Introduction
Jim Hallock
Good morning. Everybody sleep well? I’m the designated host. I provide the libation, but you will do the work and someone else will organize us, but I do have a chance to make a couple of comments.
There is a poster in the back of an educational model and it shows the continuum of medical education. There are other resources back there too I want you to have a chance to look at. As a former educator I think about this. Everything we’re doing talks about the continuing education physician but the feedback isn’t there. We talk about it, but it doesn’t show up much in practice.
My father had his hernia repaired and he was in the hospital for 2 months. The students spent a lot of wonderful time with him. There were people who spent time with him before the operation and after. When I had my hernia repaired and was in the hospital in 3 hours. The paradigm shift has occurred but slowly. We have to look at the curriculum of medical schools and residency training. As we go forward with what’s next, think about your circumstances and think about the need for this continuum. It probably even begins before medical school. We need to take these paradigm shifts
Lucien has discovered teams. When I had the chance to a chancellor, we also had team. That was 10-12 years ago but it hasn’t progressed very much. We need to continue to help these changes happen. Thanks for being here. I’ll hand it over to Michael.
Tradeshow Debrief
Michael Kaufman
Do you have any comments from the last exercise of the Tradeshows?
- I was reflecting on how interesting the parallels are between what’s going on in our respective organizations and it’s helpful to see this.
- I was most impressed by the performance improvement. It links to the business models. This is essential.
- This sometimes feels like ten conversations about the same thing and we need to do one or two things together instead of all these things separately.
MK: The potential came up in the second summit about the more coordinated effort towards measuring physicians. It’s just potential until we do something about it.
- Competence may still not be defined but there are two or three groups focused on this. Maybe as an offshoot there may be a smaller nexus within this group which are looking at this in parallel tracks but could come together to offer this.
MK: Because we’ve looked at this as a continuum and there are leverage points.
- Something did come out between licensing and certifying boards as restricted license. We don’t have a hard and fast line but we’ve been established surveys that we need to use to do some fact-finding. The CME thread and specialty boards are really coming together and reducing redundancy. This group could be a focus to unite a lot of activities, so the physician doesn’t have to do this 20 times.
Scribing
Welcome and recap
Carol Aschenbrenner
You’ve left me a great opening. Separate, united, or coordinated. Look at this poster. You’ll see that we started as separate, feeling demands from inside and outside the profession and starting several initiatives, but we were going down separate lines. A small group of people, including Jim Thompson and David Leach, said we should get together to talk about this and looked for more coordinated.
The embarkation was to set off on a journey together and ask the question about continued competence of physicians so that it serves the profession and the public. Each summit has been a decision point. At the first was to ask what was happening which led to the five scenarios. The second was the hope of a common language and the beginnings of a framework of competence. At the third, that framework began to blossom and the GMP was started. We defined some of the expectations for the different constituencies. We had the first discussions of a trusted agent and the alliance as an informal structure. In the fourth and fifth summit, we concentrated on refining the GMP document and thinking about it more conceptually and how it could be used in the different areas of regulation, education and training. We started discussing of the eFolio. At the sixth summit we focused on these summits as the commons. There were two new streams of work, a companion document to the GMP of the conditions and the shift document. We also worked on a participant agreement. If we’re going to continue this, we need to have something that is a sign of our commitment.
Throughout these six summits, our circle has widened. The core organizations have stayed at the table. One of the questions for us is to validate our goal. Are we still committed to reaching the mountain top and are we going to do this together?
It’s important to recognize a productive sideline of these meetings is the subgroups that have done some work that they may not have done together. We need to see if we’re going to go on, what we’re going to do and how we’re going to get there.
We want to continue to look at the GMP, the shift paradigm and how we can influence the transition. We want to keep the GMP as a dynamic document and to look at how it’s been used and how we can push this document further.
Tomorrow we will be faced again with the idea of another summit. But this time we’re going to talk about a ticket to these summits. Today, we’re going to pass out the participant agreement and to sign it as an individual to follow the spirit of this agreement for these next two days and into the future. If we agree, we would love for you to take it back to your respective organizations and get an official agreement on this diagram.
Thanks for being here. We’re off for another exciting day.
How is the GMP being used
Carol Clothier
I’m going to share what I’ve learned in the last several months about how the GMP is being used. I’ve gotten some emails from a couple of groups for how this can be used as a tool.
There is a question around copyright issues. I know of one woman who wanted to adapt it and include it in their educational standards and I told her that I’m sure we didn’t have it copyrighted but I’d be interested in learning about how they used it and the results of that.
I know another board that is using it as a resource for developing a framework for physicians who are re-entering the profession and to guide how they’ll try to satisfy the boards for their re-licensure. There are a few states which are using it, not to codify it, but from an educational perspective and to help their community understand how the practice of the profession is changing.
There have been a number of educational entities using it for their training programs and with their students. It is slowly being taken in by different organizations.
Conversation
Michael Kaufman
Is there anyone who uses it that wasn’t mentioned?
I work with a small groups ethic committee and we could use it there.
ABIM is using it for their milestone project.
I was stuck with the resemblance of the constitution of independence and their work to get everyone to sign on. We haven’t done that. A lot of its use will come from the support that it has. We need to have a deliberate focus to get the key bodies to sign on. We need to decide if we’re doing this over one year or ten. I think we need to get into high gear about it.
I’ve had conversations with a number of individuals and I don’t think the ACGME has included this document with their competencies but I know some people who are using it to help the directors to understand the breadth of the residency experience and to understand the competencies.
The USMLE governing committees are in the process of updating the strategic agenda which will set the path and one of the recommendations is to restructure the licensing exam with the view of competencies. In the discussions, one of the suggestions was that the USMLE adopt the GMP and the feedback was that it was just a draft and no one endorsed it. Until there is some critical mass of engagement there will be a slow move to its value. I would second the notion of getting the key players to consider and agree that this is an appropriate expansion of the definition of competency.
I’m a first timer and brought up the question of how long we’re doing this. As a surgeon I’m a little impatient. What you have up there is a constitution and I don’t think there’s any controversy. I think we should do this.
There is a significant concern that this could be used in a regulatory way and the concept of that being adopted formally is this fear. Some interesting applications of this are about the authority in power and we have to look at the unintended consequences. I want to balance that sense here.
At some point in time you have to go to the people who matter and have to say yea or nay. Maybe it will be used in ways other than we thought but we will never know until we talk to the people. We need to identify the key people for endorsement.
I’m impressed with the gallery we did yesterday and our conversation about the successes. It seems that we have a lot of internal success and we have trouble with stepping out. What happened to the trusted agent and the eFolio?
I wonder if there is some way to take the gallery on the road and another way to present this material to other groups with a slide presentation.
There is a big question of how to get this document accepted by the AMA. There is a lot of cross-over in this room with the AMA. If we don’t have their endorsement, where are we going to go?
I was going to try not to go here. I think those of us who were in Baltimore remember several conversations about the aspirational versus regulatory. We had a straw vote in Fort Worth and the majority of us said that this is not intended for regulatory use but we’re still hung up there. If you want me to take this to the AMA while that is still working in the sidebar then you’re going to have the biggest organization impacted by this document go nuts. It will be off. We want this document to succeed. I am heartened by these presentations where I see that we’re trying to make competence something we can measure. If we have the legal threat and we don’t face that down today.
MK: I have not heard anything about regulatory.
There are some major issues here that we have to deal with. I am heartened by the uses that Carol talked about, education and ethics teaching. This is the crux of what this should be about. The infrastructure of education is what we’re concerned about. Let us say that we begin at this point. This is a tool for teaching and learning at multiple levels and move forward. We’ve come a long way and we have a long way to go. The patients and the physicians that we serve are going to need something. Let’s move away from trying to imprint it into everything we’re trying to do.
I presented the document to the state board as it was published in DC and the first thing that was said was a doctor who said we need something like this. I can see where the concern is coming from because it will be looked at regulatory document if it doesn’t expressly say that it is not.
Regulation is a hot button. When we’re talking about paradigm shift from autonomy to collaboration, we become very sensitive. We have to be very cognizant of the times in which we live and the idea of self-interest and free markets governing behavior has failed. The mood of the country and maybe the world is that regulation is being looked for. The issue is that there will be some regulation. Do you want to control the process or always throwing stones at it? The medical profession has the knowledge to understand the complexity to establish the regulatory framework instead of coming at it as a tail-end approach.
There are regulations in place already with the organizations we have and I would hate very much for this process to de-rail that. These summits are really about listening to each other and I’m afraid that if we ask people to sign on the dotted line about whether we approve a document is going to sabotage the process and polarize us. We’re seeing the circle of the various organizations come together and I would hate to do anything to blow that up.
The place to put emphasis is on the education and training. It’s really about training the next generation and not converting the current one. I ask which part of this can’t we do. Which part of it do we not want to be responsible for? It’s always around informing the patient. We don’t inform our patients at our own peril. What I would like to get out of this is to understand the fear better. I agree that it is better that we decide the regulations. So what is the root of this fear? How can we address that instead of focusing on the words of the document?
This document arose from the realization that we have conflicting regulations in all our documents and we wanted to create a taxonomy that is shared by all the different boards so we have a common framework. It seems antithetical to our work to say that this should not be used by the state boards which are regulatory body. Whether we say it’s intended to be a checklist by every doctor or as a guide to good medical practice will not dictate how the individual boards use it. It seems that if we step away from the notion of the common framework we’re in trouble. I hear and ‘us and them’ and that is not the model of professional accountability. We’re all in the same boat: the boards, licensing and certifying, and the physicians. If we create a dichotomy we’re in trouble and we will perpetuate the problems that we’re here trying to solve. We are standing together which is exactly how the AMA started. It’s part of the fabric of who we are.
On one hand there is a strong feeling for self-regulation. On the other hand I can give you the experience of a body which creates standards and I can tell you that we’re very careful about creating standards as opposed to guidelines. We practice in an inefficient predatory tort system. The real concern is not the regulation but how it can be used. It is so idealistic. If we could be the ones who live by this that would be wonderful, but it’s not possible for all physicians to always be on time for their patients, they can’t always be pleasant. That would be great but it’s not realistic. So the only problem with this document is the wording. We need to put in the sad reality that we live in. We have to make sure that we don’t hurt the physicians that we’re trying to help.
MK: The reason that you have in your hand this participant agreement is that this is the spirit in which this group is coming together. If you look at it, there isn’t anything in there that says we’re out to hurt anyone. No one has talked about a hammer. The whole purpose of this is that we’re trying to create a framework and we want to coordinate the activities. If you continue as is without doing anything, you’re going to have a bad situation. You need to sign this agreement first.
I have a question. Michael, are you a facilitator or an advocator?
MK: I’m a facilitator.
But you sound like you’re an advocator.
MK: There is a group of people who we call the sponsor team and they tell me what to do. Can that group stand up?
I would like the group to know that I signed the participant agreement and I feel like I understand it. My organization has not endorsed the GMP.
I’m not the CEO of the ACGME and I can tell you that I do not have the authority to sign this document.
MK: That’s a great point. I meant to tell you that.
We decided to be the body here and not have the CEOs. If Michael doesn’t say what we want him to say, then we have to yank him. It’s up to this group to say where we want to go. The solution is in this room.
You mention the word governance. What is that?
We’ve come together voluntarily. We made an express decision for organizations not to endorse the GMP. We were putting together a philosophy and values that expresses where we want to go. So really it is a self-governance.
We have to understand that this is just a microcosm of the practicing physicians. There is a gap between my individual perspective and the organization I represent.
One of the last decisions was that the GMP document would be sent out and the organizations would make comments. A summary of that information would be presented at this session. Is that happening?
MK: We have it but I haven’t figured out yet how to present it.
I suggest that these conversations would be better informed if we had that information to have the feedback from the great unwashed.
MK: This summit is not about the GMP document. I recognize that there is a lot of energy around that but I appreciate that there is a lot of interest in it.
I want to go back to the question of governance. The name is now the national alliance about the communication being sent out on behalf of this group.
MK: There is a steering committee that was created at the last summit and I believe they sent out one communication.
What was it?
MK: They sent out an email that the GMP 1.0 is now available on gmpusa.org.
Was any message sent to Washington to the transition team?
MK: No. Ah yes, I made a post to their website.
I said I would try to get a hold of Tom Daschle. (laughter)
We’re not the only organization that is submitting quality assurance documents to the transition team. This is off the subject. I came to this meeting thinking we were about to finalize the GMP and as organizations to endorse it. I’d like you to express the objective of this summit as a facilitator.
MK: I have no objectives. I’m representing the sponsor group.
I think there was a sense of a culture of improvement. We wanted to flesh out the shift documents and what contributes to these kinds of shifts and how we can work together to improve the competency. We want to identify the role of the organizations in making this happen. I come down here to build relationships and hear about what’s happening. This meeting is an expression of eight people from different organizations who want to understand where we’re going.
To appreciate how the sponsor group works you have to know that we were assigned the task of mapping out the topics for the next summit. This group is tasked with how to carry forward the work of the previous summit and the focus is not just the GMP and there were some ideas that gained some momentum.
As a new person, the summits have taken an arc of conceptual development, consensus, and with the GMP it seems that it’s now moving to the operational. It seems that there is hesitancy because of the complexity. If this is really democratic and amorphous, it is important to identify what this group wants to push over the mountain.
My recollection from the last summit is that there would be a lot of conference calls after the last one and we would be hearing about that this time.
We have to throw this agreement away. It doesn’t have the right title or the right wording.
Why do we need to have a document?
MK: It’s metaphorical. There are a lot of people who need tangible evidence of what we’re doing. I personally don’t understand how the work that has been done is not tangible. I asked to be given a picture of the medical system. I was given these: (shows two photos) it seems that nothing was coordinated. The purpose of these summits was to try to do that.
Can you explain who these people are who wanted something more tangible?
MK: There was a sponsor group of about eight organizations, I can’t name them all, that were part of the first summit and decided to convene these meetings.
No. I want to know who wanted us to sign this participation agreement.
MK: I already answered that.
I believe it was in summit six that we came up with this. There was a group that created this. There was a team that studied organizations that didn’t have formal structures and we tried to understand how to participate in a commons. It’s not a legal agreement it’s just to participate in the commons. We didn’t want a governance structure.
Let’s take a few steps back. Where we trying to go is wonderful. We have an issue or two but we need to put that aside and keep going. We need to put these distractions aside and move on.
I’m one of the few people who don’t represent an organization and have no axe to grind, except for in my personal life which may be worse. (laughter) I just want to acknowledge that we’ve accomplished really wonderful things. All of this is worthwhile and we could be satisfied with just doing the shift papers but it seems that we’re getting hung up on the word assurance. We’re trying to look at this from the macro-view and have reasons for it, but we know that the doctors are in fear about this. We need to identify what we mean by assurance. We realize the judgment will be imperfect but maybe it is better if we have a hand in it. I think it is too bad we don’t have representation from the public here. I welcome comments from the AMA to say how we should do this. I would like the House of Delegates to endorse this fully. We know we’re not perfect but we have a tremendous opportunity.
Next exercise
MK: I’d like to transition to doing the work. Here is what the next round of work is designed to be. Almost all the work we do here is self-selected. For this round, we’ve determined the topics. Later you will do this. Those of you don’t know or don’t remember what happened in the last summits, all of your efforts are self-directed. Take care of yourself. The bathrooms are down the hall, there are beverages and lunch will be served. You will be self-documenting into a wiki.
What Jim was saying this morning led me into this definition of transition. Look at this model. It's not important what the details on it are but can you tell me what it is?
- An organizational chart
MK: And this one? (Next slide) How many of you have seen this chart? (not many hands)
This is from Dr. Deming as his idea for an organizational chart. There is supply on one side and production in the middle and customers on the end. Feedback, design and redesign is a process that goes on forever and ever.
Dr. Deming said that 85% of the results are produced by the first 15% of the process. What is the first part? Design. This is just a seed.
He said there is a system of profound knowledge and it represents inter-connected systems. I suggest you learn about that.
For this next round there will be 12 groups. There were working groups that looked at shifts in the last summit and we’re going to continue that work here. We need to look at what the alliance can do to enable this shift. The last two groups look at creating a continuous learning culture of improvement.
MK: Any questions?
Q: What distinguishes the first three?
A: I want them to look at the document and how to make strategic changes to the participation agreement.
MK: Okay, get to work.