>>BRIGHAM: They are, that’s anchored to be theoretically right now, proficiency where we would expect somebody’s ready for the unsupervised practice of medicine. So, there’s two steps after that, at least. There’s expert and mastery.

>>REGNIER: So what, so what we’ve had the opportunity to talk about is this,  this, I think, very exciting concept of the handoff of the learner.

>>BRIGHAM: Yes.

>>REGNIER: Right, so, the physician in training and then in practice

>>BRIGHAM: Yes.

>>REGNIER: We have a real opportunity to say going from GME to CME

>>BRIGHAM: Yes.

>>REGNIER: You’ve got as a learner your data. You’ve got your

>>BRIGHAM: Right.

>>REGNIER: What you’re good at, what you still need to work on and you can bring that into the world of practice into the world of CME

>>BRIGHAM: Yes.

>>REGNIER: And the goal would be to make sure the accredited providers, whether it’s the specialty societies or the places where these people work really can sort of embrace that portfolio that

>>BRIGHAM: Yes

>>REGNIER: those learning needs, those really truly individualized needs and present the education to be most effective for those individuals. That’s the handoff of these learners.

>>BRIGHAM: But there’s more than that because there’s one more piece. What we hope is, that you and the continuum of practice take those milestones and say, and put together a road map for physicians in a particular specialty or a physician in general

>>REGNIER: Or in practice.

>>BRIGHAM: What is our expectation as a community of physicians, physician educators, physician learners etcetera. What is our, what is our, what is the road map that we are have constructed so that a person in practice no matter where they are knows that this is what’s expected of them, and the public, part of,  there’s at least five constituents for them, the milestones. There’s the ACGME where we will take the aggregate milestones in a given program and look at a program and say, OK

>>REGNIER: That’s how you’ll judge the program OK. 

>>BRIGHAM: There’s the boards who can take this individual journey with their physicians from the early point that they come into residency or even before. There are the, that’s accreditation and certification world. But I think it’s the next three where I think the milestones will have its most impact. The first is on the faculty. The faculty in Iowa, in South Dakota, Philadelphia, Los Angeles, and New York will know exactly what nationally is expected of an internist or a pediatrician or a surgeon in terms of their journey and where they’re expected to be at the end of that journey in residency. So it gives the faculty an anchor in which they can assess and give formative feedback in a way that they may not have been able to do before. It gives the learner a roadmap that they might not have had before.

>>REGNIER: Right. A better understanding.

>>BRIGHAM: One of the things that I did at Jefferson is I use to give a survey every year for about 19 years to residents. And two of the questions were, Do you get enough feedback? And, the feedback that you get, is it any good? And this could be done at nay institution in the country I’ve sort of played with it in other areas, too. The answer to both of those is, no. We don’t get enough feedback and the feedback we get isn’t relevant to where we are. So, we have residents out there, in one of two domains, is the resident who is not getting feedback and makes the assumption that everything is OK. And they can be, if you put a grid up that says the Y axis is competence and the X axis is confidence their out here all they way, that’s their   

>>REGNIER: Right.

>>BRIGHAM: Confident without being competent, they’re dangerous people. There not a lot of them but we want to make sure that their number is reduced. The other one is the resident who’s up on the Y axis who is very, very competent, but not very competent, because they’re not getting feedback on any number of their skills and their growth areas. And they’re using their limited energy worried about whether they’re doing well, and that’s just tragic. So, what we would like to do with the milestones is put that competence, competence grid so they’re clearly getting feedback they’re on the trajectory and they know where they are and the program knows where they are. The fifth one is the public. For one of the really first times we can assure the public and their representatives, whether they’re members of Congress or the IOM or whoever, we can show them and demonstrate them not only are we teaching the aspects that they care about a lot, but we’re demonstrating that they have the outcomes in that area. That they really are good at communication, we’ve assessed them. That they really are good at patient care and we’ve assessed that. That they’re really good at team based, working within the context of an inter-professional team. Those are the kinds of things that I think are really, really exciting that we can do with the milestones.

>>REGNIER: So, this construct this idea of the milestone and these measurements or assessments formative, in my mind from a CME perspective they not only do what you just described in terms of meeting the needs of all these stakeholders, but by virtue of that that construct they are sort of creating, facilitating these physicians in training

>>BRIGHAM: Right.

>>REGNIER: and the faculty who are working with the physicians, right, to be operating in a space where they’re used to learning about their own practice?

>>BRIGHAM: Yes.

>>REGNIER: their own needs looking for the data that will sort of point them in the right direction on this learning and practice journey. And, I think, from a CME perspective it’s one of the things that we’ve heard is not yet sort of the environment of the learner, now.

>>BRIGHAM: Right.

>>REGNIER: So, I mean I’m sure this doesn’t come as a surprise to you the most common issue our providers are trying to make measurements of change

>>BRIGHAM: Yes.

>>REGNIER: in terms of competence meaning strategy

>>BRIGHAM: Yes.

>>REGNIER: performance, what they actually do in practice, or patient outcomes. And sort of the engagement acceptance of the learners isn’t quite there yet, because there’s nobody asking them necessarily for this data.

>>BRIGHAM: Right

>>REGNIER: It’s all going together, in my mind, because you’re creating learners who are looking for this data, who are used to having it

>>BRIGHAM Yes..

>>REGNIER: And taking a direction from it.

>>BRIGHAM: yeah

>>REGNIER: which I think hasn’t necessarily been the case.

>>BRIGHAM: What, we’re hoping, I think, is a lot of the tools that you and the boards will be using in practice, some things related to maintenance of competence, maintenance of licensure, will be driven back into residency so they will start using the same or similar tools that will be expected of them when they get into practice. And the other piece I don’t want to lose is that if you all who are involved in the continuum of learning from residency and fellowship on take the challenge and develop milestones which the milestones are organic and fluid I mean they will change over time. It’s necessary that they change over time as knowledge and new ways of practicing become the norm rather than some things we haven’t even dreamed of. But, if you take the challenge, not only will they have used to be used to being used using some of the tools, or sort of taking a look at themselves in the way that you described, but they’ll still have road map out there they can point towards and say, oh, this is where I have to go. And that’s the challenge I think that you and your providers have is to help construct that next level. Whether it’s at a national level, which I hope occurs, or at the local level of the hospital saying we’re using our data and saying here’s where our pediatricians have to go, here’s where our internists have to go, here’s where our surgeons have to go, etcetera.

>>REGNIER: What I like is the idea that the milestones provide this, this framework. It is standard it’s national, but the individual who’s operating in this space can move around. I mean you can image like we’ve talked about, the person who comes out of their residency program and goes and practices in a totally different environment

>>BRIGHAM: Right.

>>REGNIER: Right, now all of sudden their learning environment opportunities around systems based practice

>>BRIGHAM: Sure.

>>REGNIER: is very different

>>BRIGHAM: Yes

>>REGNIER: and this milestone where maybe they were proficient where they were is now an opportunity a gap a professional practice gap 

>>BRIGHAM: yes.

>>REGNIER: That’s a really great construct.

>>BRIGHAM: We have worked really, it’s interesting, our last year of our board has taken this up as sort of his legacy. There’s always going to be a gap, especially in systems based practice, but in other areas also. So, how do we help the learner transition from undergraduate to graduate? How do we help the learner transition from graduate medical education into practice in an effective way where they don’t get lost? I think that’s a huge problem right now and we’ve talked before about the transition to practice as being really important where you take that handoff. You know, the expectation that if we develop proficiency in patient care and medical knowledge that’s almost immediately transferable. Systems based practice every time you enter a new system even though system based practices is a huge construct going from the local micro system of care to the larger system of the Affordable Care Act, when they get into that next system that they are in they’re almost everybody has a learning curve in any profession takes six months to ramp up or a year to ramp up. We want to make that transition as smoothly as possible and also the milestones, I hope, will help.

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