Graduate Medical Education Programs Research Articles

Financial Barriers to Rural Graduate Medical Education: Medicare Funding Methods for Sole Community and Medicare-Dependent Hospitals.

Policymakers are exploring options to address rural-urban physician maldistribution, including reducing rural residency training barriers. This study estimated Medicare graduate medical education (GME) reimbursement that sole community hospitals (SCHs) and Medicare-dependent hospitals (MDHs) are disqualified from receiving compared with hospitals under the Prospective Payment System (PPS) and calculated the GME reimbursement per resident for MDHs and SCHs under different scenarios. This simulation study used Healthcare Cost Report Information System data on hospitals that had been SCHs or MDHs between 2011 and 2021 and did not have any resident full-time equivalents (FTEs) in the most recent year. Reimbursements were calculated under the PPS and hospital-specific rate (HSR), assuming all other hospital financing elements remained unchanged, apart from adding resident FTEs. A total of 242 hospitals were identified as current or recent SCHs or MDHs with an average daily census of 25 or more and no residents in their most recent cost reports; 139 (57.4%) were paid under the HSR. The median (interquartile range) reimbursement per resident was $179,442 ($153,078-$208,412) under PPS and $107,294 ($85,134-$128,259) under HSR, a difference of nearly $70,000 per resident. The median opportunity cost per FTE was approximately $73,000 for SCHs and approximately $65,000 for MDHs. No significant per-resident differences were observed in the GME payments based on program size. Due to higher GME payments from PPS vs HSR, the number of hospitals defaulting to HSR decreased, and by the end of the third year of the program, more than 10% hospitals switched from HSR to PPS. Under the current health care and GME reimbursement method, SCHs and MDHs face considerable financial barriers to launching or participating in GME programs. Policy adjustments to address this barrier may incentivize more rural facilities to launch or participate in GME, potentially mitigating the geographic maldistribution of physicians.

In the Eye of the Beholder: A Stakeholder Analysis of the Value of the "Promotion in Place" Competency-Based Time-Variable Graduate Medical Education Pilot.

Competency-based time-variable (CBTV) graduate medical education (GME) has been implemented in Canada, Europe, and the United States, yet its perceived value has not been explored. Promotion in Place (PIP) is a CBTV GME program in which residents graduating early advance to attending status with "sheltered independence" until the standard graduation date. This study describes perceived value of CBTV GME and PIP at Mass General Brigham by capturing diverse stakeholder perspectives. In this stakeholder analysis using semistructured interviews (June 2022-August 2023), 49 participants were invited (44 representative members and 5 external stakeholders) from 11 GME programs: PIP eligible residents, program directors (PDs), chairs, service chiefs, and external national medical education organization leaders. Authors' understanding of value was informed by Harvey and Green's conceptualization of quality in higher education as "fit for purpose," "standards monitoring," "transformation," and "value for the money." Deductive codes and inductive subcodes captured diverse perspectives of value. Of the 49 invited stakeholders, 34 (69%) were interviewed across 5 stakeholder groups. Nearly all groups cited aspects of PIP that are "fit for purpose" as evidence of value; PIP supported "workforce readiness" and provided "sheltered independence" as intended. External stakeholders, PDs, service chiefs, hospital leadership, and faculty cited value aligning with "standards monitoring" (e.g., PIP must maintain or improve patient and resident outcomes). Nearly all groups cited aspects of PIP aligning with "transformation" as evidence of value. PIP promoted "independent decision-making" and enhanced trainee confidence. Chairs cited aspects of PIP aligning with "value for the money" (e.g., "cost neutral" as optimal for sustainability and avoidance of "hidden costs" such as assessment burden). Understanding perceptions of PIP and CBTV GME value is critical to engaging diverse stakeholders and extending CBTV GME to more programs and specialties. PIP's transformative nature underscores the added value of CBTV GME.

Exploring clinician perspectives of systems-based practice: A physician training challenge.

Systems-based practice (SBP) has been a competency in US graduate medical education for over 20 years, but it is not well implemented. SBP is loosely defined as physician's responsiveness to the larger system of healthcare. The aim of this study was to describe healthcare professionals' perspectives regarding: (1) their knowledge and beliefs about SBP and (2) their beliefs regarding factors in clinical learning environments (CLE) that facilitate or hinder operationalisation and learning of SBP. Semi-structured interviews were conducted between November 2020 and April 2021 with 42 individuals from four health systems. Participants were healthcare professionals involved in graduate medical education, including physicians and interprofessional clinicians (e.g., nursing staff). Interviews were transcribed and coded using a social constructivist, codebook thematic analysis approach and themes were agreed upon through discussion amongst the research team. Five themes were constructed: (1) SBP remains a challenge to define, (2) SBP may be intuitively understood, particularly when framed at the microsystem level, (3) SBP aligns with the Health Systems Science framework, (4) SBP learning must be intentionally integrated into the CLE, through training such as onboarding and (5) multidisciplinary settings and work processes are critical to engage in SBP. Workload compression is a barrier to SBP implementation. Healthcare professionals highlighted that current CLEs are not designed to prioritise SBP. Graduate medical education programmes may benefit from focusing systems content at the microsystem level and purposefully integrating onboarding procedures, clinical settings and rotations specifically designed to teach SBP into their residencies.

Standardizing and Enhancing the Tracking of Continuing Medical Education (CME) within Graduate Medical Education (GME) Programs: A Comprehensive Analysis

Standardizing and Enhancing the Tracking of Continuing Medical Education (CME) within Graduate Medical Education (GME) Programs: A Comprehensive Analysis

Barriers to Publishing Scholarship: A Study on Neurology Physician Residents and Fellows.

Background Scholarly activity by trainees is required for US-accredited graduate medical education (GME) programs. Several factors, including financial barriers to open access (OA) journals, may impact trainees' successful completion of scholarly activity, but little is known to what extent, particularly for neurology trainees. Method The authors implemented a cross-sectional, web-based 17-item survey of US-accredited neurology residency and fellowship programs during the 2022-2023 academic year. Participant responses for producing scholarly activity during GME were analyzed by mixed methods and examined by trainee motivation and perceived barriers, available institutional research support, and OA awareness and compared against socio-demographics (i.e., disadvantaged status history, underrepresented in medicine (URiM) status, international medical school graduate (IMG))and prior research experience. Results Seventy-two respondents from 63 neurology programs completed the survey. Participants represented all US census regions and mostly from academic health centers and in advanced years of training. Overall, 17 (23.6%) self-reported as URiM and 20 (27.8%) as an IMG. Sixty-two (86.1%) were familiar with OA. Prior publications were associated with OA awareness (X2 = 5.3, p<0.05), and 27 (37.5%) reported financial barriers to publishing. IMGs reported less motivation to publish based on a journal's impact factor (odds ratio [OR] = 0.15, 95% confidence interval [CI], 0.03-0.65, p<0.01) but were nearly 5 times more likely to report financial barriers to OA publishing (OR = 4.62, 95% CI 1.31-16.80, p<0.01). Trainees successfully publishing while training reported prior research experience (OR = 7.27, 95% CI 1.71-42.64, p<0.05) and access to mentors (OR = 4.67, 95% CI 1.52-14.64, p<0.001).Dedicated time for scholarly activity and publishing were reported as significant barriers in open-ended responses. Conclusions One-third of the study participants reported financial barriers to publishing scholarship, with these barriers disproportionately affecting IMGs. Prior research experience and access to mentors were associated with a higher likelihood of publishing.

Unionization of Graduate Medical Education Trainees: Perspectives from Designated Institutional Officials.

Labor unions represent an increasing number of graduate medical education (GME) trainees in the United States. Most GME and other leaders at academic medical centers lack familiarity with resident/fellow unions, including what to expect, what decisions need to be made, and the processes involved in a unionization effort. It is important for designated institutional officials (DIOs), GME program directors, teaching faculty, and other institutional leaders to understand the drivers of resident/fellow unionization, the union organizing campaign and election process, and what follows a vote to unionize, including collective bargaining. Careful consideration of the role of educational and other institutional leaders during the unionization process is important to prevent any loss of trust between residents/fellows and those they view as their advocates. In this Commentary, the authors describe these considerations from their perspective as DIOs and GME leaders.

Evolving Patterns in Inpatient Pediatric Consultations to Allergy/Immunology at an Academic Medical Center

Background: Consultations to pediatric allergy/immunology are of benefit to many hospitalized inpatients, but there is limited current information about how T-cell receptor excision circles (TREC) screening may have changed these patterns for pediatric populations. We aimed to determine the types of consults being requested and their relative frequencies for primary pediatric allergy/immunology consults under an academic fellowship program since the start of TREC screening in 2016. Information gained could help identify focal concepts for pediatric allergy inpatient training curricula for fellowship and graduate medical education programs. Methods: Under an IRB approved study of an academic allergy fellowship consultation log, we retrospectively reviewed electronic medical records of pediatric allergy and immunology consults and categorized consultations by their primary indication. Results: Three-hundred and eighty-three pediatric allergy/immunology consultations were seen between September 4, 2016 to November 24, 2022. In terms of frequency, the most common consultation was for immunodeficiency evaluation or treatment, n=205 (53.5%), followed by drug allergy n=55 (14.4%), general allergy concerns n=43 (11.2%), skin allergy n=35 (9.1%), and less commonly inflammatory syndromes, n=26 (6.8%) and food allergy, n=19 (5.0%). Questions related to TREC screening comprised 21% of all immunodeficiency consults, at n=43. Conclusion: At an academic allergy center where all allergy/immunology service lines are currently provided, the most common reason for pediatric consultations were for help with immunodeficiency evaluation/treatment and drug allergy. TREC screening is a new key indication for consultation. Fellowship programs may benefit from focusing on these content areas for the pediatric inpatient setting.

Fostering Inclusivity in the Clinical Learning Environment.

Despite the Supreme Court's decision on race-based admissions, academic medical centers, medical societies, and accreditation bodies remain committed to recruiting a diverse workforce. Many medical schools and graduate medical education programs created initiatives to expand their census of underrepresented in medicine (UIM) as the key to addressing health care disparities. As a result, an influx of an UIM physician workforce has entered clinical learning environments, often without consideration of the inclusivity of these settings. To create inclusive, safe, and comfortable CLEs, we must first recognize the challenges faced by UIM trainees, students, and faculty and the complex ways in which discrimination manifests. Ultimately, having inclusive CLEs allows all learners, especially those from historically excluded identities, to thrive in their training and working environment, making it essential to retain the diverse workforce necessary. Using case examples, we discuss strategies of inclusivity and ways in which we can maintain clinical learning environments where learners feel safe and supported through their training.

Special Issue on Informatics Education A Longitudinal Graduate Medical Education Curriculum in Clinical Informatics: Function, Structure, and Evaluation.

There is a need to integrate informatics education into medical training programs given the rise in demand for health informaticians and the call on the Accreditation Council for Graduate Medical Education (ACGME) and the body of undergraduate medical education (UGME) for implementation of informatics curricula. This report outlines a 2-year longitudinal informatics curriculum now currently in its seventh year of implementation. This report is intended to inform United States (US) Graduate Medical Education (GME) program leaders of the necessary requirements for implementation of a similar program at their institution. The curriculum aligns with the core content for the subspecialty of clinical informatics (CI) and is led by a multidisciplinary team with both informatics and clinical expertise. This educational pathway has a low direct cost and is a practical example of the academic learning health system (aLHS) in action. The pathway is housed within an internal medicine department at a large tertiary academic medical center. The curriculum has yielded 13 graduates from both internal medicine (11, 85%) and pediatrics (2, 15%) whose projects have spanned acute and ambulatory care and multiple specialties. Projects have included Clinical Decision Support (CDS) tools, of which some will be leveraged as substrate in applications seeking extramural funding. Graduates have gone on to CI board certification and fellowship, as well as several other specialties, creating a distributed network of clinicians with specialized experience in applied CI. An informatics curriculum at the GME level may increase matriculation to CI fellowship and more broadly increase development of the CI workforce through building a cadre of physicians with HIT expertise across specialties without formal CI board certification. We offer an example of a longitudinal pathway which is rooted in aLHS principles. The pathway requires a dedicated multidisciplinary team and departmental and IT leadership support.

Meet and Greet Sessions: A Unique Virtual Opt-Out Approach to Support Trainee Well-Being.

Background Interventions to support graduate medical education (GME) trainee well-being at the institutional level continue to be an area for continuous improvement. Objective To assess participation, feasibility, and acceptability of a virtual, individual, brief, nonevaluative opt-out approach to accessing mental health support for residents and fellows. Methods From 2021 to 2023, all GME programs at one large institution were invited to participate. During orientation, incoming trainees from programs that had communicated interest were prescheduled for optional 20-minute, virtual "meet and greet" sessions with a counselor from the hospital's Employee Assistance Program. Nonformal feedback was gathered using an anonymous 6-question survey. Results Three hundred thirty-four residents and fellows from 12 of 74 (16%) participating GME programs were prescheduled for opt-out sessions over 3 academic years. Of the 334, 182 (54%) attended the sessions, 116 (35%) subsequently reached out to start counseling, and 108 (32%) responded to the survey. Each year, approximately 7 counselor hours were needed for the opt-out sessions per week over an 8-week period, which was feasible and added no extra cost. In the follow-up survey shared with all participants, 59 of 81 (73%) respondents reported that the sessions helped to reduce barriers to seeking mental health care. Conclusions During orientation, one-half of invited GME trainees participated in a virtual, individual, brief, nonevaluative meet and greet session with a counselor using an opt-out approach, and one-third subsequently requested counseling. Survey feedback was encouraging, and this approach can serve to help normalize culture surrounding accessing mental health services.

"Ardor and diligence": Quantifying the faculty effort needed in emergency medicine graduate medical education.

Regulatory requirements around protected faculty effort to support graduate medical education (GME) programs have changed. The amount of labor required to run a GME program is unknown. We sought to describe the work performed by program leadership and core faculty in emergency medicine (EM). We performed a prospective survey study of core faculty in EM. Participants completed a demographic questionnaire followed by quarterly time surveys, covering activities in eight domains: evaluation, teaching and education, scholarly activity, service, interview/recruitment, clinical supervision, student responsibilities, and wellness and administration. We collected data from April 2022 to March 2023. We calculated descriptive statistics and used analyses of variance (ANOVA) to assess differences by faculty role and quarter. A total of 596 physicians completed the demographic questionnaire and 347 (58.2%) completed at least one quarterly time survey including 142 (41%) females, 48 (14%) program directors (PDs), 84 (24%) assistant/associate program directors (APDs), and 215 (62%) general core faculty (GCF). The mean number of hours per week spent on nonclinical education work was 60 h for PDs, 47 h for APDs, and 44 h for GCF. ANOVA found significant differences in mean hours per week and faculty role in domains of evaluation (p < 0.001), service (p = 0.007), and interview/recruitment (p < 0.001). We detected differences in mean hours per week and quarter in domains of evaluation (p < 0.001), teaching and education (p < 0.001), interview and recruitment (p < 0.001), and clinical supervision (p < 0.001). Running a residency program requires many hours of faculty work, which can vary based on faculty role and time of year. These results can inform decisions regarding faculty support.

Preparing for Virtual Interviews: A Pilot Study to Understand the Needs of Interviewees.

Virtual interviews play a crucial role in the ranking process. National Resident Matching Program (NRMP) data shows a median number of 23.5 interviews per applicant. Considering this volume of interviews, graduate medical education programs must leverage the virtual pre-interview materials to impact applicants' attitudes and perceptions of the interview beforehand. This study is a secondary data analysis of an anonymous cross-sectional survey collected during two orientation sessions held in June and July 2022. Responses from 123 residents and fellows rated the usefulness of available print and virtual pre-interview resources. Using a 5-point Likert scale, social media sites scored an average usefulness score of 4.0, while the information packet and program website scored 3.88 and 3.90, respectively. This article provides recommendations for restructuring virtual resources to aid residents and fellows, specifically under-represented minorities in medicine (UiM) applicants, in having a quality interview experience.

Transition From Graduate Medical Education to Independent Practice: A Scoping Review.

This study examines the gaps in early career physician readiness for independent practice after graduating from their final graduate medical education (GME) program. The authors conducted a literature search of 4 online databases (PubMed, Scopus, Health Business Elite, and Education Resources Information Center) using the following terms: population terms (GME, fellow, resident, and others), early career terms (onboarding, hiring, early career, ready, and others), readiness terms (readiness, preparedness, knowledge, skills, competence), and independence terms (attending, physician, independent practice). The databases were searched on March 12, 2024, for articles that explored GME graduate gaps in readiness for independent practice; assessment tools, curricula, or curricular need aimed at gaps in early career physician readiness; or an area where GME graduates need more knowledge and skills. They extracted specific gaps in preparedness and categorized them using existing competency frameworks. The search returned 116 articles addressing gaps in preparedness for independent practice among recent GME graduates. Surgery yielded more articles than any other specialty (43 [37%]). Overall, 192 individual gaps were extracted; the greatest number of gaps came from patient care (75 [39%]) followed by personal and professional development (44 [23%]). The most frequently identified gaps were procedural independence (10 occurrences), practice management (9 occurrences), and billing (7 occurrences). Despite advances in GME, learners still struggle when transitioning to independent practice. Personal and professional development is a useful categorization for many gaps and should be considered for inclusion as a GME competency. Systematic assessment of new-to-practice attendings could help stakeholders better understand the true outcomes of GME programs. Concerted investment by specialty societies may drive greater understanding and innovative solutions. Additional study could help address the challenges in the GME-to-practice transition.

Controlled Burn: Managing the "Forest Fire" of Leaving a Professional Identity in Medical Education.

Professional identity formation is central to physicians' identity over their full careers. There is little guidance within military service on how to leave careers as clinician educator faculty in graduate medical education programs. The objective of our study was to explore how leaving this community of practice (COP) affects a clinician educator's professional identity. We used reflexive thematic analysis with Communities of Practice as a sensitizing construct. Fifteen semi-structured interviews were conducted among active-duty clinician educators at the point of their retirement from the military. Interview questions focused participants' lived experiences as clinician educators and professional identity changes leading to and resulting from the decision to retire. We found the clinician educators' journey through a time of professional transition led to three connected themes: Loss Precedes Growth, Fallow Season-Liminal Space, and New Growth. The experiences of military clinician educators retiring from active duty demonstrate how leaving one COP emanates across a range of professional identities. In addition, the decision to leave a professional COP can lead to a sense of disloyalty to that community. Normalizing this transition in a way that honors the community's values offers the opportunity to enable the decision to retire. Understanding retirement as a process that first involves identity loss, followed by the discomfort of a liminal space before achieving new growth creates the opportunity to engage in rituals that celebrate the service of departing community members, releasing them to grow into new identities.

PM&R Connections: A pilot study evaluating the adoptability and impact of a serious educational game on trainees at a Physical Medicine and Rehabilitation program.

To enhance engagement and educational outcomes, game-based learning has been introduced into undergraduate and graduate medical education programs. Using a free website, "PM&R Connections", a serious game, was created to provide trainees with an alternative method of reviewing content to identify knowledge gaps to direct studying. The game was used by 19/33 trainees and 92.3% of users required <10 minutes to complete a puzzle. 76.9% of users found the tool helpful, 69.2% recommended the game, and 92.3% desired more puzzles to be developed. Confusion on how to play and intimidation were the most reported barriers to play, and only 46% of users changed their study habits. The positive feedback and desire for more puzzles to be developed provide a foundation to further develop the game.

Diversity and Inclusion Through Collaboration: Co-Producing a Simulation Curriculum to Address Discrimination Against Trainees.

Discrimination toward trainees is a pervasive problem, with surveys showing it is often perpetrated by patients. For several years, residents and faculty in an internal medicine residency have participated in a workshop offering a framework for responding to discriminatory behavior by patients. As part of a larger effort to reinforce this teaching and promote an inclusive environment, the authors pursued a multi-pronged simulation curriculum that could be incorporated into graduate medical education programs across their institution. First, the authors conducted trainee and faculty focus groups to better understand their experiences. Qualitative data was collected, including recommendations for responding to discrimination, characteristics of the most common experiences, and trainees' own ideas for worthwhile simulation scenarios. Trainees and faculty were then brought together in a collaborative process to co-develop simulation cases that were later implemented in curricula across multiple learner levels, specialties, and contexts. Participants in these simulations reported improved comfort in responding to discrimination in the moment and/or in the wake of such incidents. Through trainee-faculty collaboration, the project yielded authentic and impactful simulation experiences for learners, while also giving trainees an opportunity to turn previous trauma into constructive learning opportunities that promote an inclusive environment.

The Relationship between Pediatric Medical Training and Neonatal Care in the Delivery Room and Beyond.

The modern neonate differs greatly from newborns cared for a half-century ago, when the neonatal-perinatal medicine certification examination was first offered by the American Board of Pediatrics. Delivery room resuscitation and neonatal care are constantly evolving, as is the neonatal workforce. Similarly, the Accreditation Council for Graduate Medical Education review committees revise the requirements for graduate medical education programs every 10 years, and the modern pediatric medical trainee is also constantly evolving. Delivery room resuscitation, neonatal care, and pediatric residency training are codependent; changes in one affect the other and subsequently influence neonatal outcomes. In this educational perspective, we explore this relationship and outline strategies to mitigate the impact of decreased residency training in neonatal-perinatal medicine.

Teaching Health Center Graduate Medical Education Program (HRSA)

Teaching Health Center Graduate Medical Education Program (HRSA)

Fostering Inclusivity in the Clinical Learning Environment

Despite the Supreme Court’s decision on race-based admissions, academic medical centers, medical societies, and accreditation bodies remain committed to recruiting a diverse workforce. Many medical schools and graduate medical education programs created initiatives to expand their census of underrepresented in medicine (UIM) as the key to addressing health care disparities. As a result, an influx of an UIM physician workforce has entered clinical learning environments, often without consideration of the inclusivity of these settings. To create inclusive, safe, and comfortable CLEs, we must first recognize the challenges faced by UIM trainees, students, and faculty and the complex ways in which discrimination manifests. Ultimately, having inclusive CLEs allows all learners, especially those from historically excluded identities, to thrive in their training and working environment, making it essential to retain the diverse workforce necessary. Using case examples, we discuss strategies of inclusivity and ways in which we can maintain clinical learning environments where learners feel safe and supported through their training.

A shared point of care ultrasound curriculum for graduate medical education

BackgroundPoint of care ultrasound (POCUS) education has grown significantly over the past two decades. Like most curricular items, POCUS education is siloed within individual graduate medical education (GME) programs. The purpose of this study was to evaluate the effectiveness of a shared GME POCUS curriculum between five GME programs at a single institution.MethodsPost-graduate-year-1 (PGY-1) residents from emergency medicine (EM), family medicine (FM), internal medicine (IM), combined internal medicine-pediatrics (IM-Peds) and combined emergency medicine-pediatrics (EM-Peds) residency programs were enrolled in a core POCUS curriculum. The curriculum included eleven asynchronous online learning modules and ten hands-on training sessions proctored by sonographers and faculty physicians with POCUS expertise. Data was gathered about the curriculum’s effectiveness including participation, pre- and post-curricular surveys, pre- and post-knowledge assessments, and an objective skills assessment.ResultsOf the 85 residents enrolled, 61 (72%) participated in the curriculum. Engagement varied between programs, with attendance at hands-on sessions varying the most (EM 100%, EM-Peds 100%, FM 40%, IM 22%, Med-Peds 11%). Pre- and post-knowledge assessment scores improved for all components of the curriculum. Participants felt significantly more confident with image acquisition, anatomy recognition, interpreting images and incorporating POCUS findings into clinical practice (p < 0.001) after completing the curriculum.ConclusionIn this shared GME POCUS curriculum, we found significant improvement in POCUS knowledge, attitudes, and psychomotor skills. This shared approach may be a viable way for other institutions to provide POCUS education broadly to their GME programs.