Simulation:
An Inclined Plane in the NAS
John R. Potts, III, MD, FACS
Senior Vice President, Surgical Accreditation
ACGME
Consortium of ACS-Accredited Education Institutes
8th Annual Meeting
Chicago
14 March 2015
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Disclosures
• In recovery
• DIO
• Program director in surgery
• Practicing general surgeon
• I believe that surgical training in the United
States is the best in the world
• No financial disclosure
• In this talk, I do not represent ACGME
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
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NAS
Inclined plane
Hypothesis
Requirements for simulation
Potts triangle
Roles for simulation in NAS: Milestones
Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
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•
•
•
•
•
•
NAS
Inclined plane
Hypothesis
Requirements for simulation
Potts triangle
Roles for simulation in NAS: Milestones
Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
NAS Background
• GME is a public trust
• ACGME accountable to the public
©2015 Accreditation Council for Graduate Medical Education (ACGME)
NAS Background
• Patients & payers expect doctors to be:
• Health information technology literate
• Able to use HIT to improve care
• Sensitive to cost-effective care
• Involve patients in their own care
©2015 Accreditation Council for Graduate Medical Education (ACGME)
NAS Background
• Public expects GME to produce doctors who:
• Possess these skills, and
• Requisite clinical and professional attributes
©2015 Accreditation Council for Graduate Medical Education (ACGME)
NAS Background
Macy Foundation
Institute of Medicine
Robert Wood Johnson
Foundation
COGME
MedPAC
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Next Accreditation System: Goals
• Help produce physicians for 21st century
• Accredit programs based on outcomes
• Provide public accountability for outcomes
• Reduce administrative burden of accreditation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
The Next Accreditation System
Continuous
observations
Assess
program
improvement(s)
Promote
Innovation
Identify
opportunities for
improvement
Program
makes
improvement(s)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
•
•
•
•
•
•
•
NAS
Inclined plane
Hypothesis
Requirements for simulation
Potts triangle
Roles for simulation in NAS: Milestones
Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane
Definition:
A flat supporting surface tilted at an angle,
with one end higher than the other, used as
an aid for raising or lowering a load.
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane
• Moving an object up an inclined plane
requires less force than lifting it straight
up, at a cost of an increase in the distance
moved.
Fw
MA =
Fi
MA = Mechanical Advantage
Fw = Gravitational force of the load object (weight)
Fi = Force exerted on the object, parallel to the plane, to move it up the
plane.
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane
• Probably used building:
• Stonehenge
• Egyptian pyramids
• Sloping roads and causeways by Romans
• During the Renaissance the inclined plane
was classed with the other simple machines
(lever, wheel, pulley, wedge, and screw)
• 1856 Simon Stevin (Flemish) derived the
mechanical advantage of the inclined plane
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
•
•
•
•
•
•
•
NAS
Inclined plane
Hypothesis
Requirements for simulation
Potts triangle
Roles for simulation in NAS: Milestones
Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Hypothesis
Simulation is a tool that can be used to
“smooth” the path over many of the obstacles
to:
learning,
assessment and, ultimately,
to desired outcomes for GME programs.
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
•
•
•
•
•
•
•
NAS
Inclined plane
Hypothesis
Requirements for simulation
Potts triangle
Roles for simulation in NAS: Milestones
Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Simulation in PRs
Obstetrics & Gynecology
II.D.3. There must be space and equipment for the educational
program, including meeting rooms and classrooms with
audiovisual and other educational aids, simulation capabilities,
and office space for staff members. (Core)
IV.A.3.b) [Regularly scheduled didactic] sessions should
consist of patient rounds, case conferences, simulation training,
journal clubs, and protected time for educational activities
covering all aspects of obstetrics and gynecology, including
basic sciences pertinent to the specialty. (Detail)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Simulation in PRs
Otolaryngology
IV.A.3.b).(3).(a) [Didactics in] Anatomy should include the study
and dissection of anatomic specimens, including the temporal
bone, and procedural skills laboratories, along with appropriate
lectures and other formal sessions. (Detail)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Simulation in PRs
Surgery
II.D.2. Resources must include simulation and skills
laboratories. These facilities must address acquisition and
maintenance of skills with a competency-based method of
evaluation. (Core)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Simulation in PRs
Thoracic Surgery
V.C.2.d).(2).(a) Programs must use the results of assessments
to provide program improvement (e.g., quality of the didactic
and clinical curriculum, and the use of educational tools such
as skills labs and other activities) (Detail)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Simulation in Surgical PRs
Colorectal Surgery
Neurological Surgery
Obstetrics & Gynecology
Ophthalmology
Orthopedic Surgery
Otolaryngology
Plastic Surgery
Surgery
Thoracic Surgery
Urology
Simulation
Skills Lab
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-
++
+
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+
+
+
-
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Anesthesiology FAQs
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Emergency Medicine FAQs
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
•
•
•
•
•
•
•
NAS
Inclined plane
Hypothesis
Requirements for simulation
Potts triangle
Roles for simulation in NAS: Milestones
Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
High Tech Simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
The Value Equation
Benefit
Value =
Cost
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane & Value Equation
PPPPPPPPPPPPPP
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Cost-Utilization Triangle of Simulation
Innovative & Experimental
Surgical Skills
Advanced Subspecialty
Surgical Skills
Component
Cost
Advanced Specialty
Surgical Skills
PPPPPPPPPPPPPP
Specialty Surgical Skills
Basic Surgical Skills
© Potts
Component
Utility
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
•
•
•
•
•
•
•
NAS
Inclined plane
Hypothesis
Requirements for simulation
Potts triangle
Roles for simulation in NAS: Milestones
Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Creation of Milestones
ABMS
RRC
PD Group
Residents
Academy
Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Clinical Competency Committee
Operative
Performance
Rating
Scales
Nursing and
Ancillary
Personnel
Evaluations
OSCE
Peer
Evaluations
Mock
Orals
End of
Rotation
Evaluations
ITE
Self
Evaluations
Sim
Lab
Clinical
Competency
Committee
Case
Logs
Student
Evaluations
Clinic Work
Place
Evaluations
Patient /
Family
Evaluations
Assessment of
Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
1
Miller’s Pyramid of Clinical Competence
Does
Shows How
Knows How
Knows
Clinical Observations, Multi-Source Feedback,
Teamwork Evaluation, Operative (Procedural) Skill
Evaluation, Mini CEX
Clinical Observation, Simulation,
Standardized Patients, Mini CEX
MCQ, Oral Examinations, Standardized
Patients
MCQ, Oral Examinations
1Miller,
GE. Assessment of Clinical Skills/Competence/Performance.
Academic Medicine (Supplement) 1990. 65. (S63-S67)
van der Vleuten, CPM, Schuwirth, LWT. Assessing professional competence:
from Methods to Programmes. Medical Education 2005; 39: 309–317
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
General Surgery Milestones
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outline
•
•
•
•
•
•
•
NAS
Inclined plane
Hypothesis
Requirements for simulation
Potts triangle
Roles for simulation in NAS: Milestones
Other roles for simulation
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Other Roles for Simulation
• Non-technical
•
•
•
•
•
•
•
•
Patient history
Physical examination
Breaking bad news
“On call calls”
Obtaining informed consent
Checklist event
Identifying / confronting impaired physician
Patient safety event
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Other Roles for Simulation
• Technical
•
•
•
•
•
Surgical origami
Knot board
Endoscopy
Laparoscopy
Robotics
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Other Roles for Simulation
• Could become an ACGME requirement
• Could become an ABS requirement
• Could be used for credit for rare, high
stakes procedures (as in EM)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Cost-Utilization Triangle of Simulation
Innovative & Experimental
Surgical Skills
Advanced Subspecialty
Surgical Skills
Component
Cost
Advanced Specialty
Surgical Skills
PPPPPPPPPPPPPP
Specialty Surgical Skills
Basic Surgical Skills
© Potts
Component
Utility
©2015 Accreditation Council for Graduate Medical Education (ACGME)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane
• A flat supporting surface tilted at an angle, with one end
higher than the other, used as an aid for raising or
lowering a load.
• Moving an object up an inclined plane requires less force
than lifting it straight up, at a cost of an increase in the
distance moved.
• The mechanical advantage of an inclined plane, the
factor by which the force is reduced is equal to the ratio
of the length of the sloped surface to the height that it
spans.
• Due to conservation of energy, the same amount of
mechanical energy (work) is required to lift a given object
by a given vertical distance, disregarding
losses from
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane
• 3rd century BC Archimedean simple machines: Lever,
pulley and screw
• 1st century AD Heron of Alexandria listed the classic five
simple machines that “can set a load in motion”: Lever,
windlass, pulley, wedge and screw
• It wasn't until the Renaissance that the inclined plane
was classed with the other simple machines
• 1856 Simon Stevin (Flemish) derived the mechanical
advantage of the inclined plane
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Innovative & Experimental
Surgical Skills
Component
Cost
Advanced Subspecialty
Surgical Skills
Advanced Specialty
Surgical Skills
Specialty
Surgical Skills
Basic Surgical Skills
Principles of Surgery
Component
Utility
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Cost-Utilization Triangle of Simulation
Innovative & Experimental
Surgical Skills
Component
Cost
Advanced Subspecialty
Surgical Skills
Advanced Specialty
Surgical Skills
Specialty
Surgical Skills
Basic Surgical Skills
Principles of Surgery
Component
Utility
Potts
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Cost-Utilization Triangle of
Simulation
Innovative & Experimental
Surgical Skills
Component
Cost
Advanced Subspecialty
Surgical Skills
Advanced Specialty
Surgical Skills
Specialty
Surgical Skills
Basic Surgical Skills
Principles of Surgery
Component
Utilility
Potts
©2015 Accreditation Council for Graduate Medical Education (ACGME)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane
Definition:
A flat supporting surface tilted at an angle,
with one end higher than the other, used as
an aid for raising or lowering a load.
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane & Value Equation
PPPPPPPPPPPPPP
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane & Value Equation
PPPPPPPPPPPPPP
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane & Value Equation
PPPPPPPPPPPPPP
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane & Value Equation
PPPPPPPPPPPPPP
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Cost-Utilization Triangle of Simulation
Innovative & Experimental
Surgical Skills
Advanced Subspecialty
Surgical Skills
Component
Cost
Advanced Specialty
PPPPPPPPPPPPPP
Surgical Skills
Specialty Surgical Skills
Basic Surgical Skills
Component
Utility
© Potts
©2015 Accreditation Council for Graduate Medical Education (ACGME)
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane
PPPPPPPPPPPPPP
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Data Reviewed Annually by RC
• Annual ADS Update
• Program Characteristics – Structure and resources
• Program Changes – PD / core faculty / residents
• Scholarly Activity – Faculty and residents
• Response to active citations
• Omission of data
• Board Pass Rate
• Resident Survey
• Faculty Survey
• Clinical Experience – Case logs
• Semi-Annual Resident Evaluation and Feedback
• Milestones
?
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane
• Moving an object up an inclined plane
requires less force than lifting it straight
up, at a cost of an increase in the distance
moved.
• The mechanical advantage of an inclined
plane, the factor by which the force is
reduced is equal to the ratio of the length
of the sloped surface to the height that it
spans.
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inclined Plane
Fw
MA =
Fi
MA = Mechanical Advantage
Fw = Gravitational force of the load object (weight)
Fi = Force exerted on the object, parallel to the plane, to move it up the
plane.
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Hypothesis
Simulation is a tool that can be used to
“smooth” the path over many of the obstacles
to learning, assessment and, ultimately, to
desired outcomes for GME programs.
©2015 Accreditation Council for Graduate Medical Education (ACGME)