Graduate Medical Education

Issues and Options

Frank C Wilson

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315346540
• Edition: 1
• Topic: Medizin
• Subtopic: Medizinische Theorie, Praxis & Referenz

This book explores and offers solutions to critical issues in graduate medical education, including how students are taught and evaluated and how their educational programs are funded. It will be key reading for medical educators, policy makers and all individuals and organizations with an interest in medical education.

1

Graduate Medical Education

Then and Now*

By way of overview, this survey begins with a historical fantasy and ends with a prophecy, but it deals most of all with an evolving present.

It is probably presumptuous for a specialist to address generic issues in graduate medical education (GME) because of the biases inherent in greater familiarity with one’s own specialty; and even deeper contrition is felt for the many numerical data points, which are intended to suggest direction and trend rather than factual finality.

History

The American system of graduate medical education was born at the Johns Hopkins Hospital in the late 1800s. While records of its conception are sketchy, one might imagine a scenario in which Dr. Henry Hurd, the first director of the hospital, called William Welch, Dean of the inchoate School of Medicine, and Drs. Osler, Halsted, and Kelly to his office to discuss hospital operations and to express his displeasure at being the only physician on call the previous night to take care of all emergencies. In spite of Welch’s compelling explanation that they had been planning the formation of the medical school, this experience convinced Dr. Hurd that a system of supplemental coverage was needed for the full-time staff. Osler concurred, noting that the responsibility for working up every patient in the hospital precluded the scholarly activity central to the mission of the faculty. Dr. Welch pointed out that they could not rely on part-time faculty, since they were more concerned with making money and, as such, were not good role models for students. He suggested that the hospital offer an apprenticeship to bridge the gap from medical school to practice. Halsted concurred with the need for help with routine aspects of patient care but pointed out that with departmental funds already under severe pressure, there was no source of payment for these positions. Hurd suggested that they be given room, board, and uniform in lieu of cash. Osler agreed, noting that the learning opportunities for these young men would be compensation enough.

And so it remained for almost 60 years, without, it should be added, the suggested indifference to the experience obtained by the house staff.

Thus, graduate medical education grew up in the hospital, as opposed to undergraduate education, which was a product of the medical school environment. These young physicians were called residents, a word derived from an era when they resided, or were “interned,” in the hospital on essentially a full-time basis.¹

Growth

Most of the growth of GME occurred after World War II: in 1940 there were about 5000 residents; in 2008, almost 110 000 were on duty in 8595 programs, over half of which were subspecialty programs. Of the 127 accredited disciplines in which a medical graduate might specialize, 26 were “primary” specialties and the remainder subspecialties in a primary discipline.² In 2007, 42% of all residents were in the primary programs of Internal Medicine, Family Practice, Pediatrics or Obstetrics-Gynecology.³ Approximately 21% of all residents matching into PG-1 programs in recent years have been international medical graduates (IMGs).⁴

Educational Goals and Incentives

The goals of GME are to prepare physicians for the practice of medicine, continued professional development, and lifelong learning.

For the physician, there are a number of incentives for graduate training. Completion of a residency, although not required for practice, leads to enhanced clinical skills. Certification or eligibility for certification by a specialty board is required for admitting privileges in most hospitals, and professional fees are often higher for specialists than for generalists who perform the same service.

Curricula

There are few formal curricula for GME; however, the content of the educational experience is specified in general terms for each discipline by its specialty board and residency review committee (RRC). Many requirements are common to the educational programs of all specialties, although the emphasis varies from discipline to discipline.

The time needed for competence in a discipline is determined by its specialty board; the range is from two to six years of graduate education.

Influences

In addition to evolving knowledge and technology, factors that influence GME are academic medical centers (AMCs), credentialing bodies, class size and composition, student specialty preferences, methods of health care delivery, economic constraints, and governmental regulations.

The AMC bears upon GME in a variety of ways. The program director is responsible for establishing the educational goals of the program, the selection, supervision, and evaluation of residents, counseling, censure and dismissal of residents whose performance is unsatisfactory, provision of adequate facilities and teaching staff, resident stress and working conditions, and communications with the residency review committee. With increasing fiscal constraints and emphasis on institutional responsibility, the hospital director has played a larger role in these determinations. By their number of graduates, medical schools affect the supply of residency positions. Also, deans and faculties of medicine have come to recognize more formally the importance of residents in the education of medical students.

The role of credentialing bodies is discussed in the following chapter.

Class size also affects GME. In 1967, there were 7743 graduates of U.S. medical schools; a number that had more than doubled by 2007, although in the last 25 years the annual number of graduates has not changed appreciably (15 802 to 16 139).⁵ Between, 1967 and 2007, the number of accredited U.S. medical schools increased from 84 to 126 – a growth rate of 33% in 40 years.⁶ Three additional schools were established in 2008. The average first-year class size in 1967 was 107; in 2006 it was 139, with enrollments ranging from 43 to 299.⁷

Because there is no centralized control over medical education, decisions about class size, which have national implications in the aggregate, are made institutionally, often because of factors of intense but localized significance, such as dependence on state subsidies and unmet needs for physician services in the community.

In 2006, the Association of American Medical Colleges (AAMC) Center for Workforce Studies, anticipating a physician deficit in the U.S. over the next several decades, called for medical schools approved by the Liaison Committee on Medical Education to increase their enrollment by 30% over 2002 levels during the next decade. Fully implemented, this change would increase medical school enrollments by almost 5000 per year.⁸ If the number of IMGs in GME programs remains constant, the total number of residency positions will have to be increased to accommodate them, which would require removal of current Medicare restrictions on GME funding.

Changes in the gender mix of medical school classes have also influenced the graduate arena. Women constituted 11% of first year medical school classes in 1970; by 2007 this number had risen to 48%. Over 70% of all residents in Pediatrics and Obstetrics-Gynecology in 2007 were women.⁹

The ratio of minority students has also risen steadily. Black Americans made up 6.7% of medical school graduates in 2007, up from 5.1% in 1978, while the Asian population in GME increased from 2.6% to 20.4% over the same period.¹⁰

Student preferences have also affected GME in recent years. The percentage of students entering the primary care disciplines dropped from 49 to 44 between 2002 and 2007, and the percentage of primary care residents who pursued subspecialty training has risen steadily, reaching 58% in Internal Medicine and 33% in Pediatrics in 2007.^11,12

The extent to which specialty choices have been influenced by indebtedness is problematic; however, in 2007, 65% of medical graduates had debts of over $100 000, up from 13% in 1997.¹³

Changes in health care delivery have had a major impact on residency training. Fueled by mounting costs, the system of health care delivery has changed at a revolutionary rather than an evolutionary rate. Studies and operations previously performed during hospitalization now are done on an outpatient basis, and hospital recuperation periods have been shortened by discharging patients as soon as “clinically appropriate.” As a result, patients in the hospital have more acute and complex problems that require greater intensity of care. These changes have altered the nature of residency training by confining resident experience to sicker patients, often with esoteric disorders rarely encountered by physicians in practice. Nor does the resident have the opportunity to participate in many critical aspects of patient care that take place before and after admission. Surgical education in particular has become more limited to the operating room, which, coupled with less patient contact pre- and postoperatively, has concentrated resident education on technology rather than comprehensive surgical care.

Because of this shift in the provision of health care from hospital to nonhospital sites, physicians-in-training are spending more time in remote clinics and operatories, with no opportunities in the latter for pre- or postoperative contact with the patient. Many hospitals have increased ambulatory care experiences for their house officers, but differing educational philosophies and numerous operational and funding problems confront program directors who make greater use of ambulatory settings for education.

Economic constraints have also exerted pressures on graduate education. Teaching hospitals incur significant added costs in providing GME programs. While third-party payers initially paid teaching hospitals for both patient care and education, these policies have changed. In the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, limits were imposed on Medicare’s open-ended responsibility to pay medical education costs. As a result, Medicare payments fail to cover Medicare’s share of hospital costs for medical education – and voices in Congress have questioned whether any educational costs should be paid.

Payment practices by private health insurers have changed as hospitals entered into fixed-price contracts with organized health care systems. Since the payer’s objective is to purchase care at the lowest possible cost, they are reluctant to pay extra for residency education.

Whatever the level, length, and method of funding, it seems appropriate for those who utilize resident services, namely the sick, to bear the service component of resident costs; and for all of society to share the educational costs, as everyone benefits from well-trained physicians. The problem lies in teasing apart service and education, since learning occurs during the provision of service.

Legislative constraints upon the admission of IMGs to graduate programs in the U.S. have waxed and waned. Until 1975, IMGs were welcomed under an open-door policy based upon a perceived need for more physicians. As shortage gave way to imminent surplus, Congress, in the mid-1970s, amended the Immigration and Nationality Act that made it more difficult for alien (vs. U.S. citizen) graduates of foreign medical schools to practice here. Even so, from 1990 to 2007, alien foreign graduate applicants to U.S. residency programs increased from 17% to 31% of the total.¹⁴ Unfortunately, the Liaison Committee on Medical Education (LCME) is limited in scope to medical schools in the U.S. or Canada, which raises questions about the quality of foreign medical schools that have no comparable accreditation process.

Historically, medicine has been a self-regulating vocation; however, both federal and state governments have taken increased oversight and regulatory interests in medicine and medical education. COBRA included a provision mandating the establishment of a Council on Graduate Medical Education (COGME). This Council has issued in...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Foreword
• Preface
• About the Author
• Acknowledgments
• 1 Graduate Medical Education: Then and Now
• 2 Credentialing in Medicine: Protecting the Public
• 3 Teaching and Learning: Establishing an Educational
• 4 The Evaluation of Residents: Assessing Competent Performance
• 5 Work Hours and the Supervision of Residents
• 6 Science and Service: The Pillars of Professionalism
• 7 No Tempests, No Teapots: Fostering Research in Medical Education
• 8 Psychomotor Education: Point and Counterpoint
• 9 Teaching by Residents: Passing It On
• 10 Mentoring Young Physicians: The Need for Nurture
• 11 Funding Graduate Medical Education: Who Will Pay?
• 12 Manpower: Supply and Distribution
• 13 Obligations of Residents: With Rights Come Responsibilities
• 14 Recommendations: What Then Must We Do?
• 15 Afterword
• Appendix: Graduate Medical Education Organizations
• Index