By: John Patrick T. Co ,MD, MPH, MBA
“Never doubt that a small group of thoughtful committed individuals can change the world. In fact, it’s the only thing that ever has.” Margaret Mead
It was a typical hot, muggy July evening in Washington DC. I had just checked into my hotel and was getting ready to have dinner with a mix of colleagues from Boston and pathologists from across the country that I had never met. We were there for the Association for Academic Pathology annual meeting to present our ideas on CBME to pathology department and residency program leaders from across the United States. The walk to the restaurant was not a long one but given I had never stayed in this area of town I trusted the navigation on my watch to direct me and allowed my mind to wander a bit. What was I, a pediatrician, doing here?
As the leader for (post) graduate medical education at my institution in Boston, MA, residency and fellowship program directors had over the years come to me with various questions and concerns about the performance of their trainees. One scenario that has stuck with me relates to a trainee who was making progress, but more slowly than current and historical peers. The program director was confident that with extended training time (perhaps 20 to 40% more than the standard length) that the trainee could not only equal the skill level of the typical graduate from the program, but even exceed it. Was this pathway and timeline feasible for this trainee? While the program director and trainee seemed willing, the stigma of not completing the training “on time” was daunting and ultimately, the key determinant. How would they each complete forms when asked about performance? What would the various regulatory bodies ask and require? On the flip side, there were often resident trainees that seemed “ready” for independent practice sooner than the prescribed length of training, but they had limited pathways to maximize learning through independence during the remaining time until graduation.
I arrived at the restaurant and soon was chatting with the group of pathologists that I would be joining for a panel discussion the next day, including Eyas Hattab, a neuropathologist and conference organizer, Steve Black-Schaffer and Maria Martinez-Lage, leaders of the Mass General Brigham Pathology Residency Program, Gary Procop, CEO of the American Board of Pathology, and Cindy McCloskey, a Microbiologist and Virologist who serves as Chair of the ACGME’s Pathology Review Committee.
The next day, at the start of my presentation in a room with a few hundred pathology program and department leaders, I asked if there were any other pediatricians present. Aside from laughter, the lone audience response I received was “Some of us have children.” I again asked myself, what was I doing here? I realized the answer was a Swiss Cheese created by an idea and a small group of thoughtful committed individuals with courage and fortitude.
In the field of patient safety, an area in which I have practiced and led, the Swiss Cheese model by James Reason proposes that each of several layers of cheese (for instance education, communication, process design, staffing) are barriers which, when properly applied and implemented, prevent harm to patients.1 When holes align in each layer, the result is a window for an accident or patient harm.
Could the Swiss cheese model, though, also represent a path for breakthroughs, overcoming barriers for innovation, resulting in new paradigms that benefit both learners and patients? The session I was participating in described challenging the current norm of medical education and advancement: to develop and test a different paradigm, namely competency, not time, in determining advancement to independent practice. What holes did we create to make Swiss cheese?
- The idea: I remember during a meeting with Deb Weinstein (an internist) when she considered the various barriers for time-variable competency-based advancement and had the idea to promote “in place” (PIP)2 those residents who were ready sooner than the standard length of training; “in place” meaning at our own institution (Mass General Brigham)
- Support for Change and Innovation: The American Medical Association’s Reimagining Residency initiative, led by John Andrews, provided the impetus and support for ideas that challenge existing paradigms3
- Measured Disruption: With appropriate caution, current and past leaders from the American Board of Pathology (Immediate Past (Rebecca Johnson) and current (Gary Procop) CEO) and ACGME (Eric Holmboe and Lynne Kirk) made space for innovation within existing regulatory frameworks.
- A committed and fearless team: Deb, Martin Pusic (pediatric emergency medicine) and I worked together to develop PIP. The team subsequently expanded (Mary Ellen Goldhamer (internal medicine), Eric Nadel (emergency medicine)) to refine the model, and Steve and Maria’s enthusiasm and subject matter expertise propelled them to adapt and implement the model in their program.
As Steve and Maria presented during our session, I could sense the curiosity and excitement in the audience, evidenced by the number and level of questions that followed long after the session was over. Program leaders were encouraged by Steve and Maria’s ability to implement the model at Mass General and wondered how they could do so in their own programs. I thought about residencies in other specialties and institutions that are working towards implementing time-variable competency-based medical education, including the PIP model. Have we reached a tipping point for time’s time to pass? I encourage those interested in advancing population health through health professions education to create their own Swiss cheese.
References
- Wiegmann DA, Wood LJ, Cohen TN, Shappell SA. Understanding the “Swiss Cheese Model” and Its Application to Patient Safety. J Patient Saf. 2022 Mar 1;18(2):119-123. doi: 10.1097/PTS.0000000000000810. PMID: 33852542; PMCID: PMC8514562.
- Goldhamer, Mary Ellen J. MD, MPH; Pusic, Martin V. MD, PhD; Nadel, Eric S. MD; Co, John Patrick T. MD, MPH, MBA; Weinstein, Debra F. MD. Promotion in Place: A Model for Competency-Based, Time-Variable Graduate Medical Education. Academic Medicine 99(5):p 518-523, May 2024. | DOI: 10.1097/ACM.0000000000005652
- 8 transformative residency-training projects awarded AMA grants | American Medical Association (ama-assn.org). https://www.ama-assn.org/education/improve-gme/8-transformative-residency-training-projects-awarded-ama-grantsLast accessed August 3, 2024.
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