Separate But Not Equal? A Cross-Sectional Study of Segregation by Payor Mix in Academic Primary Care Clinics.

BACKGROUND: At some US Academic Health Centers (AHCs), patients with predominantly Medicaid insurance are seen in one clinic and patients with other insurance are seen in another. The extent of this practice and implications are unknown. OBJECTIVE: To estimate the proportion of AHCs that have at least two primary care internal medicine clinics that differ substantially in proportion of patients with Medicaid and to compare patient demographic, staffing, and operational features. PARTICIPANTS: General internal medicine chiefs and clinic directors at 40 randomly selected US AHCs plus the top 10 AHCs in terms of NIH funding. MAIN MEASURE: An AHC was classified as maintaining clinics that differed substantially in the proportion of patients with Medicaid if any two differed by ≥ 40% (absolute). Other criteria were used for pre-specified secondary analyses (e.g., ≥ 30%). KEY RESULTS: Thirty-nine of 50 AHCs (78%) participated. Four of 39 (10%; 95% CI, 3 to 24%) had two clinics differing by ≥ 40% in the proportion of patients with Medicaid, eight (21%; 95% CI, 9 to 36%) had clinics differing by ≥ 30%, and 15 (38%; 95% CI, 23 to 55%) had clinics differing by ≥ 20%. Clinics with more patients with Medicaid by any of the three criteria were more likely to employ resident physicians as providers of longitudinal care (with faculty supervision) and more likely to have patients who were Black or Hispanic. CONCLUSIONS: Some US AHCs maintain separate clinics defined by the proportion of patients with Medicaid. Clinics with a higher proportion of patients insured by Medicaid are more likely to employ residents (with faculty oversight), feature residents as providers of longitudinal care, and serve patients who are Black and Hispanic. Further research is needed to understand why some AHCs have primary care clinics distinguishable by insurance mix with the goal of ensuring that racism and discrimination are not root causes.

The Undergraduate to Graduate Medical Education Transition as a Systems Problem: A Root Cause Analysis.

The transition from undergraduate medical education (UME) to graduate medical education (GME) constitutes a complex system with important implications for learner progression and patient safety. The transition is currently dysfunctional, requiring students and residency programs to spend significant time, money, and energy on the process. Applications and interviews continue to increase despite stable match rates. Although many in the medical community acknowledge the problems with the UME-GME transition and learners have called for prompt action to address these concerns, the underlying causes are complex and have defied easy fixes. This article describes the work of the Coalition for Physician Accountability's Undergraduate Medical Education to Graduate Medical Education Review Committee (UGRC) to apply a quality improvement approach and systems thinking to explore the underlying causes of dysfunction in the UME-GME transition. The UGRC performed a root cause analysis using the 5 whys and an Ishikawa (or fishbone) diagram to deeply explore problems in the UME-GME transition. The root causes of problems identified include culture, costs and limited resources, bias, systems, lack of standards, and lack of alignment. Using the principles of systems thinking (components, connections, and purpose), the UGRC considered interactions among the root causes and developed recommendations to improve the UME-GME transition. Several of the UGRC's recommendations stemming from this work are explained. Sustained monitoring will be necessary to ensure interventions move the process forward to better serve applicants, programs, and the public good.

Blue Skies With Clouds: Envisioning the Future Ideal State and Identifying Ongoing Tensions in the UME-GME Transition.

The transition from medical school to residency in the United States consumes large amounts of time for students and educators in undergraduate and graduate medical education (UME, GME), and it is costly for both students and institutions. Attempts to improve the residency application and Match processes have been insufficient to counteract the very large number of applications to programs. To address these challenges, the Coalition for Physician Accountability charged the Undergraduate Medical Education to Graduate Medical Education Review Committee (UGRC) with crafting recommendations to improve the system for the UME-GME transition. To guide this work, the UGRC defined and sought stakeholder input on a "blue-skies" ideal state of this transition. The ideal state views the transition as a system to support a continuum of professional development and learning, thus serving learners, educators, and the public, and engendering trust among them. It also supports the well-being of learners and educators, promotes diversity, and minimizes bias. This manuscript uses polarity thinking to analyze 3 persistent key tensions in the system that require ongoing management. First, the formative purpose of assessment for learning and growth is at odds with the use of assessment data for ranking and sorting candidates. Second, the function of residents as learners can conflict with their role as workers contributing service to health care systems. Third, the current residency Match process can position the desire for individual choice-among students and their programs-against the workforce needs of the profession and the public. This Scholarly Perspective presents strategies to balance the upsides and downsides inherent to these tensions. By articulating the ideal state of the UME-GME transition and anticipating tensions, educators and educational organizations can be better positioned to implement UGRC recommendations to improve the transition system.

Unintended Consequences of a Transition to Synchronous, Virtual Simulations for Interprofessional Learners.

The coronavirus pandemic shifted in-person environments to virtual environments. Little is known about the effectiveness of fully synchronous, virtual interprofessional education (IPE). This study aims to compare two IPE cases that occurred in-person pre-pandemic and virtual during-pandemic. Two cases are analyzed: a medical error care and a charity care case. Participants were students from various health science disciplines. Assessments were captured through The Interprofessional Collaborative Competency Attainment Survey (ICCAS). Effect sizes were calculated for the pre-and post-surveys and analyzed using Cohen's d for independent samples. From the in-person collection period, a total of 479 students participated in the medical error simulation and 479 in the charity care simulation. During the virtual collection period, a total of 506 students participated in the medical error simulation and 507 participated in the charity care simulation. In the data for the virtual simulations, the medical error case study maintained a large effect size (0.81) while the charity care simulation had a lesser impact (0.64 effect size). Structural details of the patient cases may be a critical variable. Future research is needed to better understand how health science students can obtain more training to notice the subtle cues from patients assessed through telemedicine modalities.

UGRC 2021 recommendations on GME transition: pros and cons, opportunities and limitations.

The Coalition for Physician Accountability's Undergraduate Medical Education-Graduate Medical Education (UME-GME) Review Committee (UGRC): Recommendations for Comprehensive Improvement of the UME-GME Transition final report includes a total of 34 recommendations and outlines opportunities to transform the current processes of learner transition from a US-based MD- or DO-granting medical school or international medical education pathway into residency training in the United States. This review provides a reflection on the recommendations from the authors, all members of the UGRC, describing the pros and cons and the opportunities and limitations, in the hopes that they might inspire readers to dig deeper into the report and contribute to meaningful improvements to the current transition. The UGRC Recommendations highlight the many opportunities for improvement in the UME-to-GME transition. They are built on the connection to the system of education and formation of physicians to a more just healthcare system, with attention to diversity, equity, and inclusion to improve health disparities and to the quality of care that patients receive. However, there are justifiable concerns about changes that are not fully understood or that could potentially lead to unintentional consequences. This analysis, reached through author consensus, considers the pros and cons in the potential application of the UGRC Recommendations to improve the UME-to-GME transition. Further debate and discussion are warranted, without undue delay, all with the intention to continue to improve the education of tomorrow's physicians and the care for the patients who we have the privilege to serve.

Role of faculty characteristics in failing to fail in clinical clerkships.

INTRODUCTION: In the context of competency-based medical education, poor student performance must be accurately documented to allow learners to improve and to protect the public. However, faculty may be reluctant to provide evaluations that could be perceived as negative, and clerkship directors report that some students pass who should have failed. Student perception of faculty may be considered in faculty promotion, teaching awards, and leadership positions. Therefore, faculty of lower academic rank may perceive themselves to be more vulnerable and, therefore, be less likely to document poor student performance. This study investigated faculty characteristics associated with low performance evaluations (LPEs). METHOD: The authors analysed individual faculty evaluations of medical students who completed the third-year clerkships over 15 years using a generalised mixed regression model to assess the association of evaluator academic rank with likelihood of an LPE. Other available factors related to experience or academic vulnerability were incorporated including faculty age, race, ethnicity, and gender. RESULTS: The authors identified 50 120 evaluations by 585 faculty on 3447 students between January 2007 and April 2021. Faculty were more likely to give LPEs at the midpoint (4.9%), compared with the final (1.6%), evaluation (odds ratio [OR] = 4.004, 95% confidence interval [CI] [3.59, 4.53]; p < 0.001). The likelihood of LPE decreased significantly during the 15-year study period (OR = 0.94 [0.90, 0.97]; p < 0.01). Full professors were significantly more likely to give an LPE than assistant professors (OR = 1.62 [1.08, 2.43]; p = 0.02). Women were more likely to give LPEs than men (OR = 1.88 [1.37, 2.58]; p 0.01). Other faculty characteristics including race and experience were not associated with LPE. CONCLUSIONS: The number of LPEs decreased over time, and senior faculty were more likely to document poor medical student performance compared with assistant professors.

Revisiting the Core Entrustable Professional Activities for Entering Residency.

The Core EPAs for Entering Residency Pilot project aimed to test the feasibility of implementing 13 entrustable professional activities (EPAs) at 10 U.S. medical schools and to gauge whether the use of the Core EPAs could improve graduates' performance early in residency. In this manuscript, the authors (members of the pilot institutions and Association of American Medical Colleges staff supporting the project evaluation) describe the schools' capacity to collect multimodal evidence about their students' performance in each of the Core EPAs and the ability of faculty committees to use those data to make decisions regarding learners' readiness for entrustment. In reviewing data for each of the Core EPAs, the authors reflected on how each activity performed as an EPA informed by how well it could be assessed and entrusted. For EPAs that did not perform well, the authors examined whether there are underlying practical and/or theoretical issues limiting its utility as a measure of student performance in medical school.

Primary care experience among older adults in the United States: a retrospective cross-sectional study.

BACKGROUND: While the importance of primary care becomes more imminent for older adults to manage multi-morbidities, the perception of primary care among this group is not well examined. AIM: To evaluate the primary care experience among older adults in the United States (US). METHODS: We conducted a retrospective cross-sectional study examining four domains of primary care: first contact, longitudinality, comprehensiveness, and coordination. Using survey responses from Medical Expenditure Panel Survey (MEPS), we used propensity score matching method to compare the percentage of geriatric (≥65 years old) and non-geriatric (< 65 years old) who answered favorably to questions that supported each domain from 2014 to 2016. Using multivariate regression, we also assessed the impact of each domain on various demographic and perceived need for care features of older adults. RESULTS: A total of 12,982 surveys were analyzed for geriatric, compared to 62,694 surveys for non-geriatric. Overall, older adults answered more favorably than younger adults for all four domains. However, uninsured older adults, Black older adults and older adults with limitation in activities, cognitive impairments, and multiple comorbidities were more likely to have difficulties in accessing their usual source of care (USC). Additionally, Black, Hispanic, and Asian older adults and cognitively impaired adults perceived less contribution in their own treatment management. CONCLUSION: Older adults in the US generally experience good quality of primary care, compared to younger adults. However, establishing and maintaining access (first contact) and being involved in disease management (coordination) were perceived as poor by several cohorts of older adults.

Mission-Based Filters in the Electronic Residency Application Service: Saving Time and Promoting Diversity.

BACKGROUND: Holistic review promotes diversity, but widespread implementation remains limited. OBJECTIVE: We aimed to develop a practical approach to incorporate holistic review principles in screening applicants in the Electronic Residency Application Service (ERAS) and to assess the impact on diversity. METHODS: Three residency programs (internal medicine [IM], pediatrics, and surgery) at McGovern Medical School developed filters to identify applicants with experiences/attributes aligned with the institutional mission. These filters were retroactively applied to each program's 2019-2020 applicant pool using built-in ERAS capabilities to group applicants by user-defined features. We compared the demographics of applicants reviewed during the cycle with those identified retrospectively through experiences/attributes filters. RESULTS: The IM, pediatrics, and surgery programs received 3527, 1341, and 1313 applications, respectively, in 2019-2020. Retrospective use of experiences/attributes filters, without scores, narrowed the IM applicant pool for review to 1301 compared to 1323 applicants reviewed during actual recruitment, while the pediatrics filters identified 514 applicants compared to 384 at baseline. The surgery filters resulted in 582 applicants, but data were missing for baseline comparison. Compared to the baseline screening approach utilizing scores, mission-based filters increased the proportions of underrepresented in medicine applicants selected for review in IM (54.8% [95% CI 52.1-57.5] vs 22.7% [20.4-24.9], P < .0001) and pediatrics (63.2% [95% CI 59.1-67.4] vs 25.3% [20.9-29.6], P < .0001). CONCLUSIONS: Program directors can leverage existing ERAS features to conduct application screening in alignment with holistic review principles. Widespread implementation could have important repercussions for enhancing physician workforce diversity.

Bridging the Gap: Holistic Review to Increase Diversity in Graduate Medical Education.

PROBLEM: Racial and ethnic disparities in health outcomes remain pervasive in the U.S. health care system. Increasing the diversity of the physician workforce is recognized as an important component of addressing these disparities. Holistic review, which gives balanced consideration to applicants' academic metrics, experiences, and attributes, has gained popularity in undergraduate medical education and led to improvement in student diversity. Limited research has investigated how holistic review and other strategies can be implemented in graduate medical education to enhance diversity. APPROACH: The internal medicine (IM) residency program of the John P. and Kathrine G. McGovern Medical School implemented a pilot intervention in academic years (AY) 2016-2017 and 2017-2018 aimed at increasing the number of matriculating residents who are underrepresented in medicine (URM). The intervention included (1) using holistic review in the process of selecting applicants for interview, (2) standardizing the interview encounters, and (3) explicitly highlighting the program's commitment to diversity on interview days. OUTCOMES: From AY 2015-2016 (preintervention) to AY 2017-2018, the percentage of URM applications reviewed increased from 14.1% (180/1,276) to 20.4% (183/897), the proportion of URM applicants interviewed rose from 16.0% (60/374) to 24.5% (95/388), and the proportion of URM residents matriculating increased from 12.5% (5/40) to 31.7% (13/41). NEXT STEPS: Further efforts are needed to expand the pool of URM applicants at McGovern and elsewhere and to identify how holistic review can be widely employed in other IM residency programs and in other specialties.