Element 3.3: Takeaways from a recent LCME webinar

It has been a goal of mine to use this blog to foster information sharing across the medical education accreditation community.  So, I was thrilled when Dr. Polly Hofmann accepted my invitation in the last newsletter to submit a piece for this space. She describes her takeaways from a recent LCME webinar that outlined upcoming changes to accreditation expectations involving Element 3.3.

The LCME webinars are an invaluable resource for medical education professionals, and we share this post in an effort to amplify the LCME’s work and support schools that are closely examining their diversity and inclusion efforts in light of recent federal and state legislative changes.  Note that Dr. Hofmann, MSAG, and this space do not represent that we are or that we speak for the LCME.

As the LCME has noted on their website, “The LCME Secretariat and the publications on [the LCME] website are the only official sources of information regarding LCME policies, procedures, and issues related to the intent of elements.” Anyone who has specific questions may wish to direct them to the Secretariat. 

– Lois Margaret Nora, MD, JD, MBA

Dear Colleagues,

The LCME Secretariat Webinar in March focused on the upcoming changes to Element 3.3, Diversity Programs and Partnerships.  These changes impact student and faculty diversity efforts, and they will be incorporated into the 2025-2026 Data Collection Instrument (DCI).  The changes were, in part, a response to the Supreme Court ruling that race-based college admissions policies are in violation of the Constitution.  This ruling was accompanied by a landslide of legislative activity related to diversity in various states. Thus, the LCME reconsidered Element 3.3 to ensure all schools would be able to meet accreditation requirements without being in conflict with state and federal law.  The following describes my takeaways from the points presented, along with a synopsis of the webinar Q&A.

Addressing Student Diversity

After offering some historical perspective, the Secretariat discussed changes to how diversity is handled.  A formal policy with diversity categories is no longer required. However, tables in the 2025-2026 DCI will continue to require school-identified diversity categories for students with reporting of outcomes in offers and enrollment in the MD program. Further, a diversity pathway program(s) with tracking of outcomes continues to be required. A new narrative response question in the 2025-2026 DCI will be “Describe how the medical school expresses its commitment to the value of diversity in the academic learning environment and aligns this commitment with its mission.”1 Thus, a “mission statement, strategic plan, or policy must demonstrate the school’s commitment to the value of diversity in the academic learning environment.”1

The Secretariat and LCME recognize that some schools may elect to change their student diversity categories and, as such, have minimal outcomes data to support the efficacy of a given activity.  For example, a school may shift from presenting 10 years of data on outcomes associated with race-conscious efforts to presenting limited data on efforts focused on students from underserved ZIP codes and/or students of lower socioeconomic status.  A reduction in available data is expected with a change in diversity categories and, depending on the specifics of that school, would at most warrant monitoring by the LCME.  In a nutshell, the LCME values diversity, but also offers flexibility to schools to select their unique student diversity categories based on the mission of the school.  Please note, the LCME does not prohibit schools from continuing to have race or gender as part of their school-identified diversity categories.  However, early and clear communication by schools with their own General Counsel and system leadership about their student diversity categories is recommended.

Addressing Faculty Diversity

Faculty and senior administrator diversity categories and related reporting of outcomes have been eliminated from the 2025-2026 DCI. Consistent with this, tables in this portion of the DCI have been modified to remove faculty and senior administrators. In addition, Element 3.3 will now read:

“A medical school has effective policies and practices in place, and engages in ongoing, systematic, and focused recruitment and retention activities, to achieve mission-appropriate diversity outcomes among its students, faculty, senior administrative staff, and other relevant members of its academic community. These activities include the use of programs and/or partnerships aimed at achieving diversity among qualified applicants for medical school admission and the evaluation of program and partnership outcomes.”1 (Strike-through added to show exact text to be removed). 

To address the important role of faculty in diversity, the LCME added a new narrative response to the 2025-2026 DCI.  Specifically, “Describe how the medical school ensures that its faculty and senior administrative staff are prepared to support its diverse student body. How does the school determine that this support is adequate and effective?”1

For Schools Shortly Undergoing Review

The Secretariat provided direction to schools that are actively preparing for a survey visit and using the 2024-2025 or older DCI.  They clarified that Element 3.3 performance, starting immediately and through June 2025, “will be based on the following:

• Mission statement, strategic plan, or policy that demonstrates the school’s commitment to the value of diversity in the academic learning environment

• Mission-aligned diversity categories for students and tracking of recruitment outcomes

• Pathway programs and partnerships, and tracking of program outcomes”1

In addition, effective immediately, schools do not need to have a policy defining the student diversity categories on their website.

Questions and Answers (paraphrased)

Q: Given that the public will have the opportunity to provide feedback about the changes in Element 3.3, what happens to these planned DCI changes if comments are extensive and concerning?

A: Any change to the DCI requires 18 months to go through proper vetting.  As such, the 2025-2026 DCI changes as presented will be going forward.

Q: What will happen to schools already given an unsatisfactory for Element 3.3 based on a failure to, for example, collect outcomes data on faculty diversity or any such information or programs that are no longer required in the 2025-2026 DCI? 

A: These schools will have their final report amended, and the citation will be expunged.  They will not be required to respond to the citation in the school status report.  However, caution is warranted as some citations involving Element 3.3 are based on criteria that will continue to be needed for accreditation.  As an example, outcomes data for pipeline programs aimed at increasing the number of diverse student applicants is still required.  If a school is unsure whether they should respond to a 3.3 citation, the Secretariat should be consulted.

Q: For schools about to undergo a self-study or site visit using an older DCI, will Element 3.3 tables and narrative responses related to faculty and senior administrators still be a part of their upcoming review?

A: No, the LCME will no longer look at or take this information into consideration. Further, schools that have not yet completed the Element 3.3 tables specifically related to faculty and senior administrators may leave those table cells blank and instead provide a notation like “Given that the LCME is no longer looking at this information, it was not collected and reported.”

Q: Is it required that the word “diversity” be used in response to Element 3.3.

A: No, a synonym or descriptive phrase is acceptable as long as the principle or concept is preserved.

Q: How far out do schools need to track students in pipeline programs?

A: For college students, it is reasonable to look at whether they went on to apply to medical school.  For pipelines that work with younger students, such as high school students, the outcomes might include how they rated the program and how it affected their next step, e.g., college enrollment.

I encourage those who are interested in this topic to download the webinar slides from the LCME website.  The revised tables and narrative responses are presented.

— Polly Hofmann, PhD

Professor & Senior Executive Associate Dean of Faculty Affairs Emeritus

University of Tennessee College of Medicine

1 Connecting with the LCME Secretariat Webinar, March 7, 2024.  Speakers Veronica Catanese, MD, MBA; Barbara Barzansky, PhD, MHPE; Robert Hash, MD, MBA.  Slides can be found at https://lcme.org/event/mar-2024-connecting-webinar/

Adequately resourcing administrative staff

Lois Margaret Nora, MD, JD, MBA

When a former colleague and I had lunch recently, we began discussing an issue that has long challenged medical education leaders: Insufficient administrative support. As my colleague discussed her own perspective at a business organization, I recognized that this issue is widespread and has consequences for the quality of our work and for the well-being of our teams.

Skilled support personnel such as office reception staff and administrative assistants are critical to the function of any leadership team. It’s difficult to overstate the importance of their assistance with scheduling, planning, document preparation, and representation of the team within and beyond the institution.  These individuals can also be a wonderful source of advice and institutional knowledge, and they may offer a safe space for discussion of and counsel on sensitive issues. Such professionals serve a pivotal role in identifying issues that need to be addressed, getting work done well and on time, and networking across the institution.

While it may be appropriate for administrative support professionals to function as a shared support system for a team, I have noticed that administrative support professionals are increasingly assigned to multiple senior leaders who have significant responsibility in an organization. In recent years, there has been a dramatic expansion in many schools of career advising, academic advising, and CQI functions, all of which require administrative support systems. While these changes appropriately include new decanal staff, I am not convinced there has been a consistent and commensurate expansion of support staff.  

A few consequences can result.  Administrative support professionals who answer to multiple leaders may be forced to prioritize among those they assist, setting the team up for possible conflict when time is short and deadlines are approaching. Overworked administrative professionals may struggle to maintain the quality of their work, hurting perceptions of customer service, not to mention the outcomes of the work itself.

These issues can also contribute to a sense of isolation and difficulty taking time off, creating a potent well-being challenge for administrative support personnel. The whole team inevitably feels the strain.  Others on the team may have to set aside work that only they can do to meet administrative needs, adding to inefficiency across the office.  It’s difficult for senior leaders to be as effective as possible if they are frequently pulled into administrative tasks that do not require their expertise, and their well-being may suffer, as well.

Blending my medical education accreditation work with my role as a change-maker coach for the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience, I have been working to identify intersections between well-being and accreditation. While the LCME does not explicitly set requirements for administrative support staffing, Element 2.4 sets an expectation that staffing will be adequate for supporting the mission of the school. In addition, the LCME expects offices such as Medical Education and Student Affairs to be accessible and for those professionals to be aware of and responsive to student concerns.  In my experience, student dissatisfaction often relates to limited administrative support and/or rapid turnover in staff, rather than any lack of diligence or caring among the people in those offices.

For the health of the team as well as optimal accreditation outcomes, I advise professionals to spend some time examining their administrative support staffing levels to ensure adequacy. Questions that may help stimulate this discussion include:   

• Has your team’s workload grown? Consider how your class size and/or program load compares with 10 years ago.

• Has the size of your support staff grown concurrently with the expansion of middle management?

• Have people been promoted to middle management without shedding their administrative support roles? Internal development and promotion are things to celebrate, but some new managers may need additional support to meet the expectations of their new jobs.

• Are people across your team working at the top of their expertise, or are they handling tasks that take time away from their most important work?

• Are there staffing guidelines available for your area of work? Some organizations, such as the National Association of Student Financial Aid Administrators, set benchmarks for staffing that may be helpful. When considering such benchmarks, keep in mind that issues faced by medical and other graduate students can have unique complexities that may influence staffing needs.

• Review your results from the AAMC GQ and any annual student surveys your school is conducting. If you are maintaining your DCI regularly as we have suggested, you can start by reviewing the latest information there. If scores related to the availability and responsiveness of staff in areas like career counseling, academic advising, and financial services suggest there are problems, consider whether the teams in those offices are overextended and could benefit from enhanced administrative support.

Hopefully, these conversations will spark meaningful ideas for supporting your full team and the work they do. These discussions will also likely inspire ideas for supporting administrative support professionals themselves. Here are five that I think are particularly important:

• Ensure adequate staffing: As discussed above, inadequate administrative support staffing puts a strain on everyone, particularly administrative support professionals themselves. These colleagues often manage entry points to our offices; if they cannot function effectively, we can expect concerns about accessibility.

• Keep an eye on compensation: It’s worth looking at benchmarks for salaries across your team, especially as workloads expand. Administrative support professionals who have not received promotion-related compensation changes may warrant particular attention. Make sure pay reflects the value these professionals bring to the team and the school.

• Engage the full team in planning: The institutional knowledge and perspectives of administrative support professionals bring unique value to goal setting and strategic planning. Meaningful inclusion of these professionals in such processes is critical to maximizing results.

• Encourage professional development: Growth is not just about promotion. Ensure your administrative support staff has access to professional development opportunities — and your full support for taking time away from day-to-day work for these activities. The whole team will benefit from this investment in professional skills and satisfaction.  

• Celebrate your team: Recognizing contributions across the team is a tenet of good leadership. Be sure your administrative support staff has the same opportunities as others to celebrate your office’s achievements, and be sure to acknowledge the great work these professionals do every day.

It’s not difficult to imagine how administrative support professionals become overloaded with work. The most skilled of these professionals make balancing many complex tasks and priorities look easy. However, real problems can result when these colleagues are stretched too thin. As accreditation professionals work to address problems that may link to the effectiveness of senior leaders, ensuring staffing adequacy and appropriate attention to the needs of administrative support professionals may be a helpful place to start.

Professional development in accreditation: Attending to CQI on a personal level

Lois Margaret Nora, MD, JD, MBA

A question I am often asked when people learn of our consulting group’s support for schools going through accreditation is “How do you recommend we keep up?”  Numerous standards, crossing all areas of the medical education program; annual updates of standards, elements, and the Data Collection Instrument (DCI); questions about how the standards and elements are interpreted and whether those interpretations change over time … these are a few of the things that cause concern.

Like all else in our professional lives, keeping up requires a commitment to ongoing learning and professional development.  Fortunately, resources for medical education professionals who are interested in accreditation have proliferated over the past few years.  Here is some of the advice I offer when asked about keeping up in this area.

• To educate yourself and your team, plan an annual review of changes to the LCME standards and elements as well as revisions to the DCI. As we have suggested previously, you can couple this process with an annual update of your school’s DCI. This is a great opportunity to remain well informed about the standards and on track for continuous quality improvement (CQI) between accreditation cycles, and it will also position you to educate colleagues across the school. The Medical Education and Student Affairs offices as well as the CQI committee will need to be aware of changes across all the standards and elements, while other committees and specialized offices (e.g., Student Health, Finance, and Registrar) may find a more focused discussion most helpful. 

• The accreditation-related sessions at AAMC meetings are always of great value.  And do not hesitate to take advantage of the LCME Secretariat’s offer of private consultation opportunities during the AAMC meeting.  Ongoing communication with the Secretariat through these sessions — and by phone or email during other times of the year — is valuable as questions arise and is particularly important if a school is contemplating substantial changes to its medical education program.  This proactive interaction can be an excellent source of learning, and it is a crucial step for ensuring any major changes are planned with accreditation implications in mind. I’m also excited about the AAMC meeting opportunities related to CQI and accreditation scholarship presented by our colleagues.  These are burgeoning areas of scholarship in medical education over the past few years.  

• Attend the regularly scheduled Connecting with the LCME Secretariat webinars.  The schedule of topics and dates can be found on the LCME website.  I have been surprised to learn that some people think these webinars are primarily useful in the period leading up to a survey visit — actually, they are terrific anytime in the accreditation cycle.  All the webinars will be useful for accreditation/CQI professionals and leaders of major areas in Medical Education and Student Affairs.  These professionals can, in turn, share the learning by spreading the word about scheduled topics that may be relevant to other offices at their schools. 

• One of the most valuable professional development opportunities for accreditation/CQI professionals that has emerged in the past several years is the CGEA Program Evaluation & Accreditation Special Interest Group. While this SIG began in the Central Group of GEA (my first professional home in medical education!), it has rapidly expanded into a national community.  Their monthly meetings span a variety of topics.  I’m particularly excited about this group, as I hope it can provide an important feedback loop to the LCME that allows schools' experiences, concerns, and questions to be conveyed to accreditors.

• Certain professional development opportunities are particularly important at key points in the accreditation cycle.  Schools should attend the orientation meetings sponsored by the LCME as they begin their self-study.  And the LCME’s Faculty Fellows program is a valuable source of learning for current or prospective faculty accreditation leads.

At MSAG, professional development is a regular part of our work. While we take part in many of the activities I have mentioned, we have other ongoing professional development — both informal and formal.  Much of our informal professional development relates to learning from one another as part of our team approach to our work.  We also have formal professional development focused on our own CQI.  Examples include regular review of feedback collected by an independent quality assurance professional following each consulting engagement, presentation of relevant literature, focused discussion of one or more elements, and professional development on a topic such as language and demeanor during a mock site visit. 

Those of us who work in accreditation are called to it for a variety of reasons. Passion — whether for improving patient care through improved health professions training; for education and making it the best it can be; or for quality improvement and the role accreditation plays — has often brought us to this work.  Passion is an important motivator, but to do our best work, we must continue learning.  That’s why ongoing, lifelong professional development is so valuable.  I am delighted to see the growing emphasis on professional development in accreditation and CQI, and I welcome your ideas about additional ways we can all work together to continue our growth.

Learning and teaching a new model for postpartum care

Lois Margaret Nora, MD, JD, MBA

One of the things I love best about this profession is having the opportunity to talk with other medical education professionals. I almost always learn something new from the ways they are advancing learning and patient care. That’s exactly what happened when I met Dr. Lorimar Ortiz, a family medicine physician who taught me a new term: the fourth trimester of pregnancy. 

Dr. Ortiz started her undergraduate studies intending to pursue a career in pharmaceuticals, and it was only through what she calls a “beautiful accident” that one of her own physicians suggested she consider a career in medicine. “I wouldn’t be a doctor if it wasn’t for something as simple as my allergist suggesting to me that I consider it. It was the best decision ever, because I don’t see myself doing anything else,” she said.

Dr. Ortiz found her path in family medicine. As she worked to support new mothers, she observed limited use of best practices such as in-hospital lactation support and measures to promote mother-infant bonding. That meant most families had little to no support when they needed it most. Furthermore, it was apparent to Dr. Ortiz that her training had not fully prepared her to bridge these gaps herself.

In an effort to develop the skills for teaching patients while preparing to welcome her own first child, Dr. Ortiz set out to become certified in breastfeeding medicine. As part of this work, she became immersed in learning about the specialized care required during the postpartum period, where additional gaps in care became apparent.

“What we usually see is, you are discharged from the hospital, and we say good luck with your baby, we’ll see you in a month or six weeks. New moms have so many questions that are left unanswered, and when they finally get to their postpartum appointment, it is reduced to when they can return to their usual physical activity, what contraception are they going to use in their family planning, and when they can resume their sexual activity,” Dr. Ortiz said. “There are so many other things that might be going on. Psychosocially, emotionally, related to pelvic floor dysfunction, related to breastfeeding. It’s a vast, vast area that was not being covered.”

Collectively, these issues fall into what is considered the fourth trimester, a time when the needs of the mother and baby remain deeply intertwined. “The mom depends on the baby, the baby depends on the mom, and their well-being needs to be seen as a unit,” Dr. Ortiz said. “To better take care of them both, you shouldn’t separate them or separate their needs.”

So, while infant nutrition is a common topic of discussion for newborn health, maternal nutrition matters, too. So does the mother’s mental health and physical well-being, including healing of lacerations and recovery from cesarean birth, which is particularly common in Puerto Rico, where Dr. Ortiz practices and teaches as an assistant professor at Ponce Health Sciences University. The fourth trimester care model seeks to unify care in a system that typically fragments maternal and infant health.

The fourth trimester model also means recognizing and managing the impact of this important and sensitive time on the entire family unit. “Who takes care of the baby? The mom. Who takes care of the mom? The dad. But who takes care of the dad as they are going through changes?” Dr. Ortiz says optimal fourth trimester care addresses that question and seeks to support quality of life for the entire family.

After listening to Dr. Ortiz describe how she thinks differently about postpartum care, I was not surprised to also hear that she brings a patient-first mindset to the way that care is delivered. She has structured her practice to allow for two days of home visits. This option is particularly helpful for new mothers and infants, who benefit from a more private environment as well as the ability to use the resources and tools they will have at their fingertips after the visit is over.

It was clear to me as we talked that Dr. Ortiz is a passionate advocate for her patients, their families, and the care they need. In addition to providing fourth-trimester care as a clinician, Dr. Ortiz hopes to address systemic barriers to that care. One way she does so is by working with nonprofits to ensure fourth-trimester care – which is not typically covered by insurance in her area – is available to families of all income levels.

Dr. Ortiz also works in a system where other public health challenges complicate the delivery of fourth trimester care. A shortage of OB-GYNs and other physicians, high levels of cesarean births, and limited uptake of best practices such as prioritizing sustained contact between mother and newborn can make it difficult to provide the best possible start for new moms and their babies. Yet enabling a strong start carries benefits not only for a given mother-infant pair, but also at the family, community, and population levels, Dr. Ortiz said.

“This is important for everybody. At some point, you are going to be a mom or a parent. Or a friend or family member is going to have a kid. Having a healthy start and a healthy postpartum period is going to have a positive domino effect, an exponential effect in mental health and health in general,” Dr. Ortiz said. “We’re talking about cardiovascular health in women, preventing diabetes, reducing rates of breast cancer, and ovarian cancer -- all of these things that we would like for ourselves and our daughters and our future kids.”

These are messages Dr. Ortiz carries not only to patients but also to students and colleagues in medical education. After coordinating a clerkship in family medicine, Dr. Ortiz moved to leading a fourth-year elective on Breastfeeding Medicine and Infant Feeding, where students learn the tenets of fourth trimester medicine. They are also exposed to Dr. Ortiz’ patient-centric model for care in her clinic and in patients’ homes, gleaning important lessons about what it means to practice medicine.

After students complete the course, they often tell Dr. Ortiz that they have developed a new perspective on their futures as physicians. “Seeing the light in their eyes and that they realize that if they want to, they can do things differently, it is very rewarding for me,” Dr. Ortiz said.

Leadership lessons from WFME’s past president

Lois Margaret Nora, MD, JD, MBA

I have been interested in leadership since the start of my career, and over the years, other leaders have been some of my most valuable teachers.  Dr. David Gordon, who recently completed his term as president of the World Federation of Medical Education (WFME, Federation), is one of those teachers. 

WFME has played an important leadership role in issues related to medical education since it was organized in 1972.  However, its importance in global education increased dramatically in the wake of a 2010 Education Commission on Foreign Medical Graduates (ECFMG) decision emphasizing the importance of medical school quality around the world and announcing plans to ultimately limit ECFMG certification to graduates of medical schools with accreditation from authorities recognized by the ECFMG. WFME responded by creating a system for recognition of accrediting agencies, by evaluating them against criteria for accreditation and promoting continuous quality improvement.  The criteria were based on standards for accreditation agreed upon at a WHO-WFME meeting in 2005. The Federation was already known for its standards for medical education at the undergraduate, graduate, and post-graduate levels, first published in 2003.

As a medical educator and voluntary assessor with WFME, I’ve seen the impact of WFME’s leadership on quality in medical education. Dr. Gordon has been a driving force behind this work.

When I learned that this important leader was retiring from the WFME presidency, I was delighted to have a chance to speak with him. Dr. Gordon generously shared thoughts on his career, his work at WFME, and the work at the Federation of which he is most proud. 

Lessons from a former medical school dean

Prior to joining and ultimately taking the helm of WFME, Dr. Gordon served as dean of the medical faculty at the University of Manchester, chair of the Council of Heads of Medical Schools of the UK, and President of the Association of Medical Schools in Europe, among other roles. As he spoke with me about his progress though roles with increasing administrative responsibilities, it became clear to me that these experiences — and Dr. Gordon’s experiences as dean in particular — provided exposure to the systems and operational perspectives needed to evolve WFME’s constitution, internal processes, and role in the global medical education community. In fact, the competencies that position medical school deans to succeed were a theme throughout our conversation.

Established by the World Medical Association and the World Health Organization, the Federation works with executive council members and partners in medical education, all of which have important roles in quality higher education, research, and professional medicine. Much like a medical school dean, Dr. Gordon could only deliver on his organizational mission by working to support the success of these and other agencies, such as the Foundation for Advancement of International Medical Education and Research (FAIMER), the International Federation of Medical Students’ Associations (IFMSA), and the Association for Medical Education in Europe (AMEE).

Support for quality and standards in medical education is a central focus of WFME’s work. However, it’s difficult to overstate the complexity of such work on a global scale. It requires a framework with relevance across cultures and medical education systems — regardless of their sophistication and resources — and the skills to work effectively with diverse groups of stakeholders.  As we talked, it became clear to me that Dr. Gordon drew on not just his own experience as he sought to build out this framework, but also on legislative leadership capabilities and a clear understanding of systems thinking, the same skills a medical school dean uses to achieve her mission.

Continuous quality improvement as common ground

A systems-thinking mindset may also explain how WFME has been able to not only manage partnerships with a variety of stakeholders, but also to leverage those same partnerships to deliver on a global mission. For example, WFME works with FAIMER to maintain the World Directory of Medical Schools, a listing of more than 3,750 undergraduate medical education programs. The collaboration unified two separate directories, streamlining data submissions for schools. The result is an integrated resource that meets needs around the world.

As I listened to Dr. Gordon talk about this work, I was reminded that standards and quality in medical education provide common ground for many stakeholders around the world, regardless of their role in healthcare and health professions education. Dr. Gordon’s ability to make the most of this common ground may explain much of his success in support of quality and continuous quality improvement in medical education. 

Relationships and people make the difference

While it’s clear that Dr. Gordon brings the skillset and mindset needed to lead a complicated organization and mission, he continually credited the relationships he formed and the people he worked with for his success. In fact, when I asked him what he’s most proud of, he said it’s his team.

“It’s very satisfying to see people you’ve worked with, and helped, doing really well,” he said.

Having received some of my most important mentoring from WFME staff, I can see what he means. It’s hard to overstate the complexity of building an international team of staff and volunteers that work as seamlessly as WFME’s teams do across international lines. While this success is a credit to many people on WFME’s staff of skilled professionals, it also speaks to leadership. 

My congratulations to Dr. David Gordon on the great work WFME has done on his watch. I am delighted to hear that he will remain in an advisory role with the Federation, which is a duty of the past president under WFME’s constitution. And congratulations as well to new WFME President Ricardo León-Bórquez and his team. I look forward to seeing what’s next for WFME, WFME’s new leadership, and Dr. Gordon himself.

How one physician is making the most of overnight medical education

Lois Margaret Nora, MD, JD, MBA

In medical school, I experienced some of my favorite and least-favorite experiences during overnight call.  And I have been dismayed at the substantial reduction in overnight experiences that more recent generations of medical students have had. So, I was excited to hear about some particularly interesting work by Dr. Jessica Chambers of Dell Medical School at the University of Texas at Austin. I was delighted to have time to talk and to learn more about her career and how she’s made the overnight rotation much more than something to simply endure. The following post is a synopsis of our conversation.

Dr. Chambers attended medical school at Texas A&M University before pursuing residency at UT. Now a practicing nocturnist and assistant professor of internal medicine, she’s been working to transform learning in the overnight hours. As we spoke, it became clear that she’s done so through a combination of passion and leadership.

Anyone who has worked overnight call knows the hospital environment is quite different at night. There are fewer patients and visitors coming and going, and the staff is smaller. Certain issues are more common in the evening, fewer specialists are available, and there is reduced access to hospital services, such as some types of imaging and surgery. However, Dr. Chambers says that’s also part of what makes overnight medicine so beneficial to learners: “I think your decision-making and triage skills are different than those developed in the daytime.”

Medical students and residents on the night rotation are part of small, highly interprofessional teams, giving them valuable experience communicating and collaborating with colleagues, and valuable exposure to team-based care. Dr. Chambers says overnight teams also spend more time on functions like admission and bedside management, enabling learners to interact with patients in a more holistic way. “We get to understand the perspective of the nursing staff, what the charge nurse does, the interplay with the respiratory therapists and the social worker in the ER. Instead of focusing on how to get the patient out of the hospital, we’re really focused on how to best take care of the patient in the hospital,” she says.  “That, I think, is why I found this niche. It’s such an ideal time for education because we often don’t have other things we have to focus on.”

A dedicated curriculum for the overnight rotation

The overnight medicine curriculum Dr. Chambers developed came out of early bedside talks she gave while working with residents. As common issues like shortness of breath, chest pain, headache – “very rote things, but out of them comes a lot of medicine” – became favorite lecture topics among residents, it became clear to Dr. Chambers that there was value in developing a defined list of areas that should be covered on the overnight rotation. Some arise organically in a hospital where the overnight team can be responsible for well over 100 internal medicine patients, and others can be worked in as short lectures during downtime.

About six months into her first faculty role as a nocturnist, Dr. Chambers recognized opportunities for a more structured approach to educating learners on the overnight shift before they reached residency. “I thought, wouldn’t it be great if you had practice doing this as a fourth-year medical student, because this was the scariest rotation I had as an intern.” She went on to establish an elective with a reasonable schedule – 11 p.m. to 7 a.m., four nights a week – to entice students who might be reluctant to try something more time-intensive. “This is not about overloading them with patient care; this is very particular to how to cross-cover patients at night,” she said.

As Dr. Chambers built out her course objectives, she saw an opportunity to help students and residents build communication skills. Overnight medicine provides more opportunity for connection with patients, who may feel especially vulnerable and alone after visitors leave. Clinicians often find they have more time for bedside conversations, where they can enhance their understanding not only of a patient’s medical condition, but also the patient experience. While these skills are important for nocturnists, they are valuable for any clinician.  

Dr. Chambers also asks learners to build skills for working with the care team, and I was especially intrigued by the way she approaches this teaching with fourth-year medical students who take part in her elective rotation. Students are asked to be the point of contact for a subset of patients, meaning they gain experience talking with nurses, pharmacists, and respiratory therapists; entering orders into the EMR; and making decisions about care.

The work is guided – a qualified physician is always present when a medical student is answering pages or replying to messages from the care team, and any order placed in the EMR by a student needs to be activated by a physician. But she encourages students to draw conclusions and also to ask questions when they are unsure of next steps. Modeling behavior helps; Dr. Chambers herself invites input from residents in the presence of medical students before making decisions, demonstrating to students that the nocturnist must have knowledge of many specialties but simply can’t be expert in everything. “They have to really embrace that level of not knowing, which is something we see every night.”

To that end, Dr. Chambers has also developed a Night Medicine Guide that draws on the expertise of her colleagues in other specialties. Listening to her describe the collaboration involved with creating the resource, I was impressed with her leadership in bringing multiple stakeholders together to develop this valuable resource.

The Night Medicine Guide reflects the guidelines of specialty medicine and outlines protocols for scenarios that can be handled by the overnight team, as well as scenarios that warrant a call to the attending physician. “A lot of the fright of doing a night shift is, when do I call cardiology? Should I call the GI doctor? Am I taking good care of this patient? Am I doing the standard of care at 2 a.m.?” she said. A grant from the medical school ensures every learner gets a copy of the guide.  

I remember from my own days on the overnight rotation, one of the more challenging scenarios is trying to navigate the line between clinical issues you can handle and those that warrant a call to another specialist. It is a gray area that can be stressful and a source of conflict. As I thought about this, I wondered if Dr. Chambers’ guide might also be a useful tool for supporting clinician well-being. The clarity it provides for handling situations like pain, delirium, suicide risk, and others strikes me as reassuring and empowering for clinicians across the healthcare team.

A culture change for overnight medicine

Talking to Dr. Chambers was particularly interesting as I thought about how overnight rotations have been commonly perceived. Although it’s easy to understand that patients have needs around the clock, persuading others to see the unique value in learning at 2 a.m. seems less easy. It’s clear that leveraging the learning opportunity as Dr. Chambers has done has required a shift in perceptions about overnight medicine.

That change has taken time, Dr. Chambers says, and since she cannot work every night, it has also taken advocacy and leadership to shift views about how learners and clinicians can make the most of the overnight rotation. It has also taken work on her part to foster a positive team culture. Things like shared meals build community. And open conversation about what’s important to stay healthy while working overnight normalizes challenges and helps colleagues – particularly those who are still getting accustomed to the schedule. She is also a strong advocate for reasonable hours that allow for, for example, dinner with family before a shift begins. “I think that connection time is very important; it’s what leads to me loving this job. I don’t go to work missing my family more than I would any other job.”

While I knew I would learn from Dr. Chambers about the possibilities of learning as part of overnight medicine, I also learned some things I didn’t know about the health effects of night work.  Resisting the body’s natural sleep cycle alone is challenging enough, but Dr. Chambers noted that overnight work is linked with poor eating habits, weight gain, metabolic syndrome, breast cancer, and potentially fertility issues.  She also said the life of a nocturnist is likely not a good fit for people who do not sleep easily.  It’s important, too, that nocturnists have a supportive home environment to facilitate daytime sleep, and a supportive working environment that includes scheduling important meetings at a reasonable time for someone who must sleep during the day.

I was thrilled to learn that Dr. Chambers is working as part of organized medicine to lead change beyond her institution. She has what sounds like an interesting talk planned at an upcoming meeting of the Society of Hospital Medicine about managing the health consequences of overnight medicine, and she’s been active with a number of other societies.  Her efforts to reimagine overnight education and the culture of the overnight shift have also helped her find a growing community of like-minded physicians who have been on the forefront of changing perceptions of nocturnal medicine and seizing its unique learning opportunities. “You could obviously do this job very easily, but to do it well, to make sure the academic opportunities are very useful, you have to put in more time. However, I find it very easy if you love what you do, which I do. I love what I do.”

Quieting noise: An opportunity to support great accreditation decisions

Lois Margaret Nora, MD, JD, MBA

I recently finished the book Noise, by Daniel Kahneman, Olivier Sibony, and Cass R. Sunstein.  While I generally agree with reviewer Caroline Criado Perez that this book was longer than necessary, the title of her piece, The Price of Poor Judgement, is apt. The book builds upon the authors’ prior work on improving decisions and sheds light on how a better understanding of what they call “noise” can help us evaluate and improve upon our decision-making.

The authors of Noise describe a body of evidence illustrating that circumstances having nothing to do with the choice at hand — from weather to the time of day to the performance of the local sports team — can influence the judgements we make.  The result can be substantial inconsistency among decisions involving similar or even nearly identical scenarios.  The authors cite evidence from criminal sentencing, hiring, foreign policy, business planning, and medicine, making the case that noise is far more pervasive than most of us realize, and that people and organizations should strive to manage noise to improve decision-making of all types.  While the book doesn’t discuss accreditation decisions, it is worth thinking about how noise and efforts to mitigate it might influence these processes.  

Many programs and institutions — including universities, hospitals, certifying organizations, and professional education programs (medicine, law, allied health) participate in accreditation programs.   Accreditation status is important to eligibility for federal funding, national rankings, attracting students, and maintaining public trust.  The stakes associated with these decisions are high, and the resources necessary to achieve and maintain accredited status are substantial.  While accreditation organizations make substantial efforts to ensure that their judgements are consistent and fair, specific attention to the issue of noise may be helpful.

Understanding noise

It’s reasonable to expect that similar circumstances will result in similar decisions.  However, that is not always the case – in fact, it is often not the case.  Using target-shooting as a metaphor, the authors note that multiple hits at the center of a target would be representative of consistent decisions involving minimal error.  Bias, which the authors distinguish from noise, would be represented by multiple shots that miss the center of the target, landing instead in a cluster to one side.  And noise is represented by a scattershot pattern: The shots are distributed in a random fashion across the target.  You will find a helpful visual in this HBR piece.

In practice, the scattershot scenario represents myriad conclusions, all different from one another for no obvious reason.  If the facts in a particular situation – criminal sentencing or hiring or accreditation – are similar, the decisions should generally also be similar. And yet, the authors present compelling evidence that such inconsistency in decision-making can occur at the individual level (when a person’s conclusions vary across multiple similar scenarios) and in group decisions (concerning a single case or multiple cases over time).  The variables associated with this inconsistency are unrelated to the circumstances of the decisions themselves. Examples include hunger, time of day, mood, and weather on the individual level and group dynamics and communication norms at the team level.   

To combat these influences, the authors urge individuals and organizations to prioritize what they call decision hygiene – a collection of tools and tactics intended to mitigate the effects of noise and otherwise improve decision-making. It is important to note that decision hygiene does not mean removing discretion from decision-making. In medicine, for example, even if two people present with similar symptoms and medical history, there may be important differences between their circumstances and preferences that are worth considering, and it may be appropriate for a healthcare professional to recommend different treatment plans to them as a result. 

Rather, the authors note, many of our heuristics or patterns of thinking — including relying on gut feelings, substituting easier questions for harder ones, halo effects, prejudgment, confirmation bias, and overconfidence — can contribute to noise.  Fortunately, it’s possible to mitigate these influences and improve our decision-making.

Assessing and minimizing noise in the context of accreditation

Accreditation decisions are complex.  Accreditors with organizations such as the Liaison Committee on Medical Education, the Southern Association of Colleges and Schools, the Joint Commission, and the National Commission for Certifying Agencies must assess compliance against many standards and elements. In many cases, those decisions draw on evidence from thousands of pages of documentation as well as site visits that can involve a week’s worth of meetings. Many perspectives are involved, including those of site visitors, staff, and committee decision-makers.

Recognizing the complexity of this work, accrediting bodies place great emphasis on bringing validated and trustworthy processes to their decisions. Throughout my own career, I have seen firsthand the efforts made by accreditation committees and staff members to ensure a consistent, fair process with integrity. Everyone involved, particularly accreditors themselves, wants these decisions to be the best they can be. Learning about and taking steps (or augmenting existing tactics) to mitigate risk of noise may be a worthwhile part of this work.

Building from the authors’ recommendations, here are some thoughts about how people involved with accreditation can work to mitigate the effects of noise in their own decision-making as well as when working as part of a team. It may be useful to think about these efforts in two buckets: prior to decisions (general efforts to understand and manage noise) and then during decision-making (procedural adjustments that may help).   

Prior to decision-making:

1.       Introduce the concept of noise. Because accreditation site visit teams and committees bring together people with diverse experiences and viewpoints, a discussion about best practices for decision-making is reasonable and expected. Orientations for individuals and groups working in accreditation provide an excellent opportunity to introduce the concept of noise. Simply learning about noise is powerful, and individuals who are exposed to the concept may proactively modify their own approach to decision-making in an effort to reduce the effect of noise.

2.       Make reducing noise and improving decision-making themes for professional development.  Consider gathering teams ahead of a site visit or program review for dedicated professional development on these topics. Scenario reviews can provide opportunities for discussion of how individuals arrive at their decisions and how groups can more effectively make decisions.  Teams can discuss how to promote expression of a variety of perspectives and explore ways of reducing noise.  Guidelines, structuring complex judgements, and deliberately incorporating counter-arguments are techniques that may warrant particular attention.  

3.       Conduct a noise audit.  Although it can be challenging to systematically examine the quality of judgments made by a group of people, noise audits involving hypothetical scenarios generate valuable information.  The process can help quantify whether noise is in fact affecting decision-making and to what extent, providing a data foundation for making improvements.  Although noise audits often involve external consultants, the expertise within accrediting organizations may mean they have resources that could allow for a thoughtful audit by an internal team.

During decision-making:

1.       Meet the group’s human needs.  Reducing noise in group decision-making begins with planning the meeting. Considering of time of day, scheduling regular breaks, and providing drinks and snacks that include protein will go a long way toward ensuring everyone is at their best. This kind of preparation ensures participants have what they need to act on their own awareness of noise — those who understand that hunger or fatigue, for example, may influence their decisions know they simply need to get a snack or take a break to improve their work.

2.       Ensure all perspectives are heard.  Use words and actions to demonstrate that alternate opinions will be welcome and listened to. Polling apps that allow people to register their opinions prior to discussion may also help ensure more perspectives are considered more fully before conclusions are drawn.  One tool we have used with success is Poll Everywhere, though there are many to choose from.

3.       Leverage decision hygiene practices. Using decision guidelines can reduce inconsistency among decision-makers by providing clarity around what constitutes acceptable performance and how to assess and weight various measures of compliance. Dividing complex decisions into component parts can reduce the likelihood that performance in one area influences perception of performance in other areas. And rotating the order in which people speak can help ensure all participants have an opportunity to influence the discussion.

4.       Actively monitor for noise. Consider tasking an independent person with watching for and speaking up as they see things that could be noise, and be sure to engage others in welcoming and legitimizing the feedback.  Questions like those listed in the bias observation checklist included in Noise may also help.

Supporting quality in all we do

Decisions are an important part of life, and we all have a stake in ensuring they are the best they can be. Practices to mitigate noise hold promise for enhancing accuracy and consistency in our own decision-making and in decisions made by groups of all types, including those involved with accreditation.  

Best practices for making the LCME DCI part of your ongoing continuous quality improvement

Lois Margaret Nora, MD, JD, MBA

It’s no exaggeration to say that at many medical schools, there are few projects more challenging than preparing the Data Collection Instrument (DCI) ahead of an LCME accreditation site visit.  The full DCI questionnaire for the 2023-24 academic year numbers more than 150 pages, and it covers every aspect of medical school operations. Organizing, drafting, reviewing, and completing a DCI is a monumental job whose importance is difficult to overstate.

Updating such an important document after not touching it for years can be overwhelming. And yet, that is the experience at many schools.  However, it doesn’t have to be that way, and at MSAG we recommend a different approach. If schools reframe the DCI as a tool for continuous quality improvement (CQI) and then weave it into regular CQI processes, the document becomes not only easier to manage, but also a more accurate representation of the school and its medical education program. It becomes a tool for evaluating and memorializing institutional progress on strategic goals while supporting ongoing compliance with the LCME standards.  

While MSAG has long advocated that schools make the most of their work on the DCI, best practices for doing so come to us from medical educators and administrators.  I was fortunate to speak with two such colleagues recently about this topic.

Dr. Susan Perlis recently retired from her role as associate dean for medical education at Cooper Medical School of Rowan University, and Dr. Tim Gilbert is associate dean for accreditation and planning at the University of South Alabama College of Medicine. Both are seasoned administrators who have extensive backgrounds in education and multiple accreditation systems, providing a wealth of experience to draw on as they work with the LCME framework.

In a recent call, we discussed challenges, best practices, and lessons learned in their years of work with the DCI, and they shared many ideas that could benefit other schools. Here are some of the points I found particularly interesting.

Foster a constructive accreditation mindset

Accreditation is fundamentally about ensuring our institutions train physicians effectively, manage resources appropriately, and serve their communities well. What could be more worthy of our time? However, the challenging and time-consuming processes involved mean accreditation is sometimes viewed as an obligation, rather than an opportunity.

Sue suggests schools reframe their thinking. While pursuing her own research into assessment, she encountered an idea that transformed her thinking about the topic: Accreditation is a process that is done for a school, and not to a school.  “That creates a paradigm shift in the way we think about accreditation. Because if you think about accreditation that way … it becomes something we do for ourselves. For our quality, for our students, for our faculty, for our institution.”

There is a lot to the accreditation process, but one of the biggest hurdles is completion of the DCI. That’s why Tim and Sue have developed processes to keep the DCI up to date.  This work has enabled each of them to reframe DCI revisions and accreditation as a whole as more constructive, positive endeavors. And as Tim notes, this work has also fostered a wonderful spirit of teamwork as colleagues move toward their common goals.

Build a system – and a schedule – for keeping the DCI up to date

Sue and Tim have each created a system for revising the DCI on an annual basis, which they say enables ongoing CQI and streamlines the process of preparing for a site visit when reaccreditation is on the horizon.

When the new DCI is published, Tim has someone on his staff review the questionnaire to note any changes to the elements before turning to content experts for substantive updates. Then, his office works with stakeholders across the school to review one of the 12 standards each month. At any point in time, no part of the DCI is more than 11 months away from update, and someone is always working on it. “We have somebody who is in the DCI at least weekly, if not daily,” he said. The benefits are myriad, but one of the most obvious is simply keeping it current so anytime it’s needed, it’s ready.

Initially, Tim’s team worked on an academic-year schedule, starting with Standard 1 in July, but this year, as part of their own office-wide CQI, they are modifying the schedule to better align with the schedules of stakeholders across the institution. The revised schedule allows completion of Standard 5 (Educational Resources and Infrastructure) to better align with the fiscal year, and Standards 10-12 are completed during quieter times for colleagues in Admissions and Student Affairs. “We simply asked all those stakeholders, what’s the best time of year for you? And that’s how we’re doing it for next year,” Tim said.

Sue’s work on Standards 6-9 involved a flexible schedule as well, and she and her colleagues spent time copying information into the new DCI and highlighting changes and key questions before distributing the document to content experts for revision.  She included notes about what survey teams would be looking for, so contributors could think through how their responses would be read.  Timelines were set for making changes, but they were generous enough to accommodate other necessary work.

Lean on the right mix of expertise – and a teamwork approach

The breadth and depth of material covered by the DCI means no single team can handle it all. As Sue and Tim described their approach to the DCI, it became apparent that partnership is key.  They contribute deep expertise in education, accreditation, and assessment, and colleagues across the institution provide key subject matter expertise needed to fully populate the DCI.

At both medical schools where Sue worked, her primary collaborators beyond her team were faculty committee chairs, who had oversight over the activities documented in the DCI. While the faculty had ownership over the curriculum, Sue brought expertise in the LCME standards to help ensure conversations about changes to the curriculum occurred in the context of the DCI.  This collaboration ensured any possibility that plans might cause issues with compliance was dealt with before ideas were implemented. “Wherever I was, I would make sure I kept the element in front of us, and if a change was made — by the curriculum committee or by the academic standing committee — then I made sure we went back into the DCI and updated that.”

Tim also relies on a mix of accreditation and subject matter expertise for DCI updates. His process also engages reviewers from the CQI committee who bring a CQI lens and an objective perspective to the content. This system means the school has gone from a small handful of people reviewing the DCI to dozens of people offering input. “One of the unintended outcomes and real benefits we didn’t expect was a broadening of understanding of the DCI,” he said. As a result, when teams across the school consider making changes such as a schedule adjustment, implications for the DCI are top of mind. “We’ve got literally dozens of people who take ownership of the DCI, and it’s really reduced the complaining about the accreditation process because they understand it.”   

Leverage the support of leadership

One of the trickier aspects of building a system for regular use of the DCI is the extent to which people who don’t report to you must contribute. I’ve proposed that legislative leadership skills and systems thinking are an important aspect of gaining cross-departmental buy-in for challenging work. Sue and Tim clearly bring both to their efforts to make the most of the DCI.

However, strong support from institutional leadership is also important. Tim said his office enjoys clear support from his dean, which has made it far easier to build the team he needs and the influence to work effectively with other departments. Sue echoed that sentiment.  The importance of the dean’s support “can’t be overstated,” she said.  “It makes all the difference.”

Embrace the teaching and learning opportunity

My conversation with Sue and Tom underscored the deep expertise accreditation professionals bring to their work. Our discussion also served as a reminder of how valuable it can be for accreditation professionals to spend time sharing that knowledge and experience with others whose expertise may lie elsewhere.  When Tim joined his current institution, he saw an opportunity to build the team he needed and took it upon himself to train and promote a staff member who ultimately became an important voice of expertise on accreditation in her own right.  Likewise, Sue built expertise on her teams with a combination of direct teaching and comments on the DCI as the team worked to update it.

When I reflected on my conversation with Tim and Sue, I was reminded that an up-to-date DCI can be a great tool to orient new employees and for job candidates to learn about an institution. I have encouraged mentees to request and read the most recent LCME summary report as they consider job opportunities; a request for the DCI may also result in helpful insights.  As Sue notes, the DCI is really “the nuts and bolts of how we conduct business in a medical school,” making it a rich resource for anyone who needs to become familiar with the institution.

The accreditation process as opportunity

At MSAG, we believe thoughtful standards in medical education support the integrity of our educational programs and help improve the quality of care provided to patients. We also believe medical educators who embrace the CQI opportunity inherent in LCME accreditation will leverage that work to improve, grow, and achieve strategic goals that go well beyond compliance with standards.

Regularly reviewing and updating the DCI may sound like a lot of work, and it certainly does take time, intention, and commitment. However, schools can get much more out of the process than they put in. Accreditation becomes a more positive endeavor that continually benefits the school, rather than a process seen as a periodic and time-consuming burden.

Many thanks to Dr. Sue Perlis and Dr. Tim Gilbert for sharing how they have operationalized these ideas. Input from other colleagues is always welcome, so please reach out anytime with thoughts, questions, and ideas. We will continue to share insights and lessons here on this blog.

Putting accreditation on the faculty retreat agenda – why and how

Lois Margaret Nora, MD, JD, MBA

It’s common during the summer months and the early weeks of fall for medical schools to host annual educational retreats for faculty – both those who are employed and those who teach on a voluntary basis. These events provide a chance for attendees to connect and share information. They also provide an opportunity for leaders from across the school to express appreciation for the invaluable work done by faculty, bring attendees up-to-date on what’s new at the school, and provide faculty development opportunities.

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A recent discussion about planning content for such a retreat reminded me that these gatherings offer a wonderful opportunity to help faculty learn more about LCME accreditation. Members of the faculty may not be aware of the ways in which accreditation expectations affect their work.  For example, a school faces real challenges from an accreditation perspective if narrative feedback is not provided or if evaluations are not submitted in a timely manner. Drawing a link between policies for student assessment and accreditation can help faculty understand the importance of following those policies. It can also help convey how expectations that may feel picky or onerous have real importance for the institution.

This is where the leadership of accreditation professionals comes in.  While accreditation is never far from the minds of those who deal with these processes regularly, it takes work to keep it on radars across the school and beyond high-profile periods like site visits. Talking with faculty about the role they play in accreditation and its importance to the school is one step in the right direction. And retreats, with their collegial atmosphere and attention to learning, may be just the right environment.

Integrating accreditation into retreat content plans

As retreat planners consider how to integrate accreditation into learning, it may help to draw cues from the accreditation cycle itself. Schools that are embarking on a self-study are at a very different place from schools that are years away from reaccreditation. The treatment of accreditation topics in retreat curricula should be adapted accordingly. Here are a few thoughts that may inspire ideas for your planning:

Considerations for schools in a self-study

If a school is poised to begin a self-study, consider focusing the entire retreat around this process.  Start by explaining how the school is accredited and outlining the timing and benchmarks involved (document submission, site visit timing, etc.)  It can be worthwhile to review past accreditation challenges, along with unique aspects of the school that may draw questions from the site visitors, such as distributed campuses or past issues with the learning environment.  Breakout groups can explore specific areas within student support, diversity, faculty affairs, and the educational program.  Involving key committee chairs and members can reinforce the importance of these discussions.

When schools are in the middle of the self-study process, consider sharing early findings from the process and discussing actions being taken to address these findings. Accreditation professionals can present topics themselves, but often this information is best presented by the faculty leaders and area administrators who work directly in these areas. 

Discussions about accreditation can help prepare faculty for conversations with the site visit team by helping them understand what they may be asked about and related expectations for compliance. These discussions also allow medical education professionals to draw a clear line between the everyday work of faculty and the accreditation process. And, importantly, they may open the door to a broader discussion of continuous quality improvement (CQI). The actions of noting red flags through student feedback, GQ and ISA responses or other sources; considering possible changes and then implementing them; and defining how the institution will follow up on outcomes are powerful illustrations of CQI.  Underscoring this message may help foster the collaboration needed for accreditation – and for improving the quality of medical education at your institution.   

Considerations for midcycle schools

Although accreditation is a common topic of concern at schools that are working on a self-study, most schools are elsewhere in the accreditation cycle.  While it can be tempting to set compliance considerations aside after reaccreditation is achieved, there are plenty of midcycle tasks —  CQI; ensuring policies and procedures are up-to-date; and building systems to support compliance — that are important and worthy of discussion at any point in the cycle.

Including an accreditation component in all annual retreats allows for review of this ongoing work.  Doing so also keeps accreditation top of mind. New expectations and standards, feedback about progress addressing past findings, and a conversation about the school’s CQI processes are all worthy topics for discussion.

There are numerous possible approaches realizing these ideas. Consider planning a short, focused session that covers accreditation “highlights.”  Conversely, accreditation could be woven throughout the retreat by asking all speakers to take a few minutes to provide an update within their area of focus (e.g., student support, faculty affairs, curriculum, etc.) Or, for retreats with a specific theme, look for ways in which that theme intersects with accreditation to inspire ideas.

Schools should pursue the approach that makes the most sense for their retreat and their institution. However they proceed, they will derive great value from involving the school’s accreditation professionals in retreat planning.  The unique lens brought by accreditation professionals is about more than preparing the school to do what is necessary for compliance. It’s also about helping the school leverage the LCME standards and processes for improving the quality of medical education at the institution.

Underscoring the value of accreditation, and the accreditation professional

At MSAG, we believe continual reinforcement of the value and principles of accreditation keeps the standards front and center at the school and enhances the quality of the education it provides.

Keeping accreditation top of mind also helps integrate accreditation professionals into the life of the school. As accreditation professionals are given (or create) opportunities to talk about how their work links to priorities across the institution, they clarify their role and value as helpful colleague, while positioning themselves as a resource on a topic of great importance to their institution.

The COVID-19 crisis may be easing; here are 5 lessons we must carry forward

Lois Margaret Nora, MD, JD, MBA

As COVID-19 mortality in the US surpasses 1 million, it is difficult to see much good in the pandemic that has dominated life over the past two years. However, while the losses are devastating, the pandemic has shed new light on important issues and accelerated progress that I hope will continue well into the future.

Some of these are conversations we should have been having all along. Others involve newer trends that hold potential to benefit many if we can seize this moment of opportunity. Creating change in a system as large and complex as healthcare has never been easy – but the pandemic has shown us how much we can do when we are aligned around a common goal.

Medical schools and other institutions of health professions education will play a key role in applying the lessons of COVID-19 and facilitating progress toward a better system of care.

Here are five lessons that we should carry forward.  

We must bridge the health equity gap

The health disparities laid bare during the pandemic were well known to public health professionals long before the crisis, but the exacerbation of those disparities as COVID-19 took hold captured a new level of attention from the general public. Reports that people of color were at higher risk of developing COVID-19, faced greater likelihood of severe disease outcomes, and often held jobs that put them on the front lines of the pandemic converged with increased attention to issues of social justice and systemic inequities.

It is difficult to overstate the scope of the challenge. The causes of health inequity are “diverse, complex, evolving, and interdependent in nature,” according to a 2017 report from the National Academies of Sciences, Engineering, and Medicine. In medicine, they involve access to care, how care is provided, and even the underlying assumptions of biology and disease on which care is based. Because inequity is omnipresent, action on the part of a few committed stakeholders will not be enough. We will need all hands on deck. And we must seize this moment.

Fortunately, many have risen to the challenge. And some of the most interesting efforts have bubbled up in our institutions of health professions education.

Consider efforts by medical students Pooja Chandrashekar and Victor A. Lopes-Carmen to ensure COVID-19 information is accessible in dozens of languages. Early in the crisis, students across the country put together small armies of volunteers to help with outreach, and they worked with leaders of their schools to take action. Meanwhile, medical education programs are leading research, examining and overhauling curricula, training faculty, and striving to expand the diversity of the student population.

The disparate health outcomes we have seen through the pandemic and throughout history are unacceptable. And yet, the momentum coming out of the pandemic is promising. We – students, educators, clinicians, leaders -- must put the plans and systems in place to ensure we do not lose it.

Clinician burnout is an urgent priority

Clinician burnout was a serious issue before the pandemic, but it didn’t necessarily register beyond the ranks of those most affected. The early pandemic’s focus on the heroism of nurses, physicians, and other clinicians (coupled with attention to inadequate supplies of personal protective equipment and other issues) put healthcare working conditions in the spotlight.

Two years later, burnout has sparked not only an alarming mental health crisis, but also staffing challenges that will have ramifications for years, if not decades. McKinsey found that while 20% of nurses were looking to leave the profession early last year, that figure was 32% by the end of 2021. In some specialties, the picture is far worse. The American Association of Critical-Care Nurses found that 66% of critical care nurses have considered leaving the profession through the pandemic, and 92% believe the experience has cut their careers short.

It is difficult to see the good in any of this, but persistent shortages of nurses and other clinicians have forced a conversation about healthcare workplaces that might otherwise not have happened. To solve workforce challenges, we must address their root causes – in particular, asking too much of professionals while providing too little support. I have been heartened by attention to these issues on the part of institutions like the US Health Resources and Services Administration, the National Academy of Medicine, and the Accreditation Council for Graduate Medical Education, which are leading productive conversations about what has gone wrong and how to reverse it. Meanwhile, the Dr. Lorna Breen Health Care Provider Protection Act, recently signed into law, will provide resources to help ensure clinicians have the support they need.   

Telehealth needs a permanent place in our systems of care

For some care, there is no substitute for an in-person visit.  But amid the rapid escalation of telemedicine early in the pandemic, many healthcare professionals were surprised by how much care could be administered from afar, with the right technology.

Mental healthcare is a particularly interesting example. While the promise of remote mental healthcare had been discussed prior to the pandemic, it took a crisis to increase uptake beyond the low single digits.  One study reported that telehealth was used by more than half of those with a behavioral health condition during the first two months of the pandemic – a higher rate of utilization than reported even for chronic physical conditions. Telehealth also opened the door to people who might otherwise forgo mental healthcare.

The flexibility to obtain care from anywhere may be particularly important given persistent shortages of mental health professionals that are expected to worsen. Across the US, just 28.1% of need for psychiatric care was met as of Sept. 30, 2021, according to the Kaiser Family Foundation. Meanwhile, worsening shortages for marriage and family therapists, mental health and substance abuse social workers, and others may be on the horizon. This is a crisis that won’t be entirely alleviated by remote care, but telehealth tools are certainly useful for managing the wide regional variation in unmet need.

Access to care is an important piece of the puzzle, but it is not the only reason to fully explore the possibilities of telehealth for behavioral and other health needs. Remote care channels also offer healthcare professionals an interesting window into the lives of their patients and clients. For example, licensed therapist Jenn Turner, who specializes in trauma in her work with individuals and couples, has noticed people are less guarded when they join therapy from home, potentially allowing care to progress more rapidly. Meanwhile, psychiatrist Dr. Alisa Burch and colleagues note life complications such as caregiving and work schedules are less likely to interfere with remote care. These considerations are important for continuity of care while also helping ease persistent business challenges like cancellations.   

Much of the flexibility that allowed the rapid escalation of telehealth was granted on a temporary basis. While it’s clear that telehealth is not going away, nor should it, it will take commitment to make the necessary changes to enable its use on a permanent basis. We also have work to do as we determine the optimal use of remote, in-person, and hybrid care. As we do so, we will help ease workforce challenges, enhance convenience for patients and professionals, and improve health outcomes.

We should make better use of our interprofessional care teams

As COVID-19 surges have strained supplies of nurses, physicians, respiratory therapists, and others, we have seen the limitations of our healthcare workforce. We have also discovered and leveraged previously untapped flexibility that holds promise for continuing to expand access and enhance continuity of care after the pandemic subsides.

Consider the wide variety of professionals who joined the effort to administer COVID-19 vaccines. Not just physicians, nurses, and other traditional providers of vaccines, but also dentists, emergency medical technicians, veterinarians, and others. The contributions of these health professionals not only rapidly expanded the vaccinator workforce; they also opened up new access points for vaccination at a time when it was important to remove all possible barriers to care.

The pandemic also opened new avenues for enabling care continuity even as practices and hospitals managed overwhelming patient volumes. Physicians shifted from their usual specialization to emergency departments, critical care units, and other places where need was high. Meanwhile, we saw allied health professionals like respiratory therapists take on new tasks for which they are trained but not always engaged. And advanced practice professionals stepped into expanded roles that allowed them to work at the top of their game while relieving burdens on their colleagues, some of whom were needed elsewhere.

The flexibility we gain when we expect and allow professionals to practice at the top of their training is important for a crisis, but it can also be a solution to challenges in ordinary times, particularly in underserved areas. We should look for opportunities to enable all professionals to make the most of their skills. We should also look beyond our hospital and practice walls to community health workers, who have been a lifeline in many areas where physicians are in short supply. What progress could we make if we better channel the expertise of all health professionals after the worst of this crisis has passed?

Our public health system needs attention and resources

Public health professionals often say the most effective public health systems go largely unnoticed by the general public. People do not see the outbreaks that are prevented and the disasters that are thwarted. Unfortunately, this means problems like chronic underfunding, poor organization, and communication gaps also go unnoticed until crisis hits.

The pandemic put a spotlight on these issues. While a novel virus would have posed a challenge to even the most robust framework, the public health system in the US lacks the clear and consistent organization and structure needed to coordinate preparation and response to a threat like COVID-19. It is no surprise that testing, contact tracing, even communication about how to stay safe were so difficult to manage. Agencies that have long seen their budgets raided to fund other priorities had neither the technology and staff, nor adequate empowerment and coordination to effectively do this work.

The public health system also lacks a consistent approach to more routine but no less important aims like reducing tobacco use and conducting injury and disease surveillance. It is difficult to overstate the consequences of not attending to these priorities. However, addressing them holds promise for improving the state of health in America — and for solving many of the challenges that became clear during the COVID-19 crisis.

Looking toward a better healthcare system

Perhaps the most important takeaways from the pandemic involve the interconnectedness of our world. It does not take long for an emerging disease threat in one part of the world to reach people everywhere. And what started as a health issue quickly affected our financial, educational, and political systems. In healthcare, COVID-19 was not just a problem for infectious disease professionals and critical care teams to manage. It challenged us all.

The solutions may also be similarly interconnected, and we may see some interesting and beneficial emergent properties arise as we build them out.  These outcomes may in fact ease some of the most pressing issues in medicine.

For example, as we develop more effective interprofessional teams, we may also uncover opportunities to enhance clinician well-being. Moving from concentrated workflows where physicians are heavily involved in all care for all patients to shared-responsibility models that spread tasks across the practice team may even help restore joy to the practice of medicine, to borrow a phrase from Dr. Christine Sinsky, whose work heavily focuses on these issues. These changes may also have implications for practice management. In fact, Sinsky and Dr. Mark Linzer argue that some of the administrative and documentation changes put in place temporarily during the pandemic transformed practice efficiency with seemingly simple changes such as allowing physicians to relay orders verbally to colleagues for entry into the electronic health record. Yet another change that we should be learning from as we move forward.

These lessons and changes will affect existing healthcare professionals. They will also have an indelible impact on the institutions of health professions education, which form the foundation of our healthcare workforce. Today’s students are tomorrow’s leaders, and those who embark on their careers with the right skills will play an outsized role in making the most of the lessons of the pandemic.

As COVID-19 evolves into an endemic disease and an unfortunate fact of life, the crisis phase of this experience will pass. However, the pandemic has shaped and scarred our world. It is my hope that we can honor the sacrifices made by so many, including so many in healthcare, by applying the hard lessons we have learned to make our healthcare and health professions education systems better.

This piece was first published on LinkedIn.

Lessons from IAMRA: Real connection at a virtual conference

Lois Margaret Nora, MD, JD, MBA

As someone who has long been interested in professional medical regulation, I knew I was sure to encounter many like-minded professionals and compelling topics at the International Association of Medical Regulatory Authorities’ 2021 meeting. What I did not know was that the meeting’s virtual format would be so deftly managed to facilitate that learning and connection.  

During the meeting, Sheila De La Cruz and I presented work that we have done with Carol Clothier and Terry Stratton over the past several years.  While the stories of medicine’s history are enlightening, they often leave out the influence, impact, and experiences of women.  During my leadership at the American Board of Medical Specialties, I realized that is certainly the case in our histories of medical professional regulation.  Attempting to fill that gap, we traveled to the archives of the Federation of State Medical Boards offices in Texas and began an examination of the documents housed there.

We examined all the photographic imagery in about 100 years’ worth of FSMB journals and newsletters, and our study yielded some interesting observations that we discussed at the IAMRA meeting and have submitted for publication as part of an academic paper.  I’ll be sure to share those results with you if/when they are published.

Judged on substance alone, the IAMRA meeting was informative and engaging.  However, it is the thoughtful and professional manner in which the meeting was executed that I found especially noteworthy.

The IAMRA audience is – as the name suggests – a truly international audience.  If you’ve attended international conferences yourself, you know that while the attendees may come from around the world, conference schedules force many of them to upend their normal sleep schedules and adapt to a single (often US-aligned) time zone.

Conversely, IAMRA meeting organizers scheduled their three-day conference with three start times, each one roughly aligned with US, European, or Australian time zones.  As a result, people from around the globe had at least one day where the plenary sessions and other activities matched their usual workday schedule. An interesting example of organizational cultural competence.

The organizers also used a hybrid approach to presentations that yielded meaningful opportunities to connect and share information.  Speakers taped their talks in advance (following firmly held time guidelines). After presentations were broadcast to the meeting, IAMRA expert moderators hosted a live discussion among the speakers and the audience.  While this approach is not that unusual, the IAMRA moderators did it particularly well, and the resulting discussions were interesting and enlightening.

My compliments and congratulations to Roxanne Huff and her colleagues on the IAMRA team. We have all done enough Zoom meetings to feel both proficient and all too familiar with “Zoom fatigue,” yet it’s clear large conferences continue to pose challenges in our heavily virtual environment. All the more reason to celebrate such a successful event!

Making sense of – and the most of – the LCME accreditation standards

Lois Margaret Nora, MD, JD, MBA

I’ll never forget sitting under the Arizona night sky and watching meteor showers with Keith and our children. Or tracking the Hale-Bopp comet in spring of 1996. Or recognizing Orion’s belt during the winter months, whether home was in Chicago, Lexington, Akron, Scranton, or Cambridge. The night skies above have been a constant for me in an ever-changing world.

Perhaps then it is not surprising that I see the night sky as a metaphor for many things. One of those things, as unexpected as it might seem, is the process of accreditation. On first glance, the star-filled sky can appear scattered, overwhelming, and incomprehensible.  However, ancient mariners and our oldest ancestors identified patterns in the sky, and those constellations have been used to tell stories, provide direction, and elucidate meaning.

Like the objects in the night sky, the 12 standards and 93 elements comprising the Liaison Committee on Medical Education standards can feel overwhelming to anyone new to accreditation, and particularly those charged with organizing the institutional Self-Study and completion of the Data Collection Instrument (DCI).  Each individual element demands attention.  However, when connections can be identified between the various elements and across the standards, accreditation work can become both easier to understand and more meaningful.

An example might be helpful.  Advising is mentioned explicitly across several elements in standards 11 and 12.  Career advising, personal counseling, academic advising, and financial counseling are often handled by different people in different offices — sometimes even located on different parts of campus. Yet, all these functions are key to an advising system that supports students during medical school and prepares them for their careers ahead.

Together, these functions are more than the sum of their parts, and program leaders who can think about the advising system holistically may be able to weave a more effective and efficient student support system. Accreditation work often opens the door to these conversations, especially when standards and elements are approached not just in isolation, but also as part of a constellation.

This holistic thinking can be useful for achieving our most complex goals in medical education. For example, many schools are striving to enhance diversity, equity, and inclusion (DEI) in their medical education programs. Although a small number of LCME elements explicitly deal with DEI, many others are potentially important. Student affairs, curriculum, admissions, and institutional resources all have a role to play, and so do their respective standards, which can be used as a lens for examining and enhancing DEI work. As connections among the standards and the offices are drawn, a holistic picture of DEI emerges, and our work at MSAG suggests outcomes may improve as a result.

Making the most of accreditation

The most obvious goal for any team working through the LCME accreditation process is to achieve a positive accreditation decision. However, the sweeping, multi-functional nature of the LCME standards and elements allows them to be used for advancing progress against any number of goals. Leaders can analyze and build on strategic priorities by working through the lens of any standard, or indeed, a constellation of standards. As each constellation is identified, clarity emerges around how multiple functional areas influence a shared goal.  Systems thinking takes shape, and institutional systems evolve as a result.

This work continues to benefit the institution long after the LCME accreditation decision has been received. Considering goals through the multitude of standards allows for a clear and consistent way of measuring and demonstrating progress at any time across an accreditation cycle. Successes can then be celebrated, while gaps present a chance to optimize and then evaluate again, continually moving the institution toward its aims.

Lessons from teaching: Giving an effective board presentation

Lois Margaret Nora, MD, JD, MBA

I recently had the privilege of presenting to a group of Executive Leadership in Academic Medicine® (ELAM) fellows.  The topic was working with governance boards, particularly formal presentations in those settings.  Invitations to participate in governance meetings are a meaningful statement of confidence in the invitee. They are also an opportunity for the invitee to have an impact, so bringing a strategic approach to these presentations is important.

Pillars of an effective presentation

I encourage people to think about these formal presentations in three parts: preparation; the actual presentation; and post-presentation debriefing. 

Preparation takes the most time, and deliberate, organized preparation is key to a successful presentation.  Some of my favorite strategies for effective preparation include developing a formal “game plan” for the presentation, clarifying the overarching goal of the presentation, and researching meeting attendees so you can tailor your approach to their perspectives and interests.

During the presentation, it’s helpful to present different types of information in different ways that meet the learning styles of the attendees. It’s also important to observe the body language of listeners, so you can adapt or pivot if appropriate. One of the harder but more important things to do is to genuinely welcome the least welcome question.  Boards are charged with asking tough questions. Recognizing this and being prepared to answer with confidence will reinforce your effectiveness.

After the presentation, it is important to debrief and follow-up. This includes tying up loose ends, such as providing additional data, answering questions you could not fully address during the discussion, and other things. And if you also make a habit of debriefing about what went well and what didn’t, you can use those lessons to inform and hopefully improve your next board presentation. 

Debriefing from my own presentation

In my opinion, one of the best parts of teaching is learning from others.  My discussion with the ELAM fellows informed my thinking in some interesting ways on some of the topics we explored.

One of the more interesting discussions during the session came from fellows who challenged my recommendation that professionals reflect the culture of the boardroom in how they dress.  We had an interesting discussion about the balance between personal authenticity and boardroom norms, and what happens when there is tension between the two. The discussion heightened my awareness of how boardroom norms can feel very limiting to some people, and it also speaks to the importance of getting greater diversity on boards.

Another interesting discussion unfolded after I told a story of a colleague who recognized a meeting attendee’s visual impairment and adjusted documents to meet his needs.  Angel Dorsey, MS, who is ELAM’s instructional designer, approached me after the meeting to share a helpful set of guidelines she has created for disability-friendly digital documents.  I plan to integrate these tips into my own materials, along with future talks about presentations like this one.

My thanks to the ELAM leadership team for a chance to connect with this year’s group of fellows, and for the always welcome reminder that there is always more to learn.