Program Director’s Corner – June 2019

The Ten Commandments of Consulting

David Lieb, MD
Program Director, Endocrine Fellowship Program
Eastern Virginia Medical School

Before I get into this month’s PD Corner topic – I wanted to follow up on a previous post. I know everyone is getting ready for the new fellows starting in July. I also know that this is a particularly stressful time – not just for new fellows, but for current fellows (that are taking on new, progressive responsibilities) – and also program coordinators, associate program directors, and program directors. Please remember to look out for each other – and be sure to sure to take care of yourselves, too.

Each year at Eastern Virginia Medical School our GME Office puts together a great Fellows’ Orientation for all medical and surgical fellows starting their programs in Norfolk. For the last few years I’ve had the pleasure of giving a talk about how to be an effective consultant. When I was first approached to give this talk, I reviewed Pubmed to see if there were any good articles covering the topic. I found a few – and the one that stood out was called “The Ten Commandments for Effective Consultations”, published by Goldman, Lee and Rudd in 1983 in Archives of Internal Medicine. It’s a great article, and what was true in the early 80s is even more true in 2019. The Prime Directive, if you will, of providing effective specialty consultations is good communication. And communication has changed significantly from the time of Return of the Jedi, ALF and the Care Bears.

Our fellows communicate via phone, email, texting, Twitter, Facebook, Instagram, and Snapchat (whatever that is). And each of these forms of communication have their advantages and disadvantages. Is a direct message on Twitter HIPAA compliant? (No -and it’s probably no mistake that the talk immediately following mine at the orientation is from EVMS Risk Management). Is texting a complicated insulin regimen the most effective way to communicate a patient plan? Probably not.  Is an email or a note buried in the EMR the best way to sign off from a consult you’ve been part of for a month? Not in most cases. Commandment number IX is “Talk is Cheap…and Effective”, and it’s true.  Fellows need to know that a phone call early on may take up more time than a text or a comment in the EMR – but it may save so much time in the future (sometimes for them, sometimes for their attending).

During my talk I stress the importance of picking up the phone – or pulling it out of your pocket – or connecting to it through Bluetooth – or whatever – and CALLING people.  Do you clearly understand the question you’ve been asked to answer? If not, call the team that called you back, and ask for more details. Lee (1983) and Rudd (1978) reported that up to 15% of consults start with different impressions of the reason for consultation. And that the consultant (that’s us) may completely ignore the question up to 12% of the time. “Determining the Question” is the First Commandment.

I also spend a fair amount of time talking about communication in the medical chart. Commandment Number IV is “Be as Brief as Appropriate”. I remind the new fellows that the EMR is not a novel – they need to be brief, but helpful. No one has time to read a treatise on the differences between total and free cortisol (as interesting as that is). If it’s an interesting topic that they’d like to share and discuss with residents and medical students – maybe the fellow can offer to participate in a morning report. It’s ok to mention a reference (or two) in a progress note, but not more than that. We talk about cutting and pasting (I say avoid it – but since everyone does it anyway – at least read what you’ve cut and pasted to ensure it is current). And by all means – do NOT get into an argument with other teams in the medical record. If you disagree about something important – call the other party. I remind the fellows that the medical record is may be reviewed by patients, lawyers and others, and that they need to be cautious in all that they write. Facts – not feelings – belong in the EMR.

Other commandments include establishing the urgency of the consult (can you see the patient tomorrow? Or as an outpatient?), looking through the original patient data yourself (you bring a special angle to data review), to provide contingency plans, and to honor thy turf (don’t covet they neighbor’s patient). It’s a really great article and I highly recommend that all new fellows read it.

Does anyone out there in APDEM-Land have a similar talk provided at their institution? It’s pretty well-received, and hopefully some of what I share sticks. Send me a note by email (liebdc@evms.edu) or DM me on Twitter (@dclieb) if I can help you.

Also – if you figure out how to use Snapchat – please let me know.

Program Director’s Corner – May 2019

The Importance of Trainees Well-being and Example of an Effective Program

Ricardo Correa, MD, Es.D
Program Director, Endocrine Fellowship Program
University of Arizona College of Medicine Phoenix

Karyne Vinales, MD
Associate Program Director, Endocrine Fellowship Program
University of Arizona College of Medicine Phoenix

Medicine is a demanding profession. Physicians, especially physicians-in-training, experience high levels of work-related stress, burnout, and mental health disorders. This is concerning, not only because physician wellness affects individual physicians, but because physician health and wellness is central to the quality and safety of the care patients receive. Physician well-being has even been suggested as a potential missing quality indicator (1). During the training stages, fellows and residents are more susceptible to developing dehumanizing traits and stigmatizing attitudes (1). This is very important because it translates to poor patient care and/or patient safety. These early years of training and practice often shape a physician’s future, especially with respect to Well-being; during this period coping strategies are established and implemented, parameters of lifestyle are set, and preventive health behaviors are acquired (1). Physician well-being is defined as the presence of positive emotions and moods, the absence of negative emotions, satisfaction with life, fulfillment and positive functioning” in the context of “physical wellness.” (2).

Physician well-being can be divided into two dimensions: 1. Stress, Burnout and Sleep Deprivation (SBSD); and 2. Substance Abuse Disorder (SAD). SBSD is not a new phenomenon, but its prevalence has been increasing in the last years (3). It is defined as a syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment that can affect the quality of care and productivity with dire consequences for health systems (4). Besides this statement, sleep deprivation has been linked to a higher risk of surgical complications, medical errors, increased rate of needle-stick injuries and post-shift car accidents (5). SAD might be more common than one would imagine. The most commonly abused substance is alcohol, but sedatives, stimulants or opiates, and psychedelics are also used by physicians (6).

Over the past years, physician well-being has become a hot topic among patients, providers and national and international medical organizations. Several systematic reviews and meta-analyses have consistently found higher suicide rates among medical professionals (7). Some of them found that the suicide rate ratio for male physicians, compared to the general population, was 1.41; for female physicians, the ratio was 2.27 (8). Every year several resident or fellows commit suicide and endocrinology is not the exception. These are not isolated events but more the tip of the iceberg of a bigger problem that involves graduate medical education, humans, and medicine as an organization.
The title VII CPR released by the ACGME in 2017 (9) introduces a new section, that we had the privilege to work for, related to well-being. The notion of keeping our fellows away from burn out and improving their wellness at work is stated in every of the core or detail program requirements.

How to implement helpful strategies for improving well-being depends on the institution’s resources, and other variables. Programs that stimulate diversity and inclusion have been shown to improve trainee wellness (we will talk about this in a future article).
We would like to present a simple project that has improved physician-in-training wellness. This strategy is based on peer support.

The program name is Big Brother. The methodology is straightforward as we explain below.

Each Junior fellow would be assigned to a senior fellow as their “Big Brother” or mentor two weeks before the start of the fellowship. These “Big Brothers” would guide the fellows through their first year of fellowship with, at minimum, monthly one-on-one meetings to discuss progression through one’s milestones and guiding through any challenges the junior fellow have. Each session should emphasize stress coping mechanisms and prioritization of self-care. Junior Fellows could be also be introduced to the Employee Assistance Plan or any other program that the institution offers. Every three months, the “Big Brothers” and mentees should collectively meet in small groups to review a pertinent topic about self-care and mental health issues in the medical community. At this time, all participants would also complete a survey to evaluate the program. The survey should contain a depression screening scale and a rubric to determine if this program was helpful. The program would end after 12 months.

If you want to implement this program in your fellowship or want to learn about other program to improve wellness, please contact us for more details on it at riccorrea20@hotmail.com and karclima@hotmail.com

References
1. Institute of Medicine, To Err is Human: Building a Safer Health System. 2000. Available at http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx
2. Centers for Disease Control & Prevention. Health-related Quality of Life: Well-being Concepts. 2013. Available at http://www.cdc.gov/hrqol/well-being.htm
3. Burnout During Residency: A Literature Review. J Grad Med Educ. Dec. 2009.
4. Dewa C et al. How does burnout affect physician productivity? A systematic literature review. BMC Health Services Res 2014; 14:325.
5. Olson E et al. Sleep Deprivation, Physician Performance, and Patient Safety. Chest 2009; 136(5):1389-96.
6. Oreskovich M et al. The prevalence of substance use disorders in American physicians. Am J on Addictions 2014; doi: 10.111/j.1521-0391.2014.12173.x
7. Schernhammer E & Colditz G. Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Anay, Am J Psychiatry 2004; 161(12):2295-2302
8. Gong, Y. et al. Prevalence of anxiety and depressive symptoms and related risk factors among physicians in China: a cross-sectional study. PLoS One, 2014; 9(7).
9. Ahn Y, Bach P, Berry T, Correa R, et al. Physician well-being. Junior Doctor Network. World Medical Association 2017. Personal communication with senior author Elizabeth Wiley.
10. Burchiel KJ, Zetterman RK, Ludmerer KM, Philibert I, Correa R, et al. The 2017 ACGME Common Work Hour Standards: Promoting Physician Learning and Professional Development in a Safe, Humane Environment. J Grad Med Educ. 2017 Dec;9(6):692-696

Program Director’s Corner – April 2019

Being APD: My take on the role of Associate Program Director and how I interface with the Program Director and Coordinator

Mitali Talsania, MD
Associate Program Director, Endocrine and Metabolism
University of Oklahoma Health and Sciences Center
Mitali-talsania@ouhsc.edu 

I am Mitali Talsania, Associate Fellowship Program Director (APD) for endocrinology at the University of Oklahoma Health Sciences Center. I was appointed as APD in July 2017, a year after joining the faculty. I was overjoyed when offered this opportunity.  With my new role, I now had the ability to truly help fellows and to be part of a process designed to improve their learning experience. I see my role as a connection between our fellows, the program coordinator (PC) and program director (PD).

When I first became APD, I was not too far off from my own fellowship training and was able to relate to their recent experiences. I developed into my role with the support of my PD and PC.  I became an ear for difficulties fellows encountered no matter how small or big. I tried to help solve their problems. These varied from teaching them how to enter insulin drip orders, to providing directions on how to navigate hospitals; finding a solution to challenging clinical cases or providing guidance for research.  My personal goal as APD was to make small but significant changes to improve their fellowship experience and enhance their learning. I wanted to empower fellows with information that I wish I knew when I was a trainee myself, while helping the PD who had delegated a few critical tasks to me. Specifically, using the APDEM curriculum as backbone, I developed a new, updated didactics curriculum for our program. I sent it to each of the faculty for topics they were teaching along with fellows for their input. I also incorporated online resources from Endocrine Society, ATA, AACE, ASBMR into the curriculum. This has helped me tremendously as I am able to guide my fellows better and improve my teaching skills as well.

Our program coordinator has been part of our program since I was an intern. She is the glue that keeps us all together. She has taught me with reminders, emails, useful information throughout my training, and then as faculty. She paves the way for execution of the fellowship match, schedules, meetings and countless other services to keep program running. I can always rely on her to be there for help at any given point with her experience about our fellowship program.

Throughout my career, I have worked very closely with my program director. I have been fortunate to have my PD as my mentor.  She is an anchor that I can count on for any question or problem I encounter. She truly embraces an open door policy and I am able to reach out to her at almost any time. Slowly and steadily, she encouraged me to be more involved in GME meetings, APDEM meetings, walked me through criteria for fellowship candidate selections at our institution, our interview process, rank order list development and sponsored me to join and complete a one-year faculty academic leadership program, focused on mentorship and pathway to promotion.  Most of our conversations occur informally over lunch in between clinics and other duties. We try to sit down together at least once a week.

With this article, I want to emphasize that working together with your program director and program coordinator, you can accomplish goals of improving the fellowship experience and enhance learning for fellows. Your program director and coordinator are your all-time support system. I will conclude this post with dedication it to my program director, Dr. Madona Azar, for her guidance, mentorship and endless efforts to improve our program.

Program Director’s Corner – March 2019

Annual Spring Meetings

David Lieb, MD
liebdc@evms.edu
Twitter: @dclieb
Program Director, Endocrine Fellowship Program
Eastern Virginia Medical School

Welcome everyone to the March 2019 APDEM Program Director’s Corner! Since many of our members will be attending the upcoming APDEM Annual Meeting (March 24th) and the APDEM meeting at AACE (April 26), this month I wanted to provide important information about ENDO 2019 (New Orleans, March 23-26) and AACE 2019 Annual Meetings (Los Angeles, April 24-28). Both ENDO and AACE have a number of sessions geared not only towards our endocrine fellows, but also program directors and associate program directors. In addition to attending APDEM’s meetings, these sessions are not to be missed!

ENDO 2019 (New Orleans, March 23-26)

The Annual APDEM meeting at ENDO 2019 will be held on Sunday, March 24^th from 5:30pm till 7:00pm in room 278 of the Ernest N. Morial Convention Center.  A reception will follow. Program Directors, Associate PDs and Program Coordinators are invited – please RSVP as soon as you can here: https://www.apdem.org/apdem-annual-meeting-materials/.

There will be sessions geared toward the Endocrine Educator – including a session entitled Programming Learner Wellness into Your Curriculum (EEF2, March 24, 1:45-2:20pm, Room 255) and another entitled Professionalism as a Competency: Why to Assess and Institutional Obligations (EEF3, March 25, 2:00-2:45pm, Room 252).

The Annual ESAP-ITE Live program (E01) will return on March 23, from 9:45-11:15am in Room 272. This session continues to receive very positive feedback from both educators and fellows.

I’d like to highlight the twelve Career Development Workshops (CDW01 – 12) that will be held throughout the meeting. These cover such topics as pathways in science, practical advice for foreign medical graduates, careers in industry, mentoring, setting up a lab, grant writing, setting up a clinical practice, and publishing.

These sessions, as well as their times and locations, can be found along with all sessions online using the ENDO 2019 Meeting Planner at: https://www.abstractsonline.com/pp8/#!/5752

This year ENDO is launching new Special Interest Groups (SIGs) – these topic-specific member communities offer a way for members to network and remain engaged year-round through webinars, networking events and online. There are SIGs focused on Adrenal and Pituitary Disease (March 23, 2:10-2:50pm, Science Hub), Transgender Health (March 24, 10:45-11:15am, Science Hub), and Early Careers (March 24, 3:00-3:45pm, Science Hub). There will also be a SIG Networking Coffee (March 25, 2:30-4:00pm, Room 243), and a session on Entrepreneurship in Endocrinology (March 26, 8:00-9:30am, Room 245).

We are also excited for the Presidential Plenary Address by NIH Director Francis S. Collins, MD, PhD, who will discuss “Whole Genome Approaches to Unraveling Diseases” on Saturday, March 23^rd, from 8:40-9:30am.

AACE 2019 (Los Angeles, April 24-28)

The Annual APDEM meeting at AACE 2019 will be held on Friday, April 26^th, from 12:00pm till 1:15pm. Location To-Be-Announced.

The Fellows-In-Training Breakfast will be held from 7:00-8:30am in the JW Marriott Diamond Salon 6 & 7. This annual event is a wonderful opportunity for fellows to network and to learn from each other.

This year AACE will feature an Education for Educators Workshop on Friday, April 26^th from 1:15-3:15pm. This interactive workshop will be chaired by Drs. Vin Tangpricha (Chair of the AACE Education Oversight Committee) and Geetha Gopalakrishnan (Past President of APDEM), and will feature Drs. Kelley M. Skeff, MD, PhD and Georgette A. Stratos, PhD from the Stanford Faculty Development Center for Medical Teachers. This session will include discussion of the following topics: evaluation of and feedback for learners, promotion of self-directed learning, promotion of understanding and retention, communication of goals, control of the teaching session and learning climate.

For Fellows-In-Training (FIT) and Young Physicians, there will be a fantastic FIT and Young Physicians Symposium chaired by Jad Sfeir, MD from the Mayo Clinic. This symposium will be on Friday, April 26^th, from 1:15-5:30pm, and will include a variety of sessions focused on the practical economics of medicine for the trainee/young physician, as well as topics including carving out a role in an academic practice, hospital based practice, private practice, and promoting your practice through social media, and international medical graduate experiences in practice. These sessions will be in the Convention Center Room 515B.

More information about the FIT and Young Physicians Symposium can be found online at: https://am.aace.com/agenda.asp?pfp=agenda, where you can find the Full Program for the AACE 2019 Meeting.

As more of us are using social media for learning and education, we are excited for the Keynote Address by Dr. Kevin Pho, who developed the popular medical blog “KevinMD.com”. Dr. Pho will be discussing “Social Media and the Physician” on Saturday, April 27^th, from 9:00-9:45am.

As always, we would love for some of YOU to write a Program Director’s Corner post. It’s a great way to start a discussion, and to share your wisdom and experience. And please ask your Associate Program Directors and Program Coordinators as well. If you are interested in writing a post, or have a topic you’d like to suggest we cover, please email me at liebdc@evms.edu or direct message me at @dclieb.

See you all at the meetings!

David

Program Director’s Corner – February 2019

#APDEM

David Lieb, MD
liebdc@evms.edu
Twitter: @dclieb
Program Director, Endocrine Fellowship Program
Eastern Virginia Medical School

Welcome everyone to the February 2019 APDEM Program Director’s Corner! I know everyone is getting excited about our upcoming APDEM meetings – first at the Endocrine Society in New Orleans on Sunday, March 24^th, and then at the American Association of Clinical Endocrinologists meeting in Los Angeles on April 26th.

This month I wanted to make a plea to all of you. Starting last year I started using Twitter.  Of course like everyone I had a Twitter account – with zero tweets, zero follows and zero followers, for the previous 10 years. I mean – I was a cool doctor, right? I enjoyed catching up with people on Facebook, and had posted some pictures of the kids on Instagram.

But Twitter…never really made sense to me. Why would anyone care what I had to say in 140 characters? And honestly I didn’t have time to see what others had to say – I was too busy ‘liking’ pictures of cats on Instagram. But then something changed. I remember the day I became a true Twitter user. I was chosen to moderate a wonderful session at the annual AACE meeting by Dr. Armand Krikorian (@ENDOUNO) entitled “#Medicine and #Socialmedia: Untapped Potential”. Armand is an endocrinologist and the Program Director for the internal medicine residency program at the University of Illinois at Chicago/Advocate Christ Medical Center. His talk was exciting, and I soon realized that Twitter was a great resource not just for politicians and celebrities, but also for medical educators.

I logged in, and was surprised and delighted by the wonderful medical education community that I found there. I found a rich medical education community – tagged #MedEd. I reconnected with my own residency program director. I saw journal clubs for nephrology #NephJC and weekly chats and book clubs for #womeninmedicine. I learned what a tweetorial was (thanks @tony_breu).  Initially there wasn’t as much endocrinology – but then in October 2018, David Cohen, endocrinologist and Vice Chair of Education at Rutgers Robert Wood Johnson Medical School (@DavidACohen_MD) suggested that we start using #EndoTwitter to tag our posts and develop our community. Then Armand suggested we have our first #EndoTwitter journal club – which happened at the end of the month, when we discussed a recent publication by Vin Tangpricha (@vtangpricha) on transgender care.  One of our EVMS fellows reviewed that same paper for our own journal club the next week, and was able to ask Vin specific questions through Twitter in real-time before her own presentation. Soon we hope to have our second #EndoTwitter journal club.

I found other uses for Twitter. When I couldn’t attend the annual American Thyroid Association meeting last fall, I was able to ‘follow’ the meeting through Twitter, and learned a great deal about exciting abstracts and important research. I’ve started to learn about endocrine care in other countries. I’ve networked. I have made friends with colleagues through Twitter – people that I have never met – but who I feel close to through our tweets and our ‘likes’, and our discussions. I’ve read and discussed pertinent articles tweeted out by endocrinologists across the globe. I see a future wherein endocrinology program directors use Twitter to share ideas, and to promote their fellowship programs to potential applicants.

So please consider using Twitter.  I’m @dclieb and would be excited to gain you as a follower, and to follow you back. Use the hashtag #EndoTwitter. Share an interesting article, or an accomplishment. Send me a direct message letting me know you are a program director, associate program director, or coordinator. We can build a community online to share ideas, and our success stories. And maybe, just maybe, we’ll see #APDEM trending someday.

On a separate note, we would love for some of YOU to write a Program Director’s Corner post. It’s a great way to start a discussion, and to share your wisdom and experience. And please ask your Associate Program Directors and Program Coordinators as well. If you are interested in writing a post, or have a topic you’d like to suggest we cover, please email me at liebdc@evms.edu or direct message me at @dclieb.

Program Director’s Corner – January 2019

Physician, Heal Thyself!

David Lieb, MD
liebdc@evms.edu
Twitter: @dclieb
Program Director, Endocrine Fellowship Program
Eastern Virginia Medical School

I wanted to introduce myself – I am David Lieb, and I am the Program Director for the Endocrinology Program at Eastern Virginia Medical School in Norfolk, Virginia. I’ve been program director for four years, and was the associate PD before that. I am proud to be the 2019 APDEM Newsletter Committee Chair, and will be reaching out to you all in the coming months, asking for ideas for our newsletter, and for articles that we can post. I’m honored to follow Dr. Rich Auchus, who was our first Newsletter Chair, and who has really blazed the trail for me to follow. I’m also excited to work with all of our wonderful program coordinators, who we all know are the real directors!

At our monthly Graduate Medical Education Committee meeting this month, we discussed resident and fellow wellness. We are entering the 3^rd quarter of the academic year – a time that is particularly difficult for our fellows. They may be back in the hospital again, on a busy consult service, while at the same time trying to get a research project off the ground that they started in July or August. They are presenting what feels like their 100^th case conference, and a maybe a journal club too.  And it’s likely cold and snowy, or rainy, or windy where they are. And they miss their families. You get the picture.  We watched an important short video on preventing medical trainee suicide that I would highly recommend you share with your fellows. Link here:

https://www.youtube.com/watch?v=I9GRxF9qEBA

Maryann Dundon touched upon wellness in her excellent Program Coordinator’s Corner post in April 2018 (Importance of Wellness). In it she talks about some of the awesome things they have done at the Allegheny Health Network Program in Pittsburgh, and I recommend everyone read about their experience.

While we discussed resident and fellow wellness at our GME meeting – we didn’t get into program director wellness too much. In some ways, when compared with peers in other specialties, endocrinologists seem pretty happy. The just-released 2019 Medscape Physician Lifestyle and Happiness Report shows that endocrinologists are among the happiest doctors (outside of work), and have higher self-esteem than many of our peers (https://www.medscape.com/slideshow/2019-lifestyle-happiness-6011057). And the Medscape Physician Compensation report from 2018 (https://www.medscape.com/slideshow/2018-compensation-overview-6009667) reported that 82% of us would choose endocrinology again.

But the 2019 Medscape National Physician Burnout, Depression and Suicide Report (https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056) shows that endocrinologists are among the most likely of all physicians to report feeling ‘burned out’ (47%), and don’t seem likely to seek help (26%) when feeling burned out and depressed. Only 26% of us report being happy at work. It’s hard to know quite what to make of such surveys given the small number of participants, and it’s not clear how many of the endocrinologists included were in academic positions.

The Physician Compensation survey also notes that Endocrinologists are in the bottom three of all specialties with respect to salary (and dropping), and finances weigh heavy on many of us. Seeing patients and trying to make financial ends meet is stressful enough, but having the added responsibility of caring for fellows and a fellowship program, along with teaching and research responsibilities, can be overwhelming. And it’s especially hard when many in your division look up to YOU to set the tone – you have to be happy, and have it all together – because if the fellowship director doesn’t…who can?

So what to do?

Well, I’m certainly not perfect, and not happy all the time (ask Natalie our program coordinator) – but here is my simple list of things to consider working on and trying during these drab winter months.

Have a mentor – this is especially important for early program directors and associate program directors – link up with a program director that has significant experience and can help you setting up programs (like a QI program for your fellows), and responding to fellow needs with which you may not have had much (or any) experience. This person may be a PD in another medical subspecialty, or another endocrinology PD that you meet at a conference, or the previous endocrine PD at your institution.

Check on and care for your colleagues in medical education – consider organizing an outing for the associate PDs and PDs at your institution – something simple – going out for dinner, or to see a movie.  A gathering at someone’s home. It doesn’t need to be much.  Just something social. It’s rare that I don’t feel better after talking with colleagues going through similar things.

Do something fun with your fellows – again, it doesn’t need to be much.  Have them over for pizza.  Maybe do a case conference or a journal club off-site at a restaurant.  It’s good for them to see you happy – and it’s easier for you to be happy and feel fulfilled when they are happy too.

Make friends through social media – I’ve been enjoying getting more involved on Twitter – #EndoTwitter – there are a handful of us right now – but it’s fun to set up polls and ask questions, post good ideas and fellowship accomplishments.

Seek help – early – Your institution most likely has a pathway for you to see a therapist, and you may need to meet with someone to discuss medications if needed.  Don’t wait – if you notice that you aren’t doing as well as you feel you should be – seek help.

Don’t multitask – it doesn’t work.  When you are with friends and family, be with friends and family.  Don’t try to do a significant amount of your work from home if you know it only makes you feel guilty.  You’d be surprised how much you can get done with two solid hours on a Saturday morning BEFORE your day really begins – and you’ll feel much better spending your non-work time later in the day.

Use your vacation time! Plan ahead – and not just for work-related meetings. Visit friends, go on trips with your family. When the kids have a teacher-work day – make it a 3 day family vacation.  But use it!

Exercise, meditate, sleep, eat right, yada yada yada – we all know this.  But the important thing is making time to plan meals, pack your lunch so you aren’t eating crackers, etc. And remember – if you aren’t well rested and healthy, your fellowship program won’t be either.  And if you can’t make a 7am meeting because it interferes with your time to care for yourself, that’s okay.  Make it clear to others that it’s a priority for you.

At our upcoming APDEM meeting at the Endocrine Society meeting in New Orleans we are hosting a presentation by Dr. Stuart Slavin – Senior Scholar for Well-Being at the ACGME. Dr. Slavin is an internationally-known expert in the area of medical student and resident well-being, and I’m looking forward to hearing his thoughts about fellows, fellowship programs and program directors.

I hope this list is helpful – just some friendly reminders. Take care of yourself, and take care of each other.

Dave

Program Director’s Corner – November 2018

Milestones are due again…

Odelia Cooper, MD
Associate Professor of Medicine, Division of Endocrinology, Diabetes, and Metabolism
Program Director, Endocrine Fellowship Program
Cedars-Sinai Medical Center
odelia.cooper@cshs.org

The email comes to you alerting you that “Your Endocrinology, diabetes, and metabolism – Internal medicine program has been scheduled to complete the Milestone Evaluations for the residents/fellows within your program.” Yes—the email comes with 2.5 months’ notice, but it often goes on the back burner until December rolls around. Truth be told, with a system in place, the milestone process can go smoothly and efficiently. I would like to share the process we have developed for our program at Cedars-Sinai Medical Center. Our goal is to keep it focused and efficient while providing comprehensive, specific, meaningful feedback to our fellows.

1. Use milestone appropriate evaluations: We changed our evaluation forms to those that APDEM developed to match the milestones, such as the outpatient endocrine evaluation form, insulin pump forms, etc (accessible on APDEM Member Connect* under the “Resources” tab). I include evaluations for each conference that the fellows present at as well as research evaluations (sometimes sent through emails as PDFs to complete). Further, any feedback that faculty, allied health professionals, or patients provide are sent to me directly, and I copy them into a Word document with the dates so that I can track the unsolicited feedback throughout the year.
2. Set up the Clinical Competency Committee meeting: I invite all faculty from our division who have interacted clinically with our fellows.
3. Gather self-assessments: Have fellows complete the online self-assessment forms prior to the CCC meeting.
4. Collect staff and patient evaluations: Ask the clinic staff to collect patient evaluations on each fellow from their continuity panels. I aim to obtain at least 5 patient evaluations per fellow, but more is better. Circulate evaluations to nurses, clinical diabetes educators, and patient service representatives. This all drives into assessing their competency in professionalism.
5. Assess procedural skills: Ensure that the evaluations for thyroid ultrasounds, fine needle aspirations, DXAs, pumps, and CGMs are completed by those who have supervised the fellows the most in these areas.
6. Gather peer feedback: I use the evaluations by our medicine residents on the fellows. I mapped the relevant questions to match the APDEM ones.
7. Distribute research evaluations: I send the APDEM form for Publications, Research, and QI projects to the fellows’ mentors. They are asked to write specific comments on how the fellows are progressing.
8. Calculate preliminary milestone scores: I created a spreadsheet which automatically calculates preliminary milestone scores. I used the matrix that APDEM developed that maps each evaluation question to each of the 24 milestones. I download and calculate the mean scores for each question on each evaluation on the fellows. I input that score into the question on the spreadsheet in each milestone category. For example, on the outpatient endocrine evaluation, I take the mean score from all question 1 scores on this form and input the score for Milestone Patient Care 1. Patient Care 1 milestone is comprised of faculty Q1 and Q2. So, I put in both mean scores for Q1 and Q2 and get a calculated mean score for PC1. For PC2– that is comprised of faculty questions 4, 5,7,8, 11 and AHP question 4, peer question 4. So, I insert all the mean scores for those questions and get a calculated mean for PC2. And so on…

You now have a starting point for milestone scores to review with your CCC.

9. Prepare for the CCC meeting: I draft a written summary of each fellows’ performance. The purpose is two-fold: one is to provide the CCC with background to review prior to the meeting and to discuss at the meeting. The second is that it provides me the written documentation which I will review with each fellow at our semi-annual evaluation meeting and which will be placed into their files. I divide up the document as follows: Patient care (resident, attending, AHP, and patient feedback); Procedures (DXA, thyroid, pumps, CGMs); Research; Publications; Awards; Teaching (i.e. conference presentations); Self-assessments; ITE scores; Career plans; 6 month action plan (added post CCC meeting); fellow feedback on program (added after individual meeting with fellows).  I write in average scores from the evaluations and the comments from both evaluations and emails. A few days before the meeting, I send out to the CCC the preliminary calculated milestone scores, the comments document on each fellow, and my slides on what each milestone means (from ACGME) so that the faculty are reminded of what is expected for each level on the milestone.
10. Run the CCC meeting: I start the meeting by reviewing the comments document for each fellow. In this way, we have the context of what each fellow has accomplished, where he is progressing or struggling. We then go to the actual milestones and decide if the calculated score is accurate or should be moved up or down after the discussion. We then summarize what specific feedback to provide each fellow and what areas to work on.
11. Meet with the fellows: I meet with each fellow individually, review their progress, and how they see their own performance. I explain and present their milestone scores, the CCC recommendations on what to work on, and solicit feedback on our program.
12. Upload milestone scores in Web/Ads.

And you are now done for the next 6 months…but again, this is a continuous process. Having timely, specific, real time evaluations and feedback is truly key to this whole process.

If you wish to contact me for any of my templates, feel free to email me anytime.

Here are is a link for additional background on the role of the CCC and milestones:

https://www.acgme.org/What-We-Do/Accreditation/Milestones/Resources

Best of luck in your milestones.

*If you have trouble accessing the member connect site, please email APDEM staff at apdem@endocrine.org for assistance.

Program Director’s Corner – November 2018

RE: 10-Year ACGME Site Visit

Andrew G. Gianoukakis MD, FACE
Professor of Medicine
David Geffen School of Medicine at UCLA
Program Director, Endocrinology and Metabolism Training program
Division of Endocrinology and Metabolism
Harbor-UCLA Medical Center

Dear Program Director Colleagues,

While any evaluation can be anxiety provoking, even for physicians who are accustomed to being repeatedly evaluated at every turn, I must say that at our recent ACGME site visit was, a much more pleasant experience than what I anticipated. I would describe it more like a visit from company headquarters to assure local compliance with company policies and documentation needs, and to achieve a convergence of visions of the stakeholders (PD, faculty and trainees) for the program. The overarching goal seemed to be to provide guidance as opposed to punitive action. Mind you, my experience may be reviewer specific. Furthermore, as of the writing of this newsletter, we have yet to receive our official ACGME site visit report; so you may want to check back with me.

Preparation:

1. We were notified of the site visit approximately 6 months in advance of the visit.
2. I would suggest going to the ACGME website, searching for ’10 year site visit’ and reading about the objectives of the visit and how to prepare for the site visit. The site contains ‘Eight steps to prepare for the 10 year ACGME site visit,’ as well as other helpful information.
3. Approximately 3 months in advance we received a letter from ACGME offering and requesting specifics of the visit.
   1. 90 min Initial Meeting with Program Director and Program Coordinator

Review of Program, including the Self-Study and the Summary of Achievements; initial discussion about the information entered and uploaded to ADS (response to citations [if applicable], major changes [including actions in response to issues identified on the ACGME Resident and Faculty Surveys], block diagram, current faculty’s board certification and medical license information) and a review of documents (see below)

1. 75 min meeting with all available Fellows
   1. The fellows were asked to prepare and submit directly to the reviewer, a single collective (consensus) list of up to five strengths, and five areas for improvement for the program.
2. 60 min meeting with up to 6 Key Faculty
   1. The faculty were asked to prepare and submit directly to the reviewer a single collective (consensus) list of up to five strengths, and up to five areas for improvement of the program
3. 30 min Concluding Meeting with Program Director & Program Coordinator

Take home points:

• In my view, the ACGME would like to see that the annual program evaluations, action plans generated as a result of the APE, goals outlined in your self-study as well as the comments of the other stakeholders (trainees and faculty) are in sync and that all stakeholders are moving in the same direction with common goals
• Cross your T’s and dot your I’s.

Preparing Documents for the Site Visit

• Update data in Accreditation Data System (ADS)
• An updated summary must be completed and uploaded through ADS a minimum of 12 days before the date of the 10-Year Site Visit.
  • Two types of updates can be made: 1) to identify changes in the program since the Self-Study Summary was submitted; and 2) to provide information on new dimensions of the Self-Study that were added in July 2017.
  • Using the template available from the ACGME 10-Year Site Visit web page, prepare the summary of achievements. This document provides a list of the program’s strengths and the improvements that have been achieved to date in areas identified during the initial self-study.

Site Visit Document Checklist for the 10-Year Accreditation Site Visit

Sponsoring and Participating Institution

1. Current, signed program letters of agreement (PLAs).

Resident Appointment and Evaluations

2. Files of recent program graduates and current fellows (1-2 in each year of training); files of any trainees who have transferred in or transferred out of the program, or have resigned or been dismissed in the past three years. Resident/fellow evaluations by faculty, peers, patients, self, other staff; semi-annual evaluations; and final evaluations are assessed during review of the fellow files.

Educational Program

3. A sample of competency-based, educational level-specific goals and objectives for one

rotation/assignment.

4. Conference schedule for current academic year.

Faculty and Program Evaluation

5. Sample of a completed annual confidential evaluation of faculty by residents/fellows.
6. Written description of Clinical Competency Committee (CCC): membership and SOP.
7. Written description of Program Evaluation Committee (PEC): membership and SOP.

Work Hours and the Learning Environment

8. Program-specific (not institutional) policies for supervision of fellows.
9. Sample work hour compliance data demonstrating your monitoring system.

Quality Improvement

10. Sample documents demonstrating fellow participation in patient safety and quality improvement projects.

Annual Program Evaluation and Self-Study Documents

(NOTE: The documents below will NOT be accessed or reviewed by the site visitor, but should be available to the program director for a discussion of the program’s ongoing improvement efforts.)

11. Annual Program Evaluations for the past five years, action plans resulting from these evaluations, data tracked and information on improvement activities.

Program Director’s Corner – October 2018

Evaluating Faculty Performance

Dr. Christopher McCartney
cm2hq@virginia.edu
Program Director, Endocrinology and Metabolism
University of Virginia

Annual faculty evaluation is required by the ACGME. According to the Revised Common Program Requirements effective July 1, 2017: [1]

V.B. Faculty Evaluation
V.B.1. At least annually, the program must evaluate faculty performance as it relates to the educational program. (Core)
V.B.2. These evaluations should include a review of faculty’s clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism, and scholarly activities. (Detail)
V.B.3. This evaluation must include at least annual written confidential evaluations by fellows. (Detail)
V.B.3.a) Fellows must have the opportunity to provide confidential written evaluations of each supervising faculty member at the end of each rotation. (Detail)
V.B.3.b) These evaluations must be reviewed with each faculty member annually. (Detail)

There are a number of complimentary ways that programs can evaluate its faculty members, but as described in V.B.3., the evaluation must include confidential written evaluations by fellows. However, some fellows may not feel at complete liberty to provide all relevant feedback (e.g., negative feedback).

Over the years, our program has primarily relied on structured faculty evaluations submitted anonymously by fellows via an online platform (New Innovations) after each rotation. These evaluations routinely suggested that faculty teaching and supervision were very good. However, circa 2015, informal fellow comments suggested to me that their views on one faculty member’s general endocrine abilities (i.e., his ability to guide fellows in areas unrelated to his specific expertise) was insufficient for the fellows’ needs on the general endocrinology inpatient consult service.[2]

Despite this perception, the faculty member had routinely received good written evaluations.

Based on subsequent discussions with fellows, I learned that some fellows worried that it could be very easy for faculty members to determine who wrote a particular evaluation. Since fellows “must have the opportunity to provide confidential written evaluations of each supervising faculty member at the end of each rotation” (italics mine), the timing of the evaluation could implicate a specific fellow. In addition, some fellows seemed reluctant to provide any negative feedback of faculty members in writing, even if completely anonymous.

To help address these issues, we initiated two program changes circa 2016.

1. In accordance with ACGME regulations, we continue to use written evaluations after each rotation with a faculty member. However, we do not immediately release these evaluations. We only release evaluations once a year as a batch, and the evaluations do not disclose the timing of the rotation. Since a faculty member receives all of the year’s evaluations at once, it is more difficult to guess which fellow submitted a particular evaluation.

2. We started asking the fellows meet alone as a group once a year (e.g., mid-academic year) for the express purpose of faculty evaluation. Such meetings are organized and moderated by a senior fellow. During these meetings, the fellows discuss and provide a summary evaluation for each faculty member. Specifically, fellows assess the following faculty characteristics using a scoring system (NA = cannot assess, 1 = poor, 2 = fair, 3 = good, 4 = excellent):

1. Possesses expertise in field of practice (clinic)
2. Possesses expertise in general endocrinology (consults)
3. Applies basic and clinical sciences relevant to patient care
4. Allows you to independent formulate your own clinical opinion and allow for academic discussions
5. Aids in your critical assessment of patients
6. Helps to develop and implement patient management plans
7. Establishes and models an environment of professionalism
8. Apparent degree to which faculty member values fellows and their education

The fellows are also invited to provide additional feedback in narrative form. Evaluations of each faculty member are then submitted to me as Program Director. After review, I share each faculty member’s evaluation with that faculty member in addition to the Division Chief (see example in appendix ).

Although group feedback has been uniformly positive for most faculty members, the fellows have recently provided important constructive feedback (i.e., minor suggestions for improvement) for a minority of faculty members—the sort of important feedback we’ve not seen in other written evaluations. Overall, we trust that program quality can be improved by facilitating constructive criticism of teaching faculty by those who can best provide it—the fellows—and we believe that these two changes have enhanced our fellows’ ability to freely evaluate our faculty members.

[1] https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/143_endocrinology_diabetes_metabolism_2017-07-01.pdf

[2] In partnership with the Division Chief, the program rectified this situation by excusing the faculty member from inpatient consult duties.

Program Director’s Corner – September 2018

Defining Noncognitive Domains During the Interview Process

Dr. Debra Simmons
debra.simmons@hsc.utah.edu
Program Director, Endocrinology and Metabolism
University of Utah

Dear Fellow Program Directors and Administrators:

Another interview season is upon us and I would like to share some of my thoughts.

Although busy, it is an exciting time when we get to meet with many of our future endocrinology colleagues. I enjoy talking with them about how they became interested in endocrinology and what they plan to do with their career. I am impressed by their desire to contribute to the field and help the many people with endocrine diseases. Many seem genuinely motivated by compassion for people suffering from our common to rare diseases and have ideas about how to help. Despite the importance of selection of candidates who have the best fit for our individual training program, there is a paucity of data that could guide us. Interestingly, we also do not have an agreed upon definition of excellence in clinical care which should be the cornerstone of our training programs. Dr. Baum has an excellent article (1) on excellence in clinical endocrinology that should be required reading for all of us! He thoughtfully proposes a definition for our specialty. He believes that key aspects of clinical excellence in endocrinology include the following: the ability to work in teams, communication and interpersonal skills, skillful negotiation of the health care system, and a strong knowledge base and scholarly approach. He calls on us as program directors to foster the development of skills necessary to deliver excellent clinical care in both our trainees and our faculty. As the ACGME has asked us to review and revise our milestones, it is an opportunity for us to consider how to best do this.

The standardized letter of recommendation for fellowship applicants endorsed by the Alliance of Academic Internal Medicine (AAIM) addresses the ability to work in teams, communication and interpersonal skills, knowledge base and scholarly activity as measured in the residency program (2). It is a starting place for us to assess the potential abilities of our applicants in the skills Dr. Baum proposes are necessary for clinical excellence. Skillful negotiation of the health care system and a scholarly approach to clinical care are not directly addressed by the current letter. The interview selection committee for my program at the University of Utah reviews all available information in the standard ERAS application. We give priority to those who engage in scholarly activity but other than attention to negative comments, do not uniformly assess for these skills either by the interview selection committee or by the interviewers.

Bosselet and colleagues (3) developed a validated customizable tool to score resident and fellow applicants for selection to be interviewed and for the interview itself in the ERAS application system. Their “ERAS Application Scoring Tool-Interview Scoring Tool” method correlated well with traditional ranking methodology at all five participating institutions. Using the tool would allow for standardization across programs and could potentially be used to compare outcomes of fellowship training. The interview tool is comprised of more subjective components including fit for the program, insight and interpersonal skills.

Tatem and colleagues (4) developed a behavioral-based interview (BBI) method to better assess the noncognitive aspects of trainees at their institution for pulmonary and critical care medicine fellowship. They plan to evaluate how this change in their interview process relates to outcomes for their fellows. They also suggest that their standardized BBI method could be adapted for use by other training programs.

Standardized interviews have also been explored in the surgical field and similarly seek to better assess noncognitive aspects in addition to knowledge and technical skills. Emotional intelligence (EI) was found to be associated with job satisfaction (5) and burnout (6) at one residency program. High EI was associated with enjoying the job and low burnout. Lin and colleagues (7) at a different training program determined that EI could not be reliably assessed in the interview. Gardner and Dunkin (8) describe the process that Baylor College of Medicine Surgery Program used to develop an evidence-based selection system to select and rank applicants. Situational judgment tests and personality profiles were used for their on-line pre-interview selection process. Wow! How innovative is that? That information was also used in the final ranking scores. In addition, Gardner and colleagues (9) developed a training program for a structured interview by faculty that resulted in improved assessment of competency and increased interrater agreement.

These are ideas that may be good for us to consider. Including a standardized assessment of noncognitive domains may be helpful for us to incorporate into our interviews and our training programs. This could be informative for work-life balance, avoidance of burnout as well as for leadership development. Many of us participated in the survey Dr. True and colleagues (10) developed about the need for leadership training in endocrinology training programs. The results clearly indicated that both the program directors and trainees believe that there is a need.

My final thoughts relate to our matching the fit of the program to the needs of the trainee. Two articles seem to address this although indirectly (11, 12). They are written for fellowship candidates trying to help them understand the process and how to assess the fit of a program with their needs. Kudos to the GI and Pulmonary/Critical Care communities for doing this! Both articles illuminate the process in very practical terms. It is informative to flip our thoughts as program directors to mirror finding a good fit from the program view. Articulating what we want is a first step for each program.

What would I like for us to do? I would like for everyone to read the two articles on excellence in endocrinology and the need for leadership training. Please think about how we could better define some of the noncognitive domains important for success as a trainee and subsequent practicing endocrinologist. Interacting with the fellow candidates during their interviews could give us insights into what they might need and help us continue to train the next generation of excellent endocrinologists.

References
1) Baum HBA. Clinical Excellence in Endocrinology. J Clin Endocrinol Metab. 2018
May 3. doi: 10.1210/jc.2018-00916. [Epub ahead of print] PubMed PMID: 29733361.
2) Alweis R, Collichio F, Milne CK, Dalal B, Williams CM, Sulistio MS, Roth TK,
Muchmore EA. Guidelines for a Standardized Fellowship Letter of Recommendation.
Am J Med. 2017 May;130(5):606-611. doi: 10.1016/j.amjmed.2017.01.017. Epub 2017
Feb 9. PubMed PMID: 28189466.
3) Bosslet GT, Carlos WG 3rd, Tybor DJ, McCallister J, Huebert C, Henderson A,
Miles MC, Twigg H 3rd, Sears CR, Brown C, Farber MO, Lahm T, Buckley JD.
Multicenter Validation of a Customizable Scoring Tool for Selection of Trainees
for a Residency or Fellowship Program. The EAST-IST Study. Ann Am Thorac Soc.
2017 Apr;14(4):517-523. doi: 10.1513/AnnalsATS.201611-938OC. PubMed PMID:
28362524.
4) Tatem G, Kokas M, Smith CL, DiGiovine B. A Feasibility Assessment of
Behavioral-based Interviewing to Improve Candidate Selection for a Pulmonary and
Critical Care Medicine Fellowship Program. Ann Am Thorac Soc. 2017
Apr;14(4):576-583. doi: 10.1513/AnnalsATS.201611-940OC. PubMed PMID: 28306323.
5) Hollis RH, Theiss LM, Gullick AA, Richman JS, Morris MS, Grams JM, Porterfield
JR, Chu DI. Emotional intelligence in surgery is associated with resident job
satisfaction. J Surg Res. 2017 Mar;209:178-183. doi: 10.1016/j.jss.2016.10.015.
Epub 2016 Oct 20. PubMed PMID: 28032557.
6) Cofer KD, Hollis RH, Goss L, Morris MS, Porterfield JR, Chu DI. Burnout is
Associated With Emotional Intelligence but not Traditional Job Performance
Measurements in Surgical Residents. J Surg Educ. 2018 Feb 23. pii:
S1931-7204(17)30516-0. doi: 10.1016/j.jsurg.2018.01.021. [Epub ahead of print]
PubMed PMID: 29483035.
7) Lin DT, Kannappan A, Lau JN. The assessment of emotional intelligence among
candidates interviewing for general surgery residency. J Surg Educ. 2013
Jul-Aug;70(4):514-21. doi: 10.1016/j.jsurg.2013.03.010. Epub 2013 Apr 30. PubMed
PMID: 23725940.
8) Gardner AK, D’Onofrio BC, Dunkin BJ. Can We Get Faculty Interviewers on the
Same Page? An Examination of a Structured Interview Course for Surgeons. J Surg
Educ. 2018 Jan – Feb;75(1):72-77. doi: 10.1016/j.jsurg.2017.06.006. Epub 2017 Jul
29. PubMed PMID: 28625496.
9) Gardner AK, D’Onofrio BC, Dunkin BJ. Can We Get Faculty Interviewers on the
Same Page? An Examination of a Structured Interview Course for Surgeons. J Surg
Educ. 2018 Jan – Feb;75(1):72-77. doi: 10.1016/j.jsurg.2017.06.006. Epub 2017 Jul
29. PubMed PMID: 28625496.
10) True MW, Folaron I, Wardian JL, Colburn JA, Sauerwein TJ, Beckman DJ,
Kluesner JK, Tate JM, Graybill SD, Davis RP, Paulus AO, Carlsen DR, Lewi JE.
Leadership Training in Endocrinology Fellowship? A Survey of Program Directors
and Recent Graduates. J Endocr Soc. 2017 Feb 9;1(3):174-185. doi:
10.1210/js.2016-1062. eCollection 2017 Mar 1. PubMed PMID: 29264475; PubMed
Central PMCID: PMC5689151.
11) Madanick RD, Yoon SS, Abraham R. Selecting a fellowship in gastroenterology.
Gastroenterology. 2012 May;142(5):1050-4. doi: 10.1053/j.gastro.2012.03.028. Epub
2012 Mar 21. PubMed PMID: 22446474.
12) Bosslet GT, Burkart KM, Miles MC, Lenz PH, Huebert CA, McCallister JW.
Preparing for Fellowship in Internal Medicine. Steps for Success with a Focus on
Pulmonary and/or Critical Care Programs. Ann Am Thorac Soc. 2015
Apr;12(4):567-73. doi: 10.1513/AnnalsATS.201501-033AS. PubMed PMID: 25742296.