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MILITARY
PHOTO AT LEFT: Dr. Michelle Ogunwole instructs her intern, Dr. Andrew Donati, in ultrasound-guided internal jugular access
on a manikin in the Audie Murphy Simulation Center. Ms. Deb Bartoshevich, VA Simulationist, observes. (Photo courtesy of
STVHCS Medical Media)
Health Care System. Over the past six years, they have taught
invasive procedures to medicine residents with such care that
complications have plummeted. Over the first two years of the
program, when the CRQS introduced ultrasonography to the
thoracentesis protocol, pneumothoraces dropped from a 12 per-
cent incidence to 3 percent. Complications from central line
placement in the Audie Murphy medical ICUs have frankly be-
come rare. VA patients are fortunate to have doctors who have
had intense, repetitive training in the safest techniques for in-
vasive procedures.
When Drs. Pat Wathen, George Crawford, and David Dooley
proposed to obtain a salary line from the VA’s Office of Academic
Affairs (OAA, VA’s directorate for medical education) six years
ago, only five of 140 VA Medical Centers in the country had a
CRQS. The concept of such a position had been jointly developed
by VA leadership in OAA and in VA’s National Center for Patient
Safety in Ann Arbor. Audie Murphy was in the second group of
five in the nation to acquire the position. The slot is filled each
year by one of the UTH-SA Internal Medicine Residency’s four
Chief Residents, a highly select group. Recruitment into the slot
is not difficult as it attracts internists who love both teaching as to their successors.
well as performing procedures. Dr. Karthik Garapati, the CRQS
from 2016-2017 who is just cycling back into a gastroenterology
fellowship, estimates that he (or Chief Resident colleagues who
shared this duty) performed over 200 paracenteses, over 150 tho-
racenteses, and over 100 lumbar punctures with trainees over this
past year.
But Dr. Ogunwole also teaches the entire sphere of Patient
Safety (PS) within the Internal Medicine program at Audie Mur-
phy. She received an extensive exposure to PS elements during
her own training (including Quality Improvement principles,
Root Cause Analyses, Simulation Training, Team Training,
Human Factors Engineering, et al.), receives a brief refresher in
June, and in September will attend a week of more intense on-
site training with other CRQSs on the same topics. There will
MEDICINE
be 60 such chiefs in the room with her from VA facilities na-
tion-wide, indicating how widely the program has spread. One
such site, stimulated in part by observing the VA/UT CRQS
success, is the San Antonio Military Medical Center, whose ex-
perience can be found published in Military Medicine (Ferraro
K. et al., March-April 2017).
Another role Dr. Ogunwole plays is that of leader of a cohort
of medicine residents in pursuing a process improvement project
over the course of the academic year. All medicine residents are
assigned to one of five such cohorts, and four other young and
energetic faculty members lead the other teams. Engagement in
the hands-on application of quality improvement processes is thus
embedded in the residents’ training. While this has been driven
in medicine by the energy and interest of Dr. Wathen as the pro-
gram director, the incorporation of QI into the curriculum of
every residency program has become standard in 2017. (A man-
date from the ACGME, the accreditation agency for training pro-
grams, has helped). Physicians in every specialty who completed
their training more than 10 years ago might be pleased and sur-
prised to know of the opportunities that are now routinely offered
By mid-morning the CRQS is having to apologize to requestors
for limiting procedural consultations to four for that day; other
inpatient teams are going to have to do their own. The lunch hour
and the afternoon are already scheduled for the Morbidity and
Mortality conference she arranges and presents and then to attend
residents in Audie Murphy’s internal medicine clinic. But by in-
vesting in and developing academicians like Dr. Ogunwole, the
VA has changed and broadened the landscape for our Affiliates’
physicians in training.
Dr. David Dooley is the associate chief of staff for education at
South Texas Veterans Health Care System and a professor of medicine
at UT Health San Antonio.
visit us at www.bcms.org 35