SAMA's talk in the Sudan House Officer Conference

The Conference of Internship Training in Sudan:

The Present And FutureUSA Experience

Sudanese American Medical Association

Bushra Ibnauf, MD, MS, ABIMConsultant Gastroenterologist/Hepatologist

King Faisal Hospital and Research Center, Jeddah KSA

CONCEPTS• Residency/Training is an essential dimension of the transformation of the

medical student to an independent practitioner.

• It is physically, emotionally, and intellectually demanding.

• The specialty education of physicians to practice independently is experiential, and necessarily occurs within the context of the health care delivery system.

• The essential learning activity is interaction with patients under the guidance and supervision of faculty

• Supervision ensures the provision of safe and effective care to the individual patient; assuring each resident's development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishing a foundation for continued professional growth.

Graduate Medical Education in the USA

Graduate Medical Education in the USAHIGHLIGHTS

1. Road Map:Training has a specific entry point an exit point.

2. Tangible Milestones:Majority of trainees complete their training, and gaining certification (American Board) as independent medical practitioners.

3. Support System4. Accountability5. Structured/Universal method to perform procedures.6. LogBook7. Disciplinary Actions8. Chain of Command

Graduate Medical Education in the USADifferences

• Pathway to residency training requires certification by the ECFMG (Educational Commission for Foreign Medical Graduates). This is expensive, time consuming and exhausting. It involves three examinations. It also requires verification of Medical School degree.

• Traditional Housemanship (3-month rotations in the major disciplines of medicine) does not exist. Instead, these rotations are done during the last year of medical school. After graduation, the newly graduated doctor joins a residency, which is a dedicated training period of 3-5 years in a specific specialty. The first year of such training is named (internship).

ACGME

• The Accreditation Council for Graduate Medical Education (ACGME) is responsible for the Accreditation of post-MD medical training programs within the United States. Accreditation is accomplished through a peer review process and is based upon established standards and guidelines.

INSTITUTIONAL ORGANIZATION AND RESPONSIBILITIES

Sponsoring Institution

• Residency programs accredited by ACGME must operate under the authority and control of one Sponsoring Institution . This institution can be university based or community based. Institutional responsibility extends to resident assignments at all participating sites.

• A Sponsoring Institution's failure to maintain accreditation will jeopardize the accreditation of all its sponsored programs.

Commitment to Graduate Medical Education (GME)

• The Sponsoring Institution must provide graduate medical education (GME) that facilitates residents' professional, ethical, and personal development.

• The Sponsoring Institution and its GME programs, through curricula, evaluation, and resident supervision, must support safe and appropriate patient care.

• A written statement must document the Sponsoring Institution's commitment to provide the necessary educational, financial, and human resources to support GME.

• It must be reviewed, dated, and signed by representatives of the Sponsoring Institution's governing body, administration, and GME leadership within at least one year prior to the institutional site visit.

Oversight/Internal Governance

• An organized administrative system, led by a Designated Institutional Official (DIO) in collaboration with a Graduate Medical Education Committee (GMEC), must oversee all ACGME-accredited programs of the Sponsoring Institution.

• The DIO and GMEC must have authority and responsibility • The DIO and/or the Chair of the GMEC must present an annual

report to the Organized Medical Staff(s)

Sponsoring Institution Requirements

INSTITUTIONAL RESPONSIBILITIES FOR RESIDENTS

Resident Educational and Work Environment

• The Sponsoring Institution and its programs must provide an educational and work environment in which residents may raise and resolve issues without fear of intimidation or retaliation.

• Mechanisms to ensure this environment must include:- An organization or other forum for residents to communicate and exchange information on their educational and work environment, their programs, and other resident issues.- A process by which individual residents can address concerns in a confidential and protected manner.- The Sponsoring Institution must provide services and develop health care delivery systems to minimize residents’ work. These services and systems must include: Patient support services, Laboratory/pathology/radiology services and Medical Records.

CASE EXAMPLE:

INTERNAL MEDICINE

Structure

Structure

Associate Program Directors:

• APDs are faculty who assist the PD in the administrative and clinical oversight of the educational program.

• Must be clinicians with broad knowledge of, experience with, and commitment to internal medicine as a discipline, patient centered care, and to the generalist training of residents.

• Must hold current certification from the American Board of Internal Medicine (ABIM) in either internal medicine or a subspecialty.

• Responsibilities- must dedicate an average of at least 20 hours per week to the administrative and educational aspects of the educational program, as delegated by the program director, and receive institutional support for this time;- must report directly to the program director; and,- must participate in academic societies and in educational programs designed to enhance their educational and administrative skills.

Subspecialty Education Coordinators

• In conjunction with division chiefs, the PD must identify a qualified individual, the Subspecialty Education Coordinator, in each of the following subspecialties of internal medicine: - cardiology, - critical care, - endocrinology, - hematology, - gastroenterology, - geriatric medicine, - infectious diseases, - nephrology, - oncology, - pulmonary disease,- rheumatology.

• The Subspecialty Education Coordinator must be: currently certified in the subspecialty by the ABIM, and accountable to the program director for coordination of the residents’ subspecialty educational experiences in order to accomplish the goals and objectives in the subspecialty.

• (N.B.: Core Faculty may also serve as Subspecialty Education Coordinators.)

Core Faculty

• The core faculty are the expert competency evaluators who work closely with the program director and associate program directors, who assist in developing and implementing the evaluation system, and who teach and advise residents.

• The core faculty must:- be ABIM-certified internists who are clinically active- dedicate an average of at least 15 hours per individual per week to residency training;- be specifically trained in the evaluation and assessment of the ACGME competencies;- spend significant time in the evaluation of residents including the direct observation of residents

with patients; and, advise residents with respect to their career and educational

ACGME COMPETENCIES

Patient Care

Patient Care

Medical KnowledgeResidents are expected to demonstrate a level of expertise in the knowledge

of those areas appropriate for an internal medicine specialist, specifically:

Supervision of Residents

• In the clinical learning environment, each patient must have an IDENTIFIABLE, appropriately-credentialed and PRIVILEGED attending physician who is ultimately responsible for that patients' care.

EVALUATION

• Resident Evaluation: Multisource and summative

• Faculty Evaluation• Program Evaluation

Resident Evaluation

Discussion

• Is Housemanship Mandatory, or can we do without it?

• What is the alternative (Sub-internship)?• Cost/Responsibility• Which approach will address the nation’s need

? Fragmented or longer but clear ?

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