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Ensuring an Effective Physician Workforce for the United States Recommendations for Graduate Medical Education to Meet the Needs of the Public

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Ensuring an Effective Physician Workforce for the United States Recommendations for Graduate Medical Education to Meet the Needs of the Public Ensuring an Effective Physician Workforce for the United States Recommendations for Graduate Medical Education to Meet the Needs of the Public The Second of Two Conferences—The Content and Format of GME Chaired by Debra Weinstein, MD May 2011 Atlanta, Georgia November 2011 This monograph is in the public domain and may be reproduced or copied without permission. Citation, however, is appreciated. Debra Weinstein, MD, Chair, Ensuring an Effective Physician Workforce for the United States, The Content and Format Proceedings of a Conference Sponsored by the Josiah Macy Jr. Foundation, held in Atlanta, GA, May 2011; New York: Josiah Macy Jr. Foundation; November 2011. Cover Photo: ©Keith Brannon, Macy Grantee Photo, Tulane University School of Medicine, Tulane Rural Immersion Program (TRIP) Accessible at www.macyfoundation.org Ensuring an Effective Physician Workforce for the United States Recommendations for Reforming Graduate Medical Education to Meet the Needs of the Public The Second of Two Conferences— The Content and Format of GME Chaired by Debra Weinstein, MD May 2011 Atlanta, Georgia Published by Josiah Macy Jr. Foundation 44 East 64th Street, New York, NY 10065 www.macyfoundation.org November 2011 C ON T E N T S Preface. 5 Introduction. 9 Conference Summary. 15 Conference Participants . 40 Commissioned Papers. 45 The History of Calls for Reform in Graduate Medical Education and Why We Are Still Waiting for the Right Kind of Change By Kenneth M. Ludmerer, MD . 47 Theory and Practice in the Design and Conduct of Graduate Medical Education By Brian David Hodges, MD, PhD and Ayelet Kuper, MD, DPhil . 65 The Resident’s Experience From the book Educating Physicians: A Call for Reform of Medical School and Residency By Molly Cooke, David M. Irby, Bridget C. O’Brien . 91 Discussion Highlights . 141 Table of Conclusions and Recommendations. 191 Selected Bibliography. 195 Participant Biographies. 203 4 PR E FAC E GEORGE E. THIBAULT, MD The keynote speaker at a 1992 Macy Conference on the state of graduate medical education (GME) in the United States called the GME issue “a hardy perennial,” and observed that “its problems never quite get solved.” It is true that calls for GME reform have occurred in every decade since the 1940s, and many of the specific recommendations in these calls for reform have not been enacted. In the past decade, some changes have occurred: schedules have been modified to comply with duty-hour restrictions, the concept of competency-based assessment has been introduced, and some training has moved from the inpatient to the outpatient setting. But many observers of GME continue to feel that the pace of change is not sufficient to keep up with the rapidly changing needs of the patients we serve and with the evolution of the health care system our trainees are entering. For that reason more than 2 years ago a group of thought leaders began to meet to discuss how we might constructively address the issue of GME reform once again. The feeling in the group was that there was even greater urgency to this issue than in decades past because the rapidity of societal change compared with the slow pace of GME change had led to a misalignment between our educational products and societal needs, and without intervention that misalignment was going to become more profound. Subsequently, the national debates on health care reform and budget deficits have only added to the urgency of these issues. We decided to plan two conferences to address different aspects of this complex GME issue. The first conference was held in October 2010. It was cosponsored by the Macy Foundation and the Association of Academic Health Centers (AAHC), and it addressed the financing and regulatory issues related to GME. The thought leaders who had had initiated this GME discussion served as the planning group for that conference, and the results of that conference have now been published as a monograph entitled Ensuring an Effective Physician Workforce for America: Recommendations for an Accountable Graduate Medical Education System.1 1 Josiah Macy Jr. Foundation. Ensuring an Effective Physician Workforce for America, Recommendations for an Accountable Graduate Medical Education System. Proceedings of a Conference Chaired by Michael M.E. Johns, October 2010; Atlanta, Georgia. New York: Josiah Macy Jr. Foundation; April 2011. Available online at: http://josiahmacyfoundation. org/publications/publication/proceedings-ensuring-an-effective-physician-workforce-for-america 5 The premise that guided the consensus recommendations of this conference is that GME is a public good that is significantly financed with public dollars and therefore must be accountable to the needs of the public. The recommendations called for a high-level review of the finances and governance of GME in order to have a system that is optimally responsive, flexible, and innovative and that has the appropriate incentives to meet the needs of the public. This report deals with the second conference, which focused on the structure, content, and efficiency of the training process itself. There was intentionally some overlap in the participants in the two conferences, but the second conference was enriched by the addition of many educators across disciplines and from many different institutional types and locations. If the goal of the first conference was to help construct a system that is more accountable, the goal of the second conference was to provide a more detailed road map of how individual programs can and should change in this accountable GME system. As background, the conferees had the four commissioned papers and six presentations from the first conference. There were two additional papers commissioned for this conference: “The History of Calls for Reform in Graduate Medical Education and Why They Have Failed,” by Kenneth Ludmerer, MD, and “Theory and Practice in the Design and Conduct of Graduate Medical Education” by Brian David Hodges, MD, PhD, and Ayelet Kuper, MD, M.Ed, D Phil. The participants met in plenary sessions and breakout groups for facilitated discussions on each of the major topics of GME content and structure. The highlights of these rich discussions are captured in the monograph. These discussions led to a series of conclusions and recommendations that are reported here in detail with accompanying rationales and requirements for implementation. Given the size and complexity of the issues discussed, it is gratifying that consensus was reached on so many points with such a degree of specificity. Having participated in many GME discussions in the past, I felt this was the most thoughtful, deep, and comprehensive review of the terrain that I have experienced. All the conferees came prepared, participated fully, and engaged in an intense but respectful discussion. The five major reforms called for are: 1 Greater accountability through public representation and public reporting 6 2 Greater relevance through broadening sites and content of training and requiring interprofessional education. 3 Greater efficiency through adopting a competency based approach, and eliminating non educational experiences and redundancies in training 4 Greater flexibility to individualize training for different career goals 5 Greater research base to improve and evaluate training The conclusions and recommendations do provide the road map we had hoped for to better align GME with contemporary needs. Not every recommendation will be applicable to every program, but every program can and should find relevance in the recommendations. Some recommendations will require regulatory changes, but many can be enacted without other changes if institutions and programs have the will to do so. This final summary of the report captures the sense of urgency the conferees expressed at this critical juncture in the history of health care in this country: “GME reform is imperative if we are to have a more robust, reliable and efficient health care delivery system…. It is critical that all GME stakeholders recognize both the urgency and the opportunity of reform. Failing to accomplish necessary change will leave an enlarging gap between society’s needs and what the graduates of our GME system can provide.” The changes that are recommended can only be accomplished with the thoughtful guidance of the profession. By doing this we can and will earn continued support for the investment in GME as a public good. I want to thank Debra Weinstein for her superb leadership of this conference from the planning stage through publication of this monograph. I also want to thank the planning committee for their high degree of involvement and many contributions at every stage, and all the conferees for the energy and intellectual investment they made in the conference and for the wisdom and guidance they provided. Finally, I want to thank Nick Romano for his tireless efforts that brought all this together. George E. Thibault, MD President, Josiah Macy Jr. Foundation 7 8 INTRODUCTION DEBRA WEINSTEIN, MD CONFERENCE CHAIRPERSON VICE PRESIDENT FOR GRADUATE MEDICAL EDUCATION PARTNERS HEALTHCARE SYSTEM, INC. MUCH HAS CHANGED, YET MUCH REMAINS THE SAME… Many individuals involved in GME will assert that fundamental change has already occurred. After all, the unscripted immersion in patient care that used to characterize residency training has been replaced by a competency-based curriculum. The off-hand “call me if you can’t manage” has given way to prescribed supervision. Expectations that residents work without any bounds on their job description or on their hours have been curbed by rules protecting the work environment and limiting duty hours. These and other improvements in GME reflect that teaching institutions have assumed greater accountability for the quality of GME, and greater responsibility for the physicians being educated and the patients they treat. However, because change has occurred through regulation, rather than by community conviction or tangible incentives, progress has been limited. Continued resistance to competency-based education, supervision, duty hour limits, and other initiatives prevents their more complete implementation.
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