Graduate Medical Education Reform Research Articles

Challenges and Solutions in Running Effective Clinical Competency Committees in the International Context.

Challenges and Solutions in Running Effective Clinical Competency Committees in the International Context.

Participation of M. I. Pirogov in the work of the Medical Council of the Ministry of Internal Affairs and the medical commission at the Ministry of Public Education

Annotation. This article is about M. I. Pyrohov’s participation in the activity of Medical Board of the Ministry of Internal Affairs and Medical Interim Committee at the Ministry of Health, about graduate medical education reform in the Russian Empire, the establishment of the Medical Department in St. Volodymyr Kyiv University.

State of the Plastic Surgery Workforce and the Impact of Graduate Medical Education Reform on Training of Plastic Surgeons.

Although recent estimates predict a large impending shortage of plastic surgeons, graduate medical education funding through the Centers for Medicare and Medicaid Services remains capped by the 1997 Balanced Budget Act. The authors' aim was to develop a plan to stimulate legislative action. The authors reviewed responses of the American Society of Plastic Surgeons, American College of Surgeons, and American Medical Association from January of 2015 to a House Energy & Commerce Committee request for input on graduate medical education funding. In addition, all program directors in plastic surgery were surveyed through the American Council of Academic Plastic Surgeons to determine their graduate medical education funding sources. All three organizations agree that current graduate medical education funding is inadequate to meet workforce needs, and this has a significant impact on specialty selection and distribution for residency training. All agreed that funding should be tied to the resident rather than to the institution, but disagreed on whether funds should be divided between direct (allocated to residency training) and indirect (allocated to patient care) pools, as is currently practiced. Program directors' survey responses indicated that only 38 percent of graduate medical education funds comes from the Centers for Medicare and Medicaid Services. Organized medicine is at risk of losing critically needed graduate medical education funding. Specific legislation to support additional graduate medical education positions and funding (House Resolutions 1180 and 4282) has been proposed but has not been universally endorsed, in part because of a lack of collaboration in organized medicine. Collaboration among major organizations can reinvigorate these measures and implement real change in funding.

Reducing the physician workforce crisis: Career choice and graduate medical education reform in an emerging Arab country.

In today's interdependent world, issues of physician shortages, skill imbalances and maldistribution affect all countries. In the United Arab Emirates (UAE), a nation that has historically imported its physician manpower, there is sustained investment in educational infrastructure to meet the population's healthcare needs. However, policy development and workforce planning are often hampered by limited data regarding the career choice of physicians-in-training. The purpose of this study was to determine the specialty career choice of applicants to postgraduate training programs in the UAE and factors that influence their decisions, in an effort to inform educational and health policy reform. To our knowledge, this is the first study of career preferences for UAE residency applicants. All applicants to residency programs in the UAE in 2013 were given an electronic questionnaire, which collected demographic data, specialty preference, and factors that affected their choice. Differences were calculated using the t-test statistic. Of 512 applicants, 378 participated (74%). The most preferred residency programs included internal medicine, pediatrics, emergency medicine and family medicine. A variety of clinical experience, academic reputation of the hospital, and international accreditation were leading determinants of career choice. Potential future income was not a significant contributing factor. Applicants to UAE residency programs predominantly selected primary care careers, with the exception of obstetrics. The results of this study can serve as a springboard for curricular and policy changes throughout the continuum of medical education, with the ultimate goal of training future generations of primary care clinicians who can meet the country's healthcare needs. As 65% of respondents trained in medical schools outside of the UAE, our results may be indicative of medical student career choice in countries throughout the Arab world.

The Nation׳s Physician Workforce and Future Challenges

There is much debate about the adequacy of the U.S. physician workforce and projections of its future size, distribution and composition. Beginning with 3 observations about the workforce we believe are largely not subject to dispute, we address the debate by providing an overview of the current state of the workforce and Graduate Medical Education in the United States; a brief history of both calls for graduate medical education reform since 1910 and the recent, intense debate about the reliability of workforce projections; and a discussion of the challenges to understanding the physician workforce. We draw 3 concluding observations: (1) Precisely because projections can be unpredictable in their impact on both physician workforce behavior and public policy development, policy makers need to devote more attention to workforce projections, not less. (2) More research devoted specifically to the workforce implications of delivery and payment reforms is strongly needed. (3) Such research must be pursued with a sense of urgency, given the rapid aging of the Baby Boom generation, which will put a disproportionate demand on the nation׳s physician workforce.

Perceptions of Leaders and Clinician Educators on the Impact of International Accreditation.

Graduate medical education (GME) is responding to calls for reform by adopting competency-based frameworks and, in some countries, by rapidly implementing external accreditation systems. The Accreditation Council for Graduate Medical Education International (ACGME-I) began accrediting institutions in 2009. This study aimed to describe ACGME-I-accredited institutions and explore perceptions of their leaders and clinician educators (CEs) regarding preparedness, challenges, and initial impact of accreditation. Cross-sectional surveys of all ACGME-I-accredited institutions' leaders and CEs were conducted from June 2013 to June 2014. Eligible participants were identified through institution Web sites and GME offices. Combinations of Web- and paper-based surveys were employed. Completed surveys were received from 24 (70.6%) of 34 institutional leaders and 274 (76.3%) of 359 CEs, representing 3 countries, 8 academic medical centers, 2 affiliated teaching hospitals, and 47 residency programs. Leaders and CEs felt prepared in the domains of knowledge and implementation of the competencies. Top challenges were excessive "demands on faculty time" and "bureaucratic procedures." The majority of both groups perceived a positive impact of accreditation on all learner, faculty, institution, and patient outcomes; most perceived no impact on patient satisfaction. Overall, 79.2% of leaders and 75.8% of CEs agreed or strongly agreed that seeking ACGME-I accreditation was worthwhile. This study indicates that despite the challenges identified, initial perceptions of the impact of ACGME-I accreditation are positive. Findings from this study may be useful to institutions and countries considering similar GME reform, though long-term outcome data are needed.

Providing Educational Content and Context for Training the Next Generation of Physicians in Quality Improvement.

Amid calls for graduate medical education (GME) to better prepare a workforce that can address growing challenges in health care quality and cost, institutions must find ways to more effectively educate and engage housestaff in quality improvement (QI) initiatives. Although the benefits for trainees and institutions alike can be significant, creating and maintaining successful strategies has proven challenging. Multiple barriers (e.g., variable backgrounds and needs of trainees) have clouded the educational and clinical effectiveness of many efforts. Recent findings suggest that trainee engagement in QI is lacking and that contextual support for practice-based learning and systems-based practice is often suboptimal.Meaningful GME reform must include changes in how institutions approach QI education, particularly in how they create appropriate learning environments for trainees. Institutions can achieve these goals and foster a positive QI culture by aligning housestaff QI teaching with institutional priorities in several ways. First, they can create common, institutional-level QI curricula to standardize expectations for learners across training levels and specialties. Second, they can engage housestaff in ongoing institutional QI efforts by encouraging these trainees to develop and execute QI projects or assemble QI-focused groups that include faculty and institutional leaders. Third, institutions can appoint housestaff to institutional QI committees and have housestaff groups review and endorse proposed QI initiatives to enhance operational decision making. Institutions can leverage the new Accreditation Council for Graduate Medical Education Clinical Learning Environment Review program to implement these strategies, measure progress, and realize important gains in housestaff QI education.

The Value of Narrative Medical Writing in Internal Medicine Residency.

Narrative medical writing can be utilized to help increase the value and patient-centeredness of health care. By supporting initiatives in areas such as population health management, quality improvement and health disparities, it provides benefits that are particularly relevant to physicians focused on health care improvement, reform and redesign. Graduate medical education (GME) represents a key time and opportunity for internists to learn and practice this form of writing. However, due to a number of local and systems factors, many have limited opportunities to engage in narrative medical writing compared to other non-clinical activities. By capitalizing on the momentum created by recent GME reform, several strategies can be utilized to overcome these barriers and establish narrative medical writing as a viable professional and communication skill.

Advancing educational continuity in primary care residencies: an opportunity for patient-centered medical homes.

Continuity of care is a core value of patients and primary care physicians, yet in graduate medical education (GME), creating effective clinical teaching environments that emphasize continuity poses challenges. In this Perspective, the authors review three dimensions of continuity for patient care-informational, longitudinal, and interpersonal-and propose analogous dimensions describing continuity for learning that address both residents learning from patient care and supervisors and interprofessional team members supporting residents' competency development. The authors review primary care GME reform efforts through the lens of continuity, including the growing body of evidence that highlights the importance of longitudinal continuity between learners and supervisors for making competency judgments. The authors consider the challenges that primary care residency programs face in the wake of practice transformation to patient-centered medical home models and make recommendations to maximize the opportunity that these practice models provide. First, educators, researchers, and policy makers must be more precise with terms describing various dimensions of continuity. Second, research should prioritize developing assessments that enable the study of the impact of interpersonal continuity on clinical outcomes for patients and learning outcomes for residents. Third, residency programs should establish program structures that provide informational and longitudinal continuity to enable the development of interpersonal continuity for care and learning. Fourth, these educational models and continuity assessments should extend to the level of the interprofessional team. Fifth, policy leaders should develop a meaningful recognition process that rewards academic practices for training the primary care workforce.

Observations: clinical revenue directly attributable to anesthesiology residents.

During the graduate medical education reform of the 1990s, anesthesiology programs across the country downsized to accommodate a perceived oversupply of anesthesiologists in the marketplace and to make room for an additional number of training positions in the primary care residencies.1 As academic programs struggled to work more efficiently either with replacement of clinical staff members or with different staffing models, many programs experienced an increase in their operational costs because of a reduction of their labor force and a discrepancy in anesthesiology billing practices.2,3 Prior to 2011, the Centers for Medicare and Medicaid Services (CMS) and many private insurance companies reimbursed anesthesiology programs at a 50% discount. Today, academic anesthesiology programs have been able to bill for 100% of the services provided, regardless of staffing ratios.4 We examined the revenue stream directly generated by the clinical activities of anesthesiology residents at our program during the time period July 1, 2011, through June 30, 2012, and demonstrated that our entire residency program delivered 4664 billable anesthetics, billed for $7,892,558, and collected $2,802,969 in total payments. We determined that direct costs for an anesthesiology resident by clinical training year, including salary and fringe benefits for Clinical Anesthesia year 1 (CA-1), CA-2, and CA-3, were $65,951, $71,492, and $75,636, respectively. With a total cost of nearly $1,300,000 for our residency, we estimate that the direct revenue attributable to the anesthesiology residents is $1,500,000. There are several limitations to our analysis. First, the applicability of this methodology to other institutions may be limited for academic programs with different staffing models. Our methodology only accounts for the differences in billing when residents are staffed at 1∶1 versus 1∶2 ratios, and we show differences between the various classes in the subgroup analyses. Second, our academic program uses both a web-based scheduling program (OpenTempo, Richmond, VT) and an electronic billing service (PAR Management, Newton, MA). Academic programs without similar services may find it difficult to accurately track the revenue stream attributable to anesthesiology residents. Third, across the country, each training program faces a different payer mix, which affects the reimbursement rates for clinical activities. Finally, we do not account for the indirect costs of training residents (eg, academic time to prepare lectures, teaching time in the operating room, assistant residents in research projects). For instance, using a survey method, Kelly et al5 estimated that the “hidden” costs average $4,439 per resident annually. As anesthesiologists are challenged to redefine their roles in perioperative medicine, the clinical and administrative scope of practice continues to expand. Academic anesthesiology departments are unique in that a portion of work performed by their residents can be quantified with an electronic billing system. Although it is tempting to presume that anesthesiology residents are capable of creating a significant revenue stream for their clinical activities, it is important to recognize that the mission of an academic anesthesiology department is to balance the clinical, research, and educational components of a well-managed program.

Addressing the nation's physician workforce needs: The Society of General Internal Medicine (SGIM) recommendations on graduate medical education reform.

The Graduate Medical Education (GME) system in the United States (US) has garnered worldwide respect, graduating over 25,000 new physicians from over 8,000 residency and fellowship programs annually. GME is the portal of entry to medical practice and licensure in the US, and the pathway through which resident physicians develop the competence to practice independently and further develop their career plans. The number and specialty distribution of available GME positions shapes the overall composition of our national workforce; however, GME is failing to provide appropriate programs that support the delivery of our society's system of healthcare. This paper, prepared by the Health Policy Education Subcommittee of the Society of General Internal Medicine (SGIM) and unanimously endorsed by SGIM's Council, outlines a set of recommendations on how to reform the GME system to best prepare a physician workforce that can provide high quality, high value, population-based, and patient-centered health care, aligned with the dynamic needs of our nation's healthcare delivery system. These recommendations include: accurate workforce needs assessment, broadened GME funding sources, increased transparency of the use of GME dollars, and implementation of incentives to increase the accountability of GME-funded programs for the preparation and specialty selection of their program graduates.

Reducing Oral and Maxillofacial Surgery Resident Risk Exposure: Lessons from Graduate Medical Education Reform

It is estimated that, in the United States, more than 40,000 patients are injured each day because of preventable medical errors. Although numerous studies examine the causes of medical trainee errors and efforts to mitigate patient injuries in this population, little research exists on adverse events experienced by oral and maxillofacial surgery (OMFS) residents or strategies to improve patient safety awareness in OMFS residency programs. The authors conducted a retrospective literature review of contemporary studies on medical trainees' reported risk exposure and the impact of integrating evidence-based patient safety training into residency curricula. A review of the literature suggests that OMFS residents face similar risks as medical trainees in medical, surgical, and anesthesia residency programs and may benefit from integrating competency-based safety training in the OMFS residency curriculum. OMFS trainees face particular challenges when transitioning from dental student to surgical resident, particularly related to their limited clinical exposure to high-reliability organizations, which may place them at higher risk than other medical trainees. OMFS educators should establish resident competence in patient safety principles and system improvement strategies throughout the training period.

Competency-Based Education, Entrustable Professional Activities, and the Power of Language

Competency-Based Education, Entrustable Professional Activities, and the Power of Language

Transforming Graduate Medical Education to Improve Health Care Value

To provide high-value care, physicians will need skills in such domains as quality improvement, cost-aware practice, and care coordination. Medicare can speed graduate medical education (GME) reform by linking some funding to programs' performance on relevant measures.

Medical Errors Involving Trainees

Despite wide recognition that the delivery of medical care by trainees involves special risks, information about the types and causes of medical errors involving trainees is limited. To describe the characteristics of and factors contributing to trainee errors, we analyzed malpractice claims in which trainees were judged to have played an important role in harmful errors. The claims were closed between 1984 and 2004, and the errors occurred between 1979 and 2001. Specialist physicians reviewed random samples of closed malpractice claim files at 5 liability insurers from 2002 to 2004 and determined whether injuries had occurred, and if so, whether they were due to error. We described the clinical circumstances and contributing factors associated with harmful errors involving trainees ("cases"). We also compared the characteristics of cases with their nontrainee counterparts and probed trainee errors attributed to teamwork problems and lack of technical competence or knowledge. Among 240 cases, errors in judgment (173 of 240 [72%]), teamwork breakdowns (167 of 240 [70%]), and lack of technical competence (139 of 240 [58%]) were the most prevalent contributing factors. Lack of supervision and handoff problems were most prevalent types of teamwork problems, and both were disproportionately more common among errors that involved trainees than those that did not (respectively, 54% vs 7% [P < .001] and 20% vs 12% [P = .009]). The most common task during which failures of technical competence occurred were diagnostic decision making and monitoring of the patient or situation. Trainee errors appeared more complex than nontrainee errors (mean of 3.8 contributing factors vs 2.5 [P < .001]). In addition to problems with handoffs, house staff are particularly vulnerable to medical errors owing to teamwork failures, especially lack of supervision. Graduate medical education reform should focus on strengthening these aspects of training.

Medicare financing of graduate medical education.

The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require "all-payer" support.

Residents’ Perspective: Graduate Medical Education Reform: Implications for Emergency Medicine Residency Training

Residents’ Perspective: Graduate Medical Education Reform: Implications for Emergency Medicine Residency Training

Transition from housestaff to nonphysicians as neonatal intensive care providers: cost, impact on revenue, and quality of care.

Nonphysician providers (NPP) increasingly fill roles traditionally performed by housestaff. Downsizing of a pediatric residency program prompted phased replacement of housestaff in a 26-bed neonatal intensive care unit (NICU). Subsidized education for neonatal nurse-practitioners, recruitment of physician assistants, and NPP leadership took place over 18 months, at which time all housestaff functions were assumed by NPP. Cost to establish the program, impact on hospital revenue under New York's prospective reimbursement system, and quality of care were evaluated. The net startup cost for the NPP program was $441,000 ($722,000 for education, salaries, staff replacement, and recruitment, partially offset by a New York State workforce demonstration project grant). Ongoing costs of the program are $1.2 million/yr (including salaries, off-hours medical backup, recruitment, administrative overhead, and loss of indirect and direct medical education reimbursement, partially offset by recaptured housestaff salaries and ancillary expense reductions). Access to care was maintained. Quality of care was assessed during the last 6 months of housestaff and the first 6 months of full NPP staffing, revealing similar weight-specific survival, and improvement in documentation and compliance with immunization and blood utilization guidelines during the NPP period. NPP are expensive in comparison to housestaff. Revenue is minimally adversely affected, but access to NICU services and quality of care was preserved and in some cases enhanced with NPP. In the context of graduate medical education reform, staffing problems such as ours will be encountered increasingly in inpatient subspecialty settings.

Making sense of federal GME reforms: The impact on osteopathic medicine

Physician workforce issues, particularly the generalist/specialist mix, surfaced as a major component of the healthcare reform debate in the last Congress. Both of the major bills before the Congress at the end of the session would have legislated reforms in graduate medical education designed to control the cost, mix, and supply of physician manpower. This article examines the graduate medical education reform measures proposed in the Gephardt (House) and Mitchell (Senate) bills and identifies elements of agreement. Discussion focuses on the potential for reforms that could be enacted in the new Congress, with a look at the implications for the osteopathic medical profession. A second article, to appear in next month's issue, will focus on recommendations for secondary reforms to prepare osteopathic medical institutions for the changing graduate medical education environment. Such a changing environment requires comprehensive reevaluation in all of the institutions of osteopathic medicine--the colleges, the hospitals, and the American Osteopathic Association.

"110- Buzz Number"

The article entitled "Graduate Medical Education and Pediatric Work Force Issues and Princples" produced by the Task Force on Graduate Medical Education Reform claims to represent the "consensus opinion of the American pediatric community." It is apparent to me that some issues addressed require discussion and, in my opinion, have not reached "consensus" status at all. Let me start with issues that continue to be debated and are far from consensus as mentioned by the Task Force.