Graduate Medical Education Training Programs Research Articles

Financial Incentive, in Place of Nonclinical Time, Increases Faculty Involvement and Improves Resident Didactic Evaluation Scores in an Anesthesiology Residency Training Program

Providing clinical faculty to lead high-quality resident didactic sessions remains a challenge for academic departments that host graduate medical education training programs. In an effort to both reduce costs and to continue to recruit faculty to give lectures, our department began to incentivize clinicians with a $500 stipend in place of a nonclinical day to present didactics. Our hypothesis is that with financial incentive, more attendings would present didactics and the quality would improve. Residents routinely evaluate all didactic sessions using a Likert scale of 1 to 5. Residents also answer yes or no to indicate whether the presenter should return. We compared academic year (AY) 2016, in which faculty were incentivized with nonclinical time, with AY 2017 and AY 2018, in which incentive came in the form of a $500 stipend. For each, the mean Likert score and percentage of positive responses for lecturer returning were calculated. A 1-way ANOVA and post hoc t tests were performed to determine significant changes. Comparing AY 2016 (before the incentive switch) with AY 2017 and AY 2018, there was more faculty involvement in resident didactic after implementing the financial incentive. The quality of lectures also improved after the incentive switch, according to resident evaluations. There were higher overall Likert scores in AY 2018 and a higher percentage of positive responses to the question of whether presenters should return in AY 2017 and AY 2018, compared with AY 2016. After implementation of a financial incentive in place of nonclinical time, more faculty became involved in lectures and overall lecture quality improved as measured by resident evaluations.

Seeing Is Believing: How Social Media Is Challenging Physician Stereotypes.

Seeing Is Believing: How Social Media Is Challenging Physician Stereotypes.

Integrated residency is associated with an increase in women among vascular surgery trainees

BackgroundDuring the past decade, the proportion of women within graduate medical education has increased. Correspondingly, the proportion of women in almost every specialty has increased, including surgical specialties. We sought to evaluate the effect of establishing vascular surgery integrated residencies (VSIRs) on the proportion of women in vascular surgery training programs. MethodsResident data were obtained from the Accreditation Council for Graduate Medical Education (ACGME) Data Resource Book for the academic years 2007 to 2016. Data were collected on overall ACGME residency numbers as well as on the following surgical subspecialties: vascular, general, thoracic, neurologic, orthopedic, otolaryngologic, and urologic surgery. The number and proportion of women per year in VSIRs and vascular surgery fellowships were compared with those in the other surgical specialties. ResultsDuring the study period, the proportion of women in ACGME-accredited residency programs increased from 0.41 (n = 43,695/107,851) to 0.44 (n = 57,130/129,720) of residents. Since the advent of the VSIR, the number of trainees within vascular surgery has increased by 56% from 221 to 501 trainees. The proportion of women in vascular surgery training programs has increased from 0.12 (n = 27/221) to 0.33 (n = 164/501) of trainees. This increase during the 9-year study period was greater than in any other surgical subspecialty and greatest within the VSIR. Compared with fellowship training programs, integrated surgical training programs within the same subspecialty had a higher proportion of women, although variability between surgical subspecialties remained notable. ConclusionsAlthough it is lower than the proportion of women within all graduate medical education training programs, an increasing proportion of women have entered vascular surgery training during the study period. This appears to be related to the introduction of VSIRs and exceeds the proportion of women entering almost all other surgical subspecialties at a rate of change faster than in all other surgical subspecialties. Further work to understand surgical specialty preferences and choice of careers after training is warranted.

The Implications of the Current Visa System for Foreign Medical Graduates During and After Graduate Medical Education Training.

The current and projected deficit in the physician workforce in the US is a challenge for primary care and specialty medical settings. Foreign medical graduates (FMGs) represent an important component of the US graduate medical education (GME) training pathway and can help to address the US physician workforce deficit. Availability of FMGs is particularly important to the internal medicine community, as recent data demonstrate that internal medicine is the specialty with the highest number of FMGs. System-based and logistical inefficiencies in the current US visa system represent significant obstacles to FMG trainees and have important psychological, emotional, and logistical consequences to FMG engagement and participation in US GME training and in the post-training workforce. In this article, we review the contemporary structure, process, and challenges of obtaining a visa for GME training. The H1B and J1 visa programs are compared and contrasted, with an emphasis on logistical specifics for FMG GME trainees and training programs. The process of and options for J1 visa waivers are reviewed. These considerations are specifically reviewed in the context of recent policy decisions by the Trump administration, with emphasis on the effects of these decisions on FMGs in medical training and practice.

The Prevalence of Faculty Physician Burnout in Military Graduate Medical Education Training Programs: A Cross-Sectional Study of Academic Physicians in the United States Department of Defense.

In military populations, physician burnout has potential to adversely affect medical readiness to deploy in support of joint operations. Burnout among Graduate Medical Education (GME) faculty may further threaten the welfare of the medical force given the central role these officers have in training and developing junior physicians. The primary aim of this investigation was to estimate the prevalence of burnout among faculty physicians in United States (US) Army, Navy, and Air Force GME programs. We conducted a cross-sectional study of faculty physicians at US military GME training programs between January 2018 and July 2018. Through direct coordination with Designated Institutional Officials, we administered the Maslach Burnout Inventory Health Services Survey (MBI-HSS) via online web link to faculty physicians listed in Accreditation Data System at each sponsoring institution. In addition to the MBI-HSS, we collected demographic data and queried physicians about common occupational stressors in order to assist institutional leaders with identifying at-risk physicians and developing future interventions to address burnout. Sixteen of 21 institutions that currently sponsor military GME programs agreed to distribute the MBI-HSS survey to core faculty. We received completed assessments from 622 of the 1,769 (35.1%) reported physician core faculty at these institutions. Of the 622 physician respondents, 162 demonstrated high levels of emotional exhaustion and depersonalization for an estimated 26% prevalence of burnout. We identified only one independent risk factor for burnout: increasing numbers of deployments (OR 1.38, 95% CI 1.07-1.77). Physicians in our cohort who reported a desire to stay beyond their initial active duty service obligation were less likely to be classified with burnout (OR 0.45, 95% CI 0.26-0.77). The most common drivers of occupational distress were cumbersome bureaucratic tasks, insufficient administrative support, and overemphasis on productivity metrics. We estimate that 26% of physician faculty in military GME programs are experiencing burnout. No specialty, branch of service, or specific demographic was immune to burnout in our sample. Institutional leaders in the MHS should take action to address physician burnout and consider using our prevalence estimate to assess effectiveness of future interventions.

A Sustainable and Effective Mentorship Model for Graduate Medical Education Programs.

Mentorship models rarely seek generalizability across training programs at the graduate medical education (GME) level. We examined the sustainability and effectiveness of an intervention to increase the number and usefulness of trainee mentorship. A 0.20 full-time equivalent GME faculty adviser position (MD, MEd) implemented mentorship programs in residencies and fellowships. In group 1, 6 GME programs implemented the mentorship strategies prior to 2014, which were used to measure whether the number of mentor relationships were longitudinally sustained. In group 2, 10 different GME programs implemented the mentorship strategies in 2016, which were used to measure whether the intervention immediately increased the number of mentor relationships. To measure mentorship usefulness, trainees rated mentors' ability to promote clinical skills and personal and professional development. The remaining programs were the comparison. Responses from the 2014 and 2016 annual institutional trainee survey were analyzed. The incidence of group 1 reporting mentor relationships in 2014 compared to the incidence of group 1 in 2016 were 89% (41 of 46) and 95% (42 of 44), respectively, suggesting that the intervention was sustained for 2 years (P = .26). Group 2 showed a higher proportion of trainees reporting mentors in 2016 (88%, 149 of 170) compared to preintervention (66%, 71 of 108; P = .00001). Groups 1 and 2 reported significant increases in mentorship usefulness. A GME initiative to enhance mentoring across specialties in 16 GME training programs was self-sustaining and effective.

Starting Line for Scholarly Activity in New Residency Programs: Lessons Learned for Institutional Success

BackgroundOne focal point of Graduate Medical Education (GME) is scholarly activity and its integration into clinical practice by evidence-based learning. Program directors and educational leaders view scholarly work as the foundation for continuing resident education; however, the high demand of scholarly activity can be cumbersome for newly accredited residency programs. MethodsWe reviewed all scholarly activity over a 2-y period (2015-2017) involving three new GME programs at a single institution (internal medicine, surgery, and transitional year). A voluntary anonymous online survey was distributed to all residents to assess their perceptions and expectations regarding research, review prior research experience, and analyze any barriers or successes within the research program. ResultsThe survey was distributed to 61 residents with a response rate of 59% (36/61), including postgraduate years 1-5. Respondent demographics included males (55.6%), ages 26-30 y (63.9%), and respondents commonly being postgraduate year–1 (58.3%) level. In total, 171 scholarly activities were recorded. Survey review of resident basic research knowledge, concepts, and experience included preresidency research (91.7%), prior scholarly activity (79.2%), and interest to meet career goals (66.7%). Barriers or delays in research were lack of structured curriculum (50%), technical support (45.8%), research experience (37.5%), and interest (33%). ConclusionsNewly accredited GME training programs can avoid an unnecessary institutional deficiency in scholarly activity by developing a structured and comprehensive research curriculum. Resident engagement, developing a mentor-mentee relationship, and research experience before residency can allow a successful research program.

Defining the Content for a Quality and Safety in Surgery Curriculum Using a Nominal Group Technique

There is growing awareness of the need to provide surgical residents with training in quality and safety. Previous studies have revealed a need for a formal curriculum, but the content and structure of such a curriculum has not been defined. Our objective was to develop a surgery resident curriculum using a consensus, team-building approach. This study consisted of moderated, structured focus groups using a nominal group technique to guide discussion. Participants generated rank lists of topics to be included and answered questions regarding structure and design of teaching and assessment modalities. Two separate focus groups among 9 surgical residents and 10 faculty experts in quality and safety were held in conjunction with the American College of Surgeons Quality and Safety Conference in July 2017. A total of 16 institutions were represented. A total of 35 topics were initially proposed by the resident group and a total of 41 topics were proposed by the expert group. After discussion, each group reached consensus on a final list of 9 topics. Most topics in the final lists fell into the broad areas of improvement science and nontechnical skills. Residents indicated that most topics were, on average, poorly covered by their current training program, however, a wide range was noted within each topic. Faculty indicated a preference for didactic instructional methods and assessment using multiple-choice questions. Quality and safety are integral components of surgical training. Learners and experts agreed that topics within the domains of improvement science and nontechnical skills should be included in a formal curriculum. Learners reported wide variation on how well these topics are currently included in graduate medical education training programs.

Workforce Analysis of Spine Surgeons Involved with Neurological and Orthopedic Surgery Residency Training

Spinal surgery is taught and practiced within 2 different surgical disciplines: neurological surgery and orthopedic surgery. We have provided a unified analysis of spine-focused faculty at U.S. residency programs. A total of 278 Accreditation Council for Graduate Medical Education training programs were assessed to identify 923 full-time faculty members with a spinal surgery designation, defined by spine fellowship training or surgeon case volume >75% spine surgeries. Faculty were assessed with respect to parent discipline, years of fellowship training, academic rank, gender, and academic productivity (h-index). The spine-teaching workforce contains 55% orthopedic surgeons and 45% neurosurgeons with wide gender asymmetry overall and at all faculty ranks. Of the female spine surgeons, those with neurosurgical training (64.44%) nearly doubled the number with orthopedic training (35.56%). Academic productivity increased with academic rank similarly for both genders and subspecialties. Orthopedic spine surgeons had a greater mean fellowship number compared with the neurological spine surgeons. Fellowship time of completion (intraresidency/infolded vs. postresidency) did not significantly affect the h-indexes. Addition of fellowship conferred academic productivity benefit for orthopedic surgeons only. Neurological and orthopedic spine surgery showed similar patterns for the spread of faculty across academic ranks and trends in academic productivity. Marked gender disparity was seen in both neurosurgical and orthopedic surgery, with fewer female spine surgeons seen at every academic rank. Orthopedic spine surgeons had a greater mean fellowship number than did their neurosurgical counterparts, and a lack of fellowship correlated with lower academic productivity in orthopedic, but not neurological, spine surgery.

Academic Productivity of Spine Surgeons at United States Neurological Surgery and Orthopedic Surgery Training Programs

Spinal surgery is taught and practiced within 2 different surgical disciplines, neurological surgery and orthopedic surgery. We have provided a unified analysis of academic productivity measured using the h-index attributable to spine-focused faculty at U.S. residency programs. A total of 278 Accreditation Council for Graduate Medical Education training programs were assessed to identify 923 full-time faculty members with a spinal surgery designation, as defined by spine fellowship training or case volume >75% in spine surgery. The faculty were assessed with respect to academic rank, duration of practice in years, and academic productivity (h-index). The comparison showed a significantly greater mean h-index for neurological spine surgeons. The mean h-index for both disciplines increased significantly as faculty rank increased. Within the academic ranks of assistant and associate professor, neurological spine surgeons had significantly greater mean h-indexes. Neurological spine surgeons had a significantly lower practice duration. At all ranks except for assistant professor, the mean practice duration was not significantly different statistically between the neurological spine and orthopedic spine surgeons. A positive correlation between the h-index and practice duration was found for both spine surgical disciplines. The proportional odds models for neurological and orthopedic spine surgeons were moderately successful at predicting faculty rank according to the h-index. We present a unified view of academic productivity as measured by the h-index among neurosurgical and orthopedic surgery spine faculty, with some noticeable differences. These results can be used for benchmark purposes to assess the relative productivity of its faculty and could be of interest to those pursuing academic opportunities in spine surgery.

Integrated Residency Is Associated With an Increase in Women Among Vascular Surgery Trainees

During the past decade, the proportion of women within graduate medical education (GME) has increased. Correspondingly, the proportion of women in almost every specialty has increased, including surgical specialties. We sought to evaluate the effect of establishing vascular surgery integrated residencies (VSIRs) on the proportion of women in vascular surgery (VS) training programs. Resident data were obtained from the Accreditation Council for Graduate Medical Education (ACGME) Data Resource Book for the academic years 2007 to 2016. Data were collected on overall ACGME residency numbers as well as on the following surgical subspecialties: vascular; general; thoracic; neurologic; orthopedic, ear, nose, and throat; plastic; and urologic. The number and proportion of women per year in VSIRs and VS fellowships were compared with those in the other surgical specialties. During the study period, the overall number of women in ACGME-accredited residency programs increased from 41% (n = 43,695/10,7851) to 44% (n = 57,130/129,720) of residents. Since the advent of the VSIR, the number of trainees within VS has grown by 56% from 221 to 501 trainees. The proportion of women in VS training programs has increased from 12% (n = 27/221) to 33% (n = 164/501) of trainees. This increase during the 9-year study period was greater than in any other surgical subspecialty and greatest within the VSIR. Compared with fellowship training programs, integrated surgical training programs within the same subspecialty had a higher proportion of women, although variability between surgical subspecialties remained notable. Although it is lower than the proportion of women within all GME training programs, an increasing proportion of women have entered VS training during the study period. This appears to be related to the introduction of VSIRs and exceeds the proportion of women entering other surgical, subspecialties. Further work to understand surgical specialty preferences and choice of careers after training is warranted.

Are Michigan State University medical school (MSU-CHM) alumni more likely to practice in the region of their graduate medical education primary care program compared to non-MSU-CHM alumni?

BackgroundOver the past 10 years, three new MD schools have been created in the state of Michigan, while the Michigan State University College of Human Medicine (MSU-CHM) has increased their class size to 850 students. The aim of this study was to determine if MSU-CHM alumni who graduate from an MSU-affiliated primary care residency from a single graduate medical education (GME) training program in Michigan are more likely to go on to practice in close proximity to the location of their training program immediately after graduation compared to non MSU-CHM alumni. Changes over time in the proportion of primary care graduates who received fellowship training immediately following residency were also compared between these groups.MethodsA review of historical data was performed for all 2000–2016 primary care (Family Medicine, FM; Internal Medicine, IM; Internal Medicine-Pediatrics, IMP; Pediatrics, Peds) program graduates sponsored by Grand Rapids Medical Education Partners (GRMEP). Study variables included primary care program, gender, age at graduation, fellowship training, practice location immediately after graduation and undergraduate medical education location. Summary statistics were calculated for the data. Comparisons were made using the chi-square test or Fisher’s Exact test when appropriate. Significance was assessed at p < 0.05.ResultsThere were 478 primary care program graduates who went into practice immediately following graduation, 102 of whom also graduated from MSU-CHM. Just over half of the graduates were female and the average age at graduation was 32 years. There were 152 FM, 150 IM, 50 IMP and 126 Peds graduates. Those that graduated from both MSU-CHM and GRMEP were more likely to practice in Michigan immediately after residency training (79.4% vs 52.0%; p < 0.001), as well as within 100 miles of GRMEP (71.6% vs 46.4%; p < 0.001). There were 8% of MSU-CHM primary care graduates who went on to fellowship training from 2000 to 2009, increasing to 34% from 2010 to 2016 (p < 0.001).ConclusionMedical school graduates of MSU-CHM who receive GME training in primary care are more likely to practice medicine within close proximity to their training site than non MSU-CHM graduates. However, plans for fellowship after training may add one caveat to this finding.

Simulation based medical education in graduate medical education training and assessment programs

The healthcare system has an inconsistent record of ensuring reliable and safe patient outcomes. One of the main factors contributing to this poor record is inadequate and unreliable interdisciplinary team behavior. Learning how to function within an interdisciplinary team must begin early in medical training. Simulation based medical education (SBME) is an essential part of graduate medical education (GME) training, the acquisition of core competencies and their assessment. In this paper, we describe SBME as it relates to learning and professional maturation. We describe the use of simulation in GME training, link simulation to the ACGME professional core competencies, present examples of simulation assessment methods, and explore simulation as part of board certification and professional life long learning. We discuss the important benefits of simulation for hospitals and patient safety. We summarize the literature on cost effectiveness of simulation in education and the growing evidence that SBME translates to improvements in communication, teamwork and clinical care and the overall improvement of healthcare. We discuss the challenges and costs required to develop a successful simulation and training center, lab or in-situ program. We discuss the return on investment of SBME as it relates to patient safety, cost savings, and improved patient care. Hospitals should embrace simulation based medical education and support the development of simulation centers so that SBME becomes an integral part of the hospitals' mission to provide patients with the best care possible.

Physician Retention in the Same State as Residency Training: Data From 1 Michigan GME Institution.

In a time of threats to the funding for graduate medical education (GME) and projected physician shortages, drawing attention to the value of physician training programs may be useful. One approach is to study the number and percentage of physicians who enter practice in the state in which they trained. We sought to examine the percentage of graduates from a single Michigan-based GME institution over a 15-year period, who practiced medicine in Michigan during their career. We performed a retrospective review of historical data for all graduates currently in practice, derived from 18 GME training programs from 2000 through 2014. Practice location data were collected and confirmed using multiple sources for accuracy. Data were available for 1168 graduates. The average age at the time of graduation was 32.6 ± 4.4 years (mean and standard deviation [SD]), and 60.2% were men (703 of 1168). There were 546 graduates (46.7%) who practiced in Michigan after graduation. Almost 80% of the graduates (279 of 358) who completed medical school and GME in Michigan also practiced in Michigan. Of those, 87.8% (245 of 279) also completed a bachelor's degree in Michigan. The findings show that graduates from our GME programs were highly likely to practice in Michigan if they completed their pre-GME education in Michigan.

Transforming the Academic Faculty Perspective in Graduate Medical Education to Better Align Educational and Clinical Outcomes.

The current health care delivery model continues to fall short in achieving the desired patient safety and quality-of-care outcomes for patients. And, until recently, an explicit acknowledgment of the role and influence of the clinical learning environment on professional development had been missing from physician-based competency frameworks. In this Perspective, the authors explore the implications of the insufficient integration of education about patient safety and quality improvement by academic faculty into the clinical learning environment in many graduate medical education (GME) programs, and the important role that academic faculty need to play to better align the educational and clinical contexts to improve both learner and patient outcomes. The authors propose a framework that closely aligns the educational and clinical contexts, such that both educational and clinical outcomes are centered around the patient. This will require a reorganization of academic faculty perspective and educational design of GME training programs that recognizes that (1) the dynamic interplay between the faculty, learner, training program, and clinical microsystem ultimately influences the quality of physician that emerges from the training program and environment, and (2) patient outcomes relate to the quality of education and the success of clinical microsystems. To enable this evolution, there is a need to revisit the core competencies expected of academic faculty, implement innovative faculty development strategies, examine closely faculty's current clinical super vision practices, and establish a training environment that supports bridging from clinician to educator, training program to clinical microsystem, and educational outcomes to clinical outcomes that benefit patients.

Association of Characteristics, Deficits, and Outcomes of Residents Placed on Probation at One Institution, 2002–2012

To describe the population of residents placed on probation, identify learner characteristics associated with being placed on probation, and describe immediate and long-term career outcomes for those placed on probation as compared with matched controls. The authors collected data for residents at the University of Colorado School of Medicine placed on probation from July 2002 to June 2012, including postgraduate year placed on probation, deficits identified, mandated evaluation for physical and mental health, duration of probation, disability accommodations requested, and number of additional training months required. They were retrospectively compared with 102 controls matched for specialty, matriculation, and postgraduate year. Variables assessed included demographics, academic performance, license status, specialty, state board certification, and board citations. Of 3,091 residents, 3.3% were placed on probation (88 residents; 14 fellows). Compared with controls, those on probation were more likely to be international medical graduates, married, not Caucasian, older (all P < .001), male (P = .01), to have transferred from another graduate medical education training program, and to have taken time off between medical school and residency (all P < .001). Among those currently in practice, 53 (63.9%) were board certified compared with 93 (100%) of the controls. Placement on probation was associated with failure to graduate and lack of board certification. All 7 graduates cited by state medical boards were in the probation group. Further research is needed to understand these associations and to determine whether changes in curricula or remediation programs may alter these outcomes.

Trauma, Critical Care, and Emergency Care Anesthesiology: A New Paradigm for the "Acute Care" Anesthesiologist?

Trauma, Critical Care, and Emergency Care Anesthesiology: A New Paradigm for the "Acute Care" Anesthesiologist?

The Future of Graduate Medical Education: A Systems-Based Approach to Ensure Patient Safety.

In the past 15 years, there has been growing recognition that improving patient safety must be more systems based and sophisticated than the traditional approach of simply telling health care providers to "be more careful." Drawing from his own experience, the author discusses barriers to systems-based patient safety initiatives and emphasizes the importance of overcoming those barriers. Physicians may be slow to adopt standardized patient safety initiatives because of a resistance to standardization, but faculty in training institutions have a responsibility to model safe, effective, systems-based approaches to patient care in order to instill these values in the residents they teach. Importantly, graduate medical education (GME) is well positioned to influence not only how future physicians provide care to patients but also how today's physicians and health care systems improve patient safety and care. The necessary systems-based knowledge and skills are rooted in both understanding and proficiently identifying threats to patient safety, their underlying causes, the development and implementation of effective countermeasures, and the measurement of whether the threat has been successfully addressed. This knowledge and its application is notably absent in the operation of most institutions that sponsor GME training programs in terms of didactic instruction and everyday demonstrated proficiency. Most important of all, faculty must model the behavior and competencies that are desirable in future physicians and not fall into the trap of the "do as I say, not as I do" mentality, which can have a corrosive deleterious effect on the next generation of physicians.

Pathways to a Career in Military Psychiatry.

Psychiatric healthcare has been an essential aspect of the military medical mission over the past century. From very limited psychiatric services available during World War I to the development of multiple psychiatric graduate medical education training programs within the military healthcare system after World War II, psychiatry within the military has markedly evolved. With the onset of Operation Enduring Freedom in 2001 and Operation Iraqi Freedom in 2003, the USA embarked on the longest continuous conflict in its history, producing thousands of personnel suffering from combat-related psychiatric disorders and placing additional psychological stress on their spouses and children requiring the services of skilled psychiatric physicians both wearing the military uniform and serving as civilian healthcare providers in a military treatment facility. This paper will present an overview of the history of military psychiatric graduate medical education, current avenues of access to serve as a military psychiatrist either in uniform or as a civilian, and the opportunities and experiences one may expect working in the military healthcare system. Psychiatry GraduateMedical Education training has significantly evolved from the first known four Department of Defense psychiatric residents (two Army and two Navy) in 1909 who trained for 2 years at Saint Elizabeth Hospital in Washington, DC. However, very few psychiatrists were sponsored for training over the next several decades despite the evident need for psychiatric services in World War I when the total number of psychiatrists in the Army increased from 50 at the beginning of the war to nearly 700 when the Armistice was signed in 1918 [1]. Attrition from themilitary psychiatry ranks post-World War I significantly reduced the inventory to less than 100 in 1940, necessitating another quick infusion of psychiatric physicians into the Armed Forces to include the establishment of a standardized 12-week neuropsychiatry course for non-psychiatric clinicians which produced 1300 graduates to augment the pool of neuropsychiatric services available for service members [2, 3]. In 1946, Congress passed the National Mental Health Act which provided funds for a number of mental health initiatives including the training of mental health professionals, and over the course of the next decade, eight military psychiatry residency programs opened and received certification from the Accreditation Council for Graduate Medical Education [4]. Since the 1950s, there has been significant change in the total number and location of military psychiatry training programs to include a significant restructuring during the 1990s in unison with the large drawdown of troops after Operation Desert Storm. Six Military Psychiatry Graduate Medical Education training programs are currently in operation. The demand for behavioral health services post-9/11 for both service members and their families greatly increased in the setting of continuous combat operations and quickly exceeded existing resources. This increase in clinical demand necessitated increasing the numbers of psychiatrists within military treatment facilities and thus expanded opportunities for entry intomilitary psychiatry besides the traditional path of completing a military graduate medical education training program. A career in military psychiatry can now be achieved through several different pathways as discussed below.

Building the pipeline: the creation of a residency training pathway for future physician leaders in health care quality.

Many health care organizations seek physicians to lead quality improvement (QI) efforts, yet struggle to find individuals with the necessary expertise. Although most residency programs incorporate QI and patient safety principles into their curricula, few provide a specialized training program for residents exploring careers as physician leaders in quality. Recognizing this training void, the authors designed and implemented the Healthcare Leadership in Quality (HLQ) track for residents at the University of Pennsylvania Health System in 2010. This longitudinal, two-year graduate medical education (GME) track aligns with the quality goals of the University of Pennsylvania Health System and includes a core curriculum, integration into an interprofessional health care leadership team that is accountable for quality and safety outcomes on a hospital unit, a capstone QI project, and mentorship. Early evaluation has demonstrated the feasibility and efficacy of the track diverse graduate medical education training programs. Using Yardley and Dornan's interpretation of the Kirkpatrick framework, the authors have demonstrated the track's impact on four levels of educational and organizational outcomes. Building on their early experiences, the authors are integrating project and time management skills into the core curriculum, and they are focusing more effort on faculty development in QI mentorship. Additionally, the authors plan to follow HLQ track graduates to determine whether they seek leadership roles in quality and safety and to assess the influence of the program on their careers.