Graduate Medical Education System Research Articles

Residency Training and International Medical Graduates

Residency Training and International Medical Graduates

Teaching Health Centers

The Patient Protection and Affordable Care Act of 2010 created the Teaching Health Center Graduate Medical Education (THCGME) program to provide graduate medical education (GME) funding directly to community-based health centers that expand or establish new primary care residency programs. The THCGME program was the legislation's only new investment in GME, and it represents a significant departure from the Medicare GME funding system. It provides payments to ambulatory care centers for both direct and indirect GME expenses, and mandates a level of reporting from recipients that is not required for Medicare GME support. This initial look at the 11 inaugural teaching health centers (THCs) shows that they are training primary care residents in relevant delivery models (e.g., interprofessional teams, patient-centered medical homes), developing educational initiatives that address primary care practice in underserved areas, and transforming organizational and funding structures to support community-based training. The THCs plan to evaluate and report resident performance, patient quality of care, and graduate outcomes. The work of the first THCs has implications for primary care training, the GME system, and future policies and legislation aimed at strengthening the health care workforce.

A Study on the Improvement of the Medical Education System in Korea Since 1999

The main purpose of this study is to examine the improvement and discourse of the medical education system in Korea since 1990. In particular, this study, focusing on the graduate medical education system initiated in 2002, has explored the discussions that led to the system’s establishment and what the context of those discussions. To meet this objective, this study analyzed research report related to the medical education system authored by members of the government and medical community, suggestions to the government, discussion materials, and data with regard to the Medical (Dental) Education Eligibility Test. The improvement of the medical education system in Korea has been an important issue in education reform by the expansion of the number of years of higher education, the requirements for increased levels of professional knowledge by improving public educational standards, and the basic formation policy of higher education consisting of graduate school, special graduate school, and professional graduate school. Nevertheless, the views of the government and the medical community on improving medical education system have made an obvious difference. This was due to different aims about how to improve the medical education system and different perception of the degree and medical education system. The medical community at least tended to prefer the status of academic positions over professional positions. The policy of medical education for people with a bachelor’s degree which was introduced in 2002 spread to many colleges of medicine based on the government’s administrative and financial support policy. Even so, the absence of accompanying policy by the relevant government agencies and department of education, which could have ensured the success of the system, has led to continued debate. In conclusion, without a consistent and persistent government policy, the graduate medical education system has led to confusion in many medical institutions. Above all, an evidence-based policy decision and policy approach based on a long-term perspective are necessary in order to improve the medical education system.

Commentary: Meeting Future Medical Care Needs: A Perfect Storm on the Horizon

Recent studies indicate that the number of first-year residency positions must increase to meet the United States' projected need for physicians, but these studies rarely consider whether it will be possible to increase the country's graduate medical education system to meet the need. State-level studies suggest that most existing programs have already reached their approved capacity, and nonteaching hospitals are unlikely to create new programs because of the financial impact and their lack of faculty and staff who would meet accreditation standards as program directors and institutional officials. A perfect storm is therefore brewing: The effects of the Patient Protection and Affordable Care Act of 2010, the obesity epidemic, the rise in chronic disease, and the aging and continuing growth of the population will combine to create a much greater demand for medical services at the same time as the relative size of the physician workforce will begin to decline. Given the urgency of the situation, the author calls for medical professionals (with significant representation from the academic medicine community) to enter into meaningful partnerships with state and federal officials to develop strategies for addressing this challenge. They must work together to increase the number of entry-level positions to the level needed to produce the doctors required to meet the growing demand for medical care. Otherwise, the perfect storm will soon disrupt the U.S. health care system.

Further restrictions on resident duty hours

Imagine you were creating a system of graduate medical education from scratch. If someone proposed a plan calling for the least experienced physicians to stay awake for 36 hours or more at a stretch, with no on-site supervision during periods of maximal sleep deprivation, you would probably be skeptical. Even strict adherents of Nietzsche's dictum that “What doesn't kill me makes me stronger” would have a hard time arguing that such a system optimizes patient care. Increasing recognition of the consequences of sleep deprivation prompted the 2003 Accreditation Council for Graduate Medical Education (ACGME) guidelines restricting resident duty hours.1 Unfortunately, we do not have the luxury of developing residencies from scratch. Academic medical centers have come to rely on the work that residents perform during their long shifts. The ACGME mandate to limit resident duty hours was not accompanied by a proportional increase in the number of residents, so other physicians and medical professionals were compelled to take up the slack. Furthermore, briefer shifts meant more “hand-offs” and greater potential for miscommunication and other errors. In short, duty hour restrictions have negative consequences as well as positive ones, and it is legitimate to ask whether the benefits outweigh the costs. In 2007, at the request of Congress, the Institute of Medicine (IOM) formed a consensus committee to examine the relationship between resident duty hours and patient safety.2 The committee's report was formidable, spanning 338 pages, with …

Commentary: Flexner Redux 2010: Graduate Medical Education in the United States

The author posits that if Abraham Flexner could be brought back to write a report to address the same question that his 1910 report answered-How are doctors being prepared for practice?-he would not focus on the state of medical students' education, because today's medical students no longer enter practice on graduation from medical school. Instead, he would ask how the country's graduate medical education (GME) system is preparing residents for clinical practice. Such a report is needed because (as concluded by a variety of sources, including recent reports by the Institute of Medicine) GME training must be changed as part of the effort to improve medical care quality. Despite this finding, professional organizations that regulate how GME is designed and conducted have been unwilling to make substantive changes in the ways residents are being prepared for practice. The author reviews the reasons for this, emphasizes the need for a new Flexner-type report to make the public aware of the training deficiencies so the public could exert pressure on government officials to take action, describes groups that have already recognized the problem and proposed solutions (such as having individual programs held accountable for their residents' performance in practice), and makes recommendations, such as (1) having the Medicare program, the single largest payer of GME costs, require certain needed reforms in residents' training, and (2) modernizing state laws so that residents completing training would have to demonstrate that they are adequately prepared to enter practice before being granted licenses.

Collision Course: The Privatization of Graduate Medical Education at One University

On December 18, 2003, Tenet Healthcare Corporation, an investor-owned hospital corporation, announced the closure of Medical College of Pennsylvania Hospital, a historic institution that was home to many of Drexel University College of Medicine's (DUCOM's) faculty, residents, and medical students. The authors summarize the steps that were taken and lessons learned to avoid a disruption in the education of over 200 residents. The authors highlight the response by the medical school; the concerns of the Accreditation Council for Graduate Medical Education (ACGME); the interaction between the Center for Medicare and Medicaid Services (CMS) and the ACGME; the importance of the designated institutional official (DIO) in a crisis situation; and the role of residents as students versus employees when their employer wishes to move or "trade" them to another institution. Through the lens of the DUCOM experience, the authors explore the legal, political, and educational conflicts that occur when an investor-owned company or private hospital employs residents but another entity holds moral and academic accountability for their future. Finally, the authors outline five lessons learned: (1) the important role the ACGME plays as the educational conscience of graduate medical education (GME), (2) the dramatically different roles that the ACGME and the CMS play in regulating and funding the national GME system, (3) the need for constant communication with the affected residents, (4) the important role that the DIO plays in GME, and (5) the need for medical school leaders to remain focused on their educational mission and responsibilities to young physicians.

Surgical training in the United States

Surgical education in the United States has developed along with the graduate medical education (GME) system. Changes in health care delivery and payment systems, changes in the practice and specialisation of surgery, attempts to improve the system of graduate medical training and even generational changes among those entering surgical training have influenced and changed the way surgeons are trained in the US. Although a thorough examination of these factors and their influence on surgical training is beyond the scope of this brief review, some of these influences and our current surgical training system will be described.

The Predicament of Osteopathic Postdoctoral Education

The growth of colleges of osteopathic medicine (COMs) during the past 20 years has been a catalyst for change and has created new challenges in osteopathic medicine. None of these challenges is more daunting than the task of sustaining an osteopathic graduate medical education (OGME) system that has suffered during this period of rapid development. Notable trends within the osteopathic medicine community since 1990 include allopathic residency programs obtaining OGME accreditation, COM graduates bypassing OGME, repeated major changes in American Osteopathic Association (AOA) accreditation policies, a growing dependence on Accreditation Council for Graduate Medical Education programs to train osteopathic graduates, and a lessening of options for the AOA to effectively direct its OGME system. The predicament is whether COMs can continue to grow without resulting in the demise of the OGME system and a loss of professional identity.

ANALYSES/LITERATURE REVIEWS: Evaluating Competence Using a Portfolio: A Literature Review and Web-Based Application to the ACGME Competencies

Background: The Accreditation Council for Graduate Medical Education is shifting its focus from a structure and process system of graduate medical education to one that is outcomes based, requiring all residents in training to achieve competence in six broad domains and presenting educators with the challenge of evaluation. Summary: We searched the literature and reviewed all articles relating to portfolio assessment in medicine. In addition, we reviewed articles that addressed standard tools currently in use for resident performance assessment. The use of a portfolio allows one to incorporate a variety of assessment tools needed to evaluate the diverse domains of competence and also fosters reflective learning, which is key to professional development. From lessons learned through this review, we developed a Web-based evaluation portfolio for residency training that we describe here in the hope of facilitating this process for others. Conclusions: Web-based portfolio assessment provides an ideal venue for the evaluation of competence and has the ability to provide educators with a research infrastructure to practice evidence-based education.

Jung v. Association Of American Medical Colleges: the lawsuit challenging our system of graduate medical education

This article examines the antitrust case in which three physicians have challenged the Match Program and various other aspects of the system of graduate medical education in the United States. After describing the parties to the litigation, the author explains the plaintiffs’ theories of liability. He suggests how the plaintiffs are likely to claim damages in the multibillion dollar range and speculates about the injunctive relief that the plaintiffs are likely to seek. The author then sets forth some of the principal defenses to the case, as well as the basis for the defendants’ position that the plaintiffs have not been injured at all. The author goes on to explore developments that have occurred since the lawsuit was filed on May 7, 2002. These include a motion by the National Residency Matching Program to refer the case to arbitration; motions by certain teaching hospital defendants asserting that they are not subject to suit in the District of Columbia; and motions by the American Medical Association, the Accreditation Council for Graduate Medical Education, and other organization defendants to the effect that the plaintiffs have not alleged conduct by them that violates the antitrust laws. The author then discusses the motion by the plaintiffs to have the case certified as a class action. Finally, he considers legislative initiatives that the litigation has engendered.

Resident Training and Education in the United States

Critical institutional and organization issues affect the education of pediatricians, influence their knowledge about child health disparities, and shape their attitudes and approaches to community pediatrics. Understanding the US graduate and postgraduate medical education system is necessary if critical and sustainable changes are to be made to ensure the capacity of pediatricians to respond to critical contemporary determinants of child health.

US Graduate Medical Education, 1996-1997

Workforce planners continue to be concerned that unlimited growth in graduate medical education (GME)-principally fueled by unrestrained federal support-will lead to a physician surplus. Because of this concern, in 1996 six major professional organizations called for a reduction in Medicare support of GME to bring residency training programs into more rational alignment with population needs. As of July 1, 1997, no final action had been taken by Congress to limit GME funding, although extensive discussions are under way. Even without governmental restrictions, the American Medical Association's annual survey of GME programs showed a reduction in the numbers of first-year residents in most major specialties and subspecialties. Minor reductions were initially noticed last year; now, the decreases are significant. Nearly all the specialties that had difficulty placing their graduates for 2 consecutive years also reported at least 10% fewer first-year residents than in 1994. More importantly, disciplines without employment difficulties also reported downsizing. The overall effect of these first-year reductions is easily masked by the addition of programs in new disciplines and some residents staying in the GME system longer. Entry-level reductions appear to be broader and more extensive than can be explained by market forces alone.

The kaleidoscope of general internist careers

As internal medicine residency programs struggle to produce general internists in greater numbers and assure that they are adequately prepared for practice, it is imperative that the graduate medical education system have a clear picture of what competencies will be expected of those entering general internist careers. Feedback from the practicing community and large managed care organizations in Minnesota has made it clear that general internists in that state are functioning in a variety of positions requiring a wide range of skills depending on the practice description, choice of practice setting, and the complement of other primary care providers. General internists functioning in nontraditional careers have special curricular needs. It is imperative that training programs constantly monitor the changing practice environment and stay current on the variety of new generalist career choices to adequately prepare their residents for generalist careers. The graduate medical education enterprise needs to be involved in determining the best teaching strategies for the broad range of ambulatory general medicine competencies and in determining how best to preserve the richness of the medical subspecialty experience critical to the training of excellent general internists.

The Role of Medical Schools in Graduate Medical Education

THIS ISSUE ofThe Journalcontains a considerable amount of information about the country's graduate medical education (GME) system and about the resident physicians enrolled in GME programs (Appendix II, page 725). The data in Appendix II document clearly the size and complexity of the GME enterprise and the fact that both the total number of resident physicians and the number on duty in first-year positions increased in 1993. The unremitting growth in the aggregate number of resident physicians enrolled in GME programs, in association with what is viewed as an imbalance in the specialty mix of those programs, has led policymakers once again to express concerns about the adverse impact the GME system has on the size and specialty composition of the physician workforce. These concerns are not new nor are the strategies being proposed to address them. See also p 725. During the past 20 years, the federal

Graduate medical education reform. Service provision transition costs

<h3>Objective.</h3> —To analyze the potential strategies and costs of house staff substitution under a reformed system of graduate medical education. <h3>Design.</h3> —An economic model using two scenarios for substitution of house staff (residents and fellows): (1) a lower-cost model under which nonphysician providers assume many house staff responsibilities, but additional aspects of their workload are taken over by staff physicians, nurses, and ancillary personnel; and (2) a higher-cost traditional model that relies more heavily on staff physicians to replace house officers. <h3>Setting.</h3> —US teaching hospitals. <h3>Main Outcome Measures.</h3> —Projected net substitution costs of house staff on a per full-time equivalent basis and aggregate national cost estimates of substitution. <h3>Results.</h3> —Net annual house staff substitution costs were estimated to be $58000 and $77000 per replaced full-time equivalent house officer, respectively, under the two scenarios. Assuming elimination of approximately 23200 house staff under a reformed system, total (net) substitution costs to teaching hospitals were estimated at approximately $1.4 billion to $1.8 billion nationally on an annual basis. <h3>Conclusions.</h3> —Graduate medical education reform, while likely to result in substantial long-term cost savings, will necessitate transitions in service provision that are likely to generate some new costs in the short term. (<i>JAMA</i>. 1994;272:53-58)

Graduate Medical Education in the Changing Environment of Medicine

THE US graduate medical education system has been strongly criticized by policymakers and by private and public agencies for not being responsive to the population's health needs. Comments usually focus on the unwillingness of the accreditation and education systems to generate the proper mix of specialties and to influence a more equitable geographical distribution of physicians. No one disputes the inadequacy of the distribution of medical specialties, particularly in the medical care of underserved populations, but to blame solely the graduate medical education and accreditation systems is to ignore the absence of population-based planning for health services—a governmental responsibility—and the important, though lesser, contributions of other medical education components. Education, accreditation, licensure, certification, and practice, although interrelated, are all directed by different organizations. Changes in only one or two of these components will never be sufficient to solve the health manpower problems of the health care delivery system, which would

The Organization and Financing of Graduate Medical Education in Canada

IN THE mid-1970s, US government officials and other health policymakers began expressing concerns about the impact of physician maldistribution, both by specialty and by location, on the provision of medical care. 1-3 Government committees were established to study the problem and determine how the organization and financing of the nation's graduate medical education (GME) system was a contributing factor. 4,5 Stimulated by the government's interest, professional organizations and foundations sponsored independent studies of the relation between physicians' choice of specialty and location and the organization of GME. In general, these groups concluded that the policymakers' concerns were legitimate and the imbalances could not be effectively redressed without changing the way GME is organized and financed. 6-8 Although many in the medical profession agree that the policymakers' concerns are legitimate, there is still no concensus within the profession as to how the GME system should be reformed to improve physician specialty

Evaluating policy change in physician manpower planning.

The decade of the 1980s witnessed a revitalization of free-market interest in the use of incentives and voluntary participation to promote activities in a wide range of fields. Because of its history of decentralized control over physician residency training, the state of New Jersey found such an approach appealing when it sought to restructure its graduate medical education system. Two statewide task forces spent a year developing policy changes designed to produce voluntary changes in such areas as the size and growth of the state system. However, a 2-year follow-up survey of the directors of state residency programs revealed little perceivable change.

The Challenging Future of Medical Education

The decade of the 1980s has brought serious and diverse challenges to medical education. All of these challenges are due to unprecedented changes in medical knowledge and practice. Many of the pressures for change are external to medicine itself, with an increase in public demand for selfdiscipline and accountability. Other pressures such as the increased number of medical students and medical schools in the 1970s, the long-term impact of which is now being felt, are due to health care policies that misfired. An overloaded system of graduate medical education and the commercialization and fragmentation of continuing medical education (CME) programs are also creating smoldering new fires that require innovative management approaches and solutions. In the following pages of this issue ofTHE JOURNAL, American Medical Association staff present data documenting some of these concerns. Perhaps the single most important challenge for medical education at this time is to develop approaches