our fellows are spread across several hospitals. In conjunction with a highly responsive leadership, my role promotes and rapidly facilitates process improvement.

l began my time as chief fellow understanding the defined roles of the position. I have been rewarded by the dynamic and fulfilling nature of advocating for my colleagues and promoting the collective success of our program.”

Dr. Ruchi Gaba is a member of the APDEM Newsletter Committee. 

Program Director’s Corner – July 2021

2020 Hindsight on Virtual Interviewing:  Tips for Program Directors

Ismat Shafiq, MD, Program Director
Marilyn Augustine, MD, Associate Program Director
Division of Endocrinology and Metabolism, University of Rochester, NY

Though the COVID-19 pandemic is slowing down, it is not finished yet. The APDEM council and the Fellowship Recruitment Subcommittee (FRS) of the APDEM COVID Task Force have recommended that endocrine programs offer virtual interviews for all applicants during the 2021 recruitment cycle. This decision was based on survey results indicating that  84% of the program directors (PDs) and 88 % of incoming fellows favored virtual interviews. The APDEM leadership agreed that standardization of the interview process promotes safety, health, and equity. In a live poll among PDs during the APDEM national meeting, more than 72% favored virtual interviews with optional in-person tours, over a hybrid model.

The COVID-19 pandemic forced many fellowship progams to use a virtual interview process for the first time.   We were skeptical as the process began, but were pleased to discover that we were able to get a sense of our applicants’ strengths through the virtual format, and could also provide a positive impression of our program.  Virtual interviewing will be more familiar for the coming season.  Here are some insights we gained from last year’s virtual interview season.

1. Update Online Program information:

Over the past few years, program websites, Instagram, and Twitter have become the primary tools for residents to gain insight into different training programs. Updating the program website is key.  Including a short virtual tour of the fellowship program with faculty and fellows can help give a sense of the culture and diversity of the program. Our program has an Instagram account, and we try to celebrate achievements in our department with posts.

2. Preparing for the interview:

We kept our interview format similar to the schedule we used for face-to-face interviews, but shortened the duration to around 4 hours to limit Zoom fatigue.   We usually conduct interviews on a day when we have a morning case conference and noon core curriculum conference. Attending the conferences gives insight into our curriculum and an opportunity to see the culture of the program. We chose to keep conference attendance optional to avoid brain fog and long hours of interviews, but, not surprisingly, most applicants were eager to attend.

An interview itinerary was provided to the interviewers and applicants in advance and included phone numbers in case of Zoom failure.  Our faculty and fellowship staff met virtually a week before the interviews to practice with the Zoom breakout rooms, which gave us a chance to work out the kinks in our process.

3. Day of the interview:

The program director started the interview day with a brief explanation of the interview day and then an introduction to the program.  Following that, individual interviews were conducted for 60-90 minutes, with short rest breaks. We chose to include one additional informational session about halfway through the interviews. We also incorporated slides with photos of fellows and of our area so that applicants could get as sense of what it would be like to live here.  The current fellows and applicants then had an informal session with no attendings present, and this was the part of the day that  we got the most positive feedback about.

4. Concluding the interview day: The finishing touch leaves an ever-lasting impression. We provided an opportunity for final questions and shared web resources about the city as well as our contact information.

We were pleasantly surprised by the level of engagement that was possible during the virtual interview process. It was interactive, fun, and the residents seemed more relaxed. Many applicants do not have protected time for interviewing. Over the last few years, we have noticed that it has been challenging for residents to attend dinner with the fellows the evening before interview day.   Though differing time zones did result in some applicants starting their interview day early in the moning, at least none had to travel overnight for the interviews!  Another advantage of virtual interviews is financial.  Since paid travel and lodging is not required, economically disadvantaged residents may interview at more programs of their choice.

Though there are certainly some advantages to the virtual interview process, there are also disadvantages.  Notably, programs and residents missed the face-to-face interactions.  An in-person visit allows personal observation of the program, hospital and the area, which is not possible in the virtual format

We are working now to plan  the interview process for this fall.  Together we can thrive and grow. We’d love to hear the thoughts and experiences of others regarding virtual interviewing.

Dr. Ismat Shafiq is a member of the APDEM All-in-Match Task Force.

Program Director’s Corner – February 2021

APDEM Involvement:  APDEM Committees

David C. Lieb, MD, FACE, FACP
Program Director, Endocrinology and Metabolism Fellowship
Eastern Virginia Medical School

Welcome everyone to the February 2021 APDEM Program Directors’ Corner! I hope everyone is well – mentally and physically. I’m hopeful that all of your fellows and faculty are getting vaccinated – and that you are too. It’s been a tough year – and many of our institutions have declared ACGME emergency status due to COVID – some of us for the second time. Many of our colleagues are also dealing with weather-related emergencies – including the terrible power outages across Texas. My thoughts are with all of you and your fellows.

This month I want to talk about the great benefits of APDEM involvement. Specifically – the benefits of getting involved on APDEM committees. When I started as chair of the APDEM Newsletter Committee in 2019 I was excited. I was a relatively new program director – and was looking forward to meeting other program directors who were engaged and finding ways to not only better their own fellowship programs, but also help other programs to do the same. I enjoyed writing our monthly newsletter and asking others to help assist as well.  And then…2020 happened.  Of course, I could not have foreseen the COVID-19 pandemic that changed all of our lives so greatly.  This led to the formation of the APDEM COVID-19 Task Force which I was selected to co-chair with APDEM immediate-past president Chris McCartney, along with guidance from our president Andrew Gianoukakis and our APDEM council members.

It’s been through that experience that I’ve learned how being actively involved in APDEM is important both personally and professionally. I’ve met so many wonderful people – and have expanded my professional network to include colleagues from around the country, all of whom can share their experiences and recommendations for how to better my own fellowship program. I’m learning how to effectively work with APDEM staff and leadership to bring new ideas to fruition, and to enact real change, including during a time of crisis.

This past year APDEM also established the new Diversity, Equity and Inclusion committee co-chaired by Rana Malek and Ricardo Correa – I have been fortunate to participate on a committee charged with helping fellowship programs work to improve diversity and add curriculum centered around health equity issues in medicine and in endocrinology. And I continue to meet wonderful people working hard to better their programs and assist others to do the same.

This is my story with APDEM. Everyone’s story is different, and people may be at different time points in their career, with different needs. However, I feel strongly that some of the greatest personal and professional satisfaction in my life has come from my engagement with others. This happens both at one’s home institution, but also through involvement in national and international organizations. APDEM has become one of my new homes and has brought me much happiness during a difficult year. I want others to share in that experience, and hope that many of you will consider participating on one of the many APDEM committees currently available, including:

• All-in-Match Committee
• COVID-19 Task Force Subcommittees: Pandemic Emergency Status L3, Fellow Didactic, Patient Care, and Fellow Recruitment
• Diversity, Equity & Inclusion Committee
• Finance Committee
• Newsletter Committee

APDEM needs you – we can only thrive and grow with an active, involved membership. And I know you’ll thrive from your experiences with APDEM, too. If you would like to join one of these committees or if you would like to volunteer within APDEM, please email APDEM@endocrine.org.

Take care of yourself, and of your fellows. Be safe.

David Lieb serves as chair of APDEM’s Newsletter Committee. 

Program Director’s Corner – January 2021

APDEM Pandemic Emergency Category Disaster Plan

Aaron Schulman, MD
Program Director, Fellowship in Endocrinology, Diabetes and Metabolism
New York-Presbyterian Hospital/Weill Cornell

Definition by ACGME: Sponsoring Institutions facing substantial and sustained disruption of GME operations resulting from the COVID-19 pandemic.

Who Declares: DIO, with the attestation of the sponsoring institution’s clinical leadership, via submission of Emergency Categorization Request Form to the ACGME.

Duration: 30 days. Extension beyond 30 days subject to review by the Institutional Review Committee.

Scope: Declaration applies at the institution level and involves all residents and fellows in all specialty and subspecialty programs.

Requirements: Sponsoring institution is still expected to fully comply with and ensure adherence to the following:

1. Adequate resources and training – including appropriate infection protection
2. Adequate supervision
3. Adherence to work hour requirements
4. Fellows may function in their core specialty (in our case, internal medicine) if: a) they are ABMS or AOA board-eligible or -certified; b) they are appointed to the medical staff; c) their time spent in their core specialty service is limited to 20 percent of their annual education time in any academic year.
5. Continued assessment by programs of fellows in all six Core Competencies, with assessments forming the basis for decisions regarding promotion of fellows

If your sponsoring institution has requested or is considering requesting Emergency Categorization, consider drafting a disaster plan that is acceptable to everyone involved. Consider the following issues:

1. Fellow deployment:

• What is the minimum number of fellows needed to maintain a functional inpatient endocrine consult service? Consider discussing with DIO to allow retaining them.
• Will a faculty-only inpatient consult service be necessary? Alert faculty to this possibility.
• Will fellows’ clinics need to be canceled or scaled back?
• Create a backup schedule for coverage of fellows who are deployed.
• Can fellows graduate on time or will extension of training be needed?
• Will fellows have completed required number of procedures by graduation?

2. Faculty deployment:

• Will faculty be deployed?
• Working with your division chief, create a backup schedule for coverage of teaching faculty who are deployed (for inpatient consult service, precepting fellows’ clinics, didactics, etc.)

3. Didactics:

• Should didactic activities continue or be temporarily suspended?
• Are faculty familiar with and able to use remote teaching platforms such as Zoom, Skype, Microsoft Teams, etc?

4. Telehealth considerations:

• Are inpatient e-consults available and permitted?
• Are outpatient televisits (phone and/or video) available and permitted?
• What platforms are available for telehealth (me, Doximity, Amwell, etc.)? Do they support precepting and/or interpreter use?
• Are faculty and fellows familiar with these platforms? Is information technology (IT) support available?
• Does everyone have the equipment they need for televisits (webcams, headsets, etc.)?
• Make sure you review televisit requirements of CMS and private insurers with regard to resident encounters.

5- Support:

• Consider scheduling regular (at least weekly) virtual meetings with fellows to hear their concerns, keep them updated, maintain their connection to division and peers during deployment.
• Consider organizing regular meetings with participation of institutional mental health providers for support of fellows (and faculty).
• Consider asking for regular meetings with other PDs and DIO.
• Program Directors can contact members of the APDEM Pandemic Emergency Category committee with any questions:
• Aaron Schulman aas9008@med.cornell.edu
• Mira Sofia Torres torres@umassmemorial.org

Program Directors’ Corner – October 2020

Endocrinology Fellowship Educational Collaboration

Ricardo Correa, MD, EdD, FACP, FAPCR, CMQ
Deepika Reddy, MD
Co-chairs, APDEM Fellow Didactic Subcommittee, COVID-19 Task Force

In the spring of 2020, APDEM leadership created a task force to address issues in endocrine education that had arisen as a consequence of the COVID-19 pandemic. One such issue was the ability to maintain didactic and other educational sessions. A sub-committee composed of members from the COVID-19 task force was developed to identifying ways in which programs could work together to provide uninterrupted educational sessions for the fellows.

After multiple virtual meetings the sub-committee members developed a guideline on how collaborations among programs could be initiated. The assumption was that programs would continue collaborative efforts beyond the COVID-19 pandemic timeline. The guideline addressed determining the types of educational sessions to offer, what virtual platforms to employ, whether these would be live or recorded, and what other types of activities could be offered to fellows. This set of guidelines was distributed to all members of APDEM and a survey was used to determine program interest in participating in joint activities. Those programs expressing interest were divided into groups based on geographic regions and time zones. In total, 10 regional groups were formed.

The most important step was to bring program directors from these regional groups together in an introductory virtual meeting. Members of the APDEM COVID-19 task force met with program directors from all these regions, a brief summary of the guidelines was presented at the beginning and then a discussion amongst members of the region was facilitated.

The majority of the meetings were productive in the following ways: bringing together program directors (introducing some of them to others in the group for the first time), gaining insight into ongoing collaborations, and determining the needs for each region. As would be expected there is a great deal of heterogeneity between regional needs. Some regions already had educational collaborations even before the COVID-19 pandemic. In those regions inability of fellows to interact socially and network due to lack of face-to-face national and local meetings was felt to be of greater concern. Other programs felt there would be benefit to ‘sharing’ didactic sessions or other activities such as clinical case presentations or journal clubs. All agreed that having fellows involved in the decision-making from the beginning of the process would be of utmost importance. At the end of each session one or two program directors volunteered to lead the efforts for that region and a region-specific plan was developed. Most planned to develop a survey for the faculty/fellows to gather information on type of session (didactic, case presentation, journal club, networking opportunity), and the day and time that would work best for all.

APDEM will follow up with the program director leading the effort in 3 months to receive feedback on progress. This feedback can then be disseminated for the benefit for all programs. It appears quite feasible to establish collaborative processes to enhance education in endocrinology.  This model might be used for collaboration in other areas (improving fellow assessment, health equity education, etc.). The online format will likely make it easier to bring programs together for the growth of our endocrine community.

Ricardo Correa, MD, EdD, FACP, FAPCR, CMQ is the Program Director for the Endocrinology, Diabetes and Metabolism Fellowship program at the University of Arizona College of Medicine-Phoenix (ricardocorrea@arizona.edu)

Deepika Reddy, MD, is the Program Director for the Endocrinology Fellowship Program at the University of Utah Health (Deepika.Reddy@hsc.utah.edu)

Program Director’s Corner – September 2020

Should we be flipping over the ‘flipped classroom’?

David C. Lieb, MD, FACE, FACP
Program Director, Endocrinology and Metabolism Fellowship
Eastern Virginia Medical School

The flipped, or inverted classroom, is not a new concept. It first became popular in 2007 when two high school chemistry teachers in Denver, Colorado wanted to help students who had missed class due to illness (Bergman, Sams). The teachers pre-recorded their lesson plans and shared them with the students. They soon found that sharing these lessons with all of their students before class led to more robust and interactive discussions.

The chemistry teachers credited their ideas to a paper they had read called “Inverting the Classroom” written by a group of economics professors at Miami University (Ohio) who had used a similar concept in an introductory economics course in 2000 (Lage, Platt, Treglia). These professors found that the traditional lecture format was incompatible with the learning styles of many of their students and felt it would help all students to receive educational materials prior to class in order to better prepare for discussion of the subject matter. These materials included textbook readings, lecture videos, voice-over Powerpoint presentations and printed-out Powerpoint slides. Students were given these materials, as well as worksheets that were periodically collected and graded.  The professors noted that they could spend valuable class time on activities that encouraged students to apply what they had learned in small group discussions. The students seemed more motivated to learn, and both students and teachers felt that this new approach was a positive one.

In the flipped classroom model students gain first-exposure learning before class takes place -and are then able to focus on processing what they have learned during class time with instructor assistance. Processing involves synthesizing information, analyzing what one has learned and problem-solving. Students are typically given assignments before class that combine reading and writing assignments. They then receive feedback through processing activities during class. Studies in college students have shown that the flipped classroom approach leads to not only more engaged students, but also higher test scores on the material reviewed.

Data exists demonstrating that the flipped classroom concept is an effective learning-strategy in graduate medical education. A recent publication in The Clinical Teacher by Rachel Blair, Julia Caton and Ole-Petter Hamnvik – who is the Endocrinology Fellowship Program Director at Brigham and Women’s Hospital/Harvard Medical School – evaluated a flipped classroom model in 43 second-year internal medicine residents at their program. Participants watched a video involving pharmacotherapy for type 2 diabetes prior to the in-session class (Blair, Caton and Hamnvik, April 2020). During class time the learners were engaged in case-based discussions. They filled out surveys and a knowledge test before, immediately after and six months after the intervention. The authors found that learners did significantly better on knowledge tests both immediately after and six months after the intervention when compared to before, suggesting retention of knowledge. The majority of learners reported that the pre-class instruction was a valuable use of their time, and 90% of those surveyed preferred the flipped classroom format over a more traditional lecture format. Of note, learners did mention some concerns regarding finding enough time to watch the video prior to class.  Importantly, six months after the intervention the residents were likely to consider prescribing one of the medications discussed, and 57% had actually prescribed one of the medications in their clinical practice.

For those of you who are interested in learning more about the flipped classroom model of instruction, I found this page at Vanderbilt University to be very helpful. This blog post at schoology.com is also helpful and includes specific tips and recommendations, as well as a bit of history.

I’d be interested to hear what you all think! Are you currently using a similar flipped classroom for your fellowship didactics? If so, how well does it work? How has the increased use of virtual technology such as Zoom affected your ability to use such a model? Email me at liebdc@evms.edu with your thoughts, and I can share them in a future Program Directors’ Corner!

Program Director’s Corner – August 2020

APDEM Diversity, Equity and Inclusion Committee

Ricardo Correa, MD, EdD and Rana Malek, MD
University of Arizona College of Medicine-Phoenix (ricardocorrea@arizona.edu)
University of Maryland School of Medicine (rmalek@som.umaryland.edu)

Biases based on ethnicity, race and gender serve as the basis for the discriminatory policies and practices that uphold systemic inequity. While some biases stem from real-world encounters, most develop from the stories we are told. As mechanisms that encourage self-expression and critical inquiry—as well as transmit knowledge and values—multiple strategies have the potential to positively shift, as well as exacerbate deep-rooted historical biases.  In June 2020, The Association of Program Director for Endocrinology, Diabetes and Metabolism (APDEM), as a leader on graduate medical education training, established the Diversity, Equity and Inclusion (DEI) committee to address many of these issues specifically for our endocrine program community.

A call for volunteers for the DEI resulted in a diverse group of program directors, fellows and, program coordinators. The first meeting was held via Zoom in July and the participation was outstanding.  The committee’s proposed diversity statement is: APDEM strives to have an endocrinology community that is diverse and inclusive. This encompasses many characteristics for our fellows, faculties, program leaders and program coordinators, including but not limited to race, ethnicity, gender, age, sexual orientation, education, culture, heritage, religion, geography, physical abilities and socio-economic status. We want to engage in change not only at the individual program level but also at system level practices nationwide that advance diversity and inclusion creating an environment that fosters belonging and respect for all.

Furthermore, the goals of the committee are:

1. To increase fellows’ and faculty’s understanding of diversity, inclusion and health equity through multiple methods
2. To create curricula and programs focused on addressing the social determinants of health and health equity, with specific focus on local/program specific healthcare disparities
3. To develop resources to assist programs in recruiting a diverse group of fellows, including efforts aimed at decreasing unconscious bias during the application review and interview processes
4. To increase recruitment of underrepresented minorities (URM) in endocrine and prepare them to stay in academic medicine with appropriate mentorship with a goal of creating an inclusive environment

Given the large scope of the committee, two sub-committees—Diversity/Inclusion and Health Equity were created with sub-committee specific meetings occurring in August 2020.  The immediate task for the D/I subcommittee was to create a toolkit that could be used to increase diversity in the fellowship application process.  You can find the toolkit in this link here.

Health Equity

Health disparities, also called health inequities, have gained a tremendous amount of attention from physicians and health policy experts over the past few years and most recently during the COVID-19 pandemic. Since 2019, it has been an ACGME common program requirement to train fellows in health disparities and most recently was included in the ACGME survey for the 2019-2020 academic year.  Addressing health disparities requires a multi-level approach and examination of contributing structural and social factors.  To understand how our clinical practice impacts health inequities among our patient populations, it is critical to develop a health equity curriculum that should be teach to our fellows and faculties.  The Health Equity Sub-committee will be tasked with addressing this need.

The DEI Committee is a commitment from APDEM to address the diversity and inclusion in our field as well as train the future generation of endocrinologists in health equity.  We will periodically update APDEM members in the Program Director’s Corner.

References

1. AAMC “Teaching Residents Population Health Management” https://store.aamc.org/downloadable/download/sample/sample_id/311/​ 2019
2. Graduate Medical Education Interest Group, Institute for Healthcare Improvement, http://www.ihi.org/education/IHIOpenSchool/Chapters/Groups/Faculty/Pages/GMENetw ork.aspx