Training Tomorrow’s Physicians

More than 80 physicians attended the ISMS/CMS annual Residency Program Directors Meeting on Dec. 10. Participants gained insight and direction on the training of residents, and also reviewed the trends and steep funding challenges ahead in GME.

Will physician supply meet the demand?

With a physician shortage looming, the funding and training of new physicians should be a high national priority, according to Paul H. Rockey, MD, MPH, Director of the AMA’s Graduate Medical Education Division, and program presenter.

Citing a 2008 report in JAMA, Dr. Rockey predicted the U.S. will require an additional 21,000 residency slots in the next decade alone, and that the demand will continue to rise, particularly for primary care doctors.

Physician demand and supply is a complex issue but Dr. Rockey highlighted several key trends: the demands of a growing U.S. population; doubling of the nation’s elderly; expanding Medicaid population in the face of near stagnant growth in primary care; one in three physicians nearing retirement; and the threat of decreases in GME funding.

Despite the opening of new medical schools and explosive growth in DO programs, the percentage of residents who completed any core program (leading to initial board certification) grew only by 4.8% between 2001-2010, Dr. Rockey stated.

In the same period, hospital-based core specialties expanded dramatically; 24% for anesthesiology, 28.3% for emergency medicine, and 33.1% for diagnostic radiology.  Subspecialty graduates increased by 53.7%, with those completing a non-internal medicine subspecialty at 77%, compared to those with an internal medicine subspecialty at 32.6%.  The number of new core training programs remained at zero.

Despite the lure of the subspecialties, “it is the generalist who exemplifies the core mission of a “doctor,” Dr. Rockey told his audience.

The challenging role of the generalist—managing multiple problems, advising patients on competing interventions, and accepting responsibility for their overall care—demands leadership skills and the ability to oversee team members.

In the military, for example, the general has the stars, not the technical specialist, Dr. Rockey wryly noted.

More information is needed on why residents drop out of core programs, and the impact of gender and age on the work-life balance.  Other factors, such as medical school debt and projected future earnings require exploration also, Dr. Rockey said.

Funding is critical not only for more residency slots, but also for new training models, such as medical homes and ACOs; new technology, simulation training, and faculty development.

Working with other groups, the AMA has stepped up efforts to educate legislators and the public about the urgent need for new funding.

The AMA supports incentives for going into primary care.  Private payers such as insurance companies should also be asked to contribute in “all-payer systems,” Dr. Rockey said.

The future of accreditation

In response to the workforce challenge, the ACGME has set new “milestone goals” for institutions to meet, according to Thomas J. Nasca, MD, chief executive officer and program presenter.

Designed to make institutions more accountable—for quality, safety and oversight—the goals set the stage for “accreditation based outcomes,” for both the program and the individual residents who master the core competencies, Dr. Nasca said.

This outcomes-based model tracks what is important, while also fostering improvement across the continuum of medical education.

Key features include the rapid introduction of new competencies and standardization of basic core competencies and methods of evaluation.  In the future, physicians in one state will learn the same material as their peers in the same specialty in another part of the country, Dr. Nasca explained.  Educators within each specialty will work together to establish core competency elements and performance levels.

Rather than lagging behind the curve, Dr. Nasca says: “The new structure and content of residency programs guarantees that education has the opportunity to anticipate change in the delivery system,”

Ensuring performance, professionalism

Participants also enjoyed interactive discussion and case examples.  Presenter Nicole K. Roberts, PhD, led the audience through a process for identifying and addressing performance problems.

Dr. Roberts, who is Director of the Academy for Scholarship in Education at Southern Illinois University, says that early intervention is critical.

Generally, problems become visible within the first six months, giving educators ample time to evaluate and regularly monitor those individuals with performance weaknesses, while also providing feedback and resources to correct the problem.  Developing a plan and formally assessing the resident’s progress is also recommended.

The “whole meal deal” analogy is useful, she said, because it emphasizes strength in every area, from teamwork, to professionalism, to knowledge.

Dr. Roberts and her colleagues at SIU created a tool based on the Beaufort Wind Scale for evaluating individuals.  Assessments along The Person Impact Factor Scale can range from a gentle breeze to hurricane strength.

Final decisions, Dr. Roberts stressed, should be clear and straightforward.

In the end, audience members agreed that educators should keep an open mind but maintain a high degree of vigilance.

Tomorrow’s NRMP

Changes are coming in National Resident Matching Program (NRMP) policy, according to presenter Baretta R. Casey, MD, MPH, and treasurer of NRMP.

Beginning with the 2013 Main Residency Match, programs that participate in the Match must register and attempt to fill all their positions through the Match.  In other words, programs must place all positions in the Match or no positions in the Match, Dr. Casey explained.

Recent studies show that the number of unmatched applicants in the Main Residency Match declined during the last decade, while the number of unfilled positions remained constant, Dr. Casey said.

Medical schools produced more U.S. graduates than ever, and increasing numbers chose to specialize in radiology and plastic surgery.  One of every seven residents found positions outside the Match, she said.

In Illinois, for example, 38.6% of the state’s programs, offered positions to 11.1% of residents outside the Match.

The total number of residency slots is declining due to decreased funding. And with drastic Medicare cuts on the horizon, the U.S. will have nowhere near the number of training positions needed to meet future demand, Dr. Casey cautioned.

Funding cuts impact

A 2011 survey of designated institutional officers indicates the potential impact of GME funding cuts, reported presenter Thomas J. Nasca, MD, chief executive officer of ACGME. Of the 306 respondents (total 680), 94.8% said they would reduce programs and positions under a 50% reduction scenario, and 87.7% would reduce programs and positions under the 33% reduction scenario.  Fewer than 10% say they would reduce only subspecialty programs.  Under the first scenario, Illinois would lose 25 to 35% of its resident and fellow positions.