Graduate Medical Education Should Not Be A Commodity.

The demise of Hahnemann University Hospital demonstrates the need for health care and graduate medical education policy reform.

Expansion of Surgical Graduate Medical Education Training Programs: A Return on Investment Analysis.

BACKGROUND: The productivity of surgical departments is limited by the staffing of attending surgeons as well as surgical residents. Despite ongoing surgeon shortages, many health care organizations have been reluctant to expand training programs because of concerns about cost. We sought to determine the return on investment for the expansion of surgical training programs within our health system. METHODS: This study was completed as a retrospective review comparing two independent surgical departments at separate hospitals within a single integrated health system, including complete fiscal information from 2012 to 2019. Hospital A is a 594-bed hospital with large growth in its graduate surgical training programs over the study's period, whereas Hospital B is a 320-bed hospital where there was no expansion in surgical education initiatives. Case volumes, the number of full-time employees (FTE), and revenue data were obtained from our health systems business office. The number of surgical trainees, including general surgery residents and vascular surgery fellows, was provided by our office of Graduate Medical Education. The average yearly net revenue per surgeon was calculated for each training program and hospital location. RESULTS: Our results indicate a positive association between the number of surgical trainees and departmental net revenue, as well as the annual revenue generated per physician FTE. Each additional ancillary provider per physician FTE resulted in a positive impact of $112,552-$264,003 (R2 of 0.69 to 0.051). CONCLUSIONS: Regardless of hospital location or surgical specialty, our results demonstrate a positive association between the average net revenue generated per surgeon and the number of surgical trainees supporting the department. These findings are novel and provide evidence of a positive return on investment when surgical training programs are expanded.

The Value of Surgical Graduate Medical Education (GME) Programs Within An Integrated Health Care System.

OBJECTIVE: Surgical graduate medical education (GME) programs add both significant cost and complexity to the mission of teaching hospitals. While expenses tied directly to surgical training programs are well tracked, overall cost-benefit accounting has not been performed. In this study, we attempt to better define the costs and benefits of maintaining surgical GME programs within a large integrated health system. DESIGN: We examined the costs, in 2018 US dollars, associated with the surgical training programs within a single health system. Total health system expenses were calculated using actual and estimated direct GME expenses (salary, benefits, supplies, overhead, and teaching expenses) as well as indirect medical education (IME) expenses. IME expenses for each training program were estimated by using both Medicare percentages and the Medicare Payment Advisor Commission study. The projected cost to replace surgical trainees with advanced practitioners or hospitalists was obtained through interviews with program directors and administrators and was validated by our system's business office. SETTING: A physician lead, integrated, rural health system consisting of 8 hospitals, a medical school and a health insurance company. PARTICIPANTS: GME surgical training programs within a single health system's department of surgery. RESULTS: Our health system's department of surgery supports 8 surgical GME programs (2 general surgery residencies along with residencies in otolaryngology, ophthalmology, oral-maxillofacial surgery, urology, pediatric dentistry, and vascular surgery), encompassing 89 trainees. Trainees work an average of 64.4 hours per week. Total health system cost per resident ranged from $249,657 to $516,783 based on specialty as well as method of calculating IME expenses. After averaging program costs and excluding IME and overhead expenses, we estimated the average annual cost per trainee to be $84,171. We projected that replacing our surgical trainees would require hiring 145 additional advanced practitioners at a cost of $166,500 each per year, or 97 hospitalists at a cost of $346,500 each per year. Excluding overhead, teaching and IME expenses, these replacements would cost the health system an estimated additional $16,651,281 or $26,119,281 per year, respectively. CONCLUSIONS: Surgical education is an integral part of our health system and ending surgical GME programs would require large expansion of human resources and significant additional fiscal capital.

A National Evaluation of Scholarly Activity Requirement in Osteopathic EM Residency Programs: Survey of EM Program Directors.

OBJECTIVES: The objectives of the study were to determine the percentage of osteopathic emergency medicine (EM) residencies that require an original research project to meet the American Osteopathic Association requirement, describe the resources available to the residents and faculty members to complete their projects, and determine resident and faculty research productivity. METHODS: This was a cross-sectional online survey of program directors from osteopathic EM residency programs. Participants were asked about demographics and specifics related to their program's research curriculum, which included resources, outcomes, and challenges. RESULTS: The response rate was 48.21% (27/56) of program directors from EM residencies. The majority (82.77%) of respondents were from a community-based EM program, had a requirement that a research project be completed before graduation from residency (87.5%), and did not have a research associate program to assist in recruiting patients (83.33%). A physician research director was noted to lead the department in 53.57% of respondents, whereas 70.83% noted having a statistician on staff. A total of 2.91% of program faculty had received federal grant funding, and 13.88% had a research study indexed in PubMed. EM programs that had a physician-led research director were more likely to have core faculty with federal funding, articles indexed in PubMed, residents who submit their research for publication, and residents with competitive grants, as compared with programs without a research director. Program directors noted that analyzing data, designing a study, and generating a hypothesis were the biggest challenges to conducting research in the residency. CONCLUSIONS: Osteopathic EM residencies significantly differ from their allopathic counterparts in their research curriculum, capabilities, and outcomes.

Development and Validation of a Novel and Cost-Effective Animal Tissue Model for Training Transurethral Resection of the Prostate.

OBJECTIVES: To develop and validate a new and cost-effective animal tissue training model for practicing resection skills of transurethral resection of the prostate (TURP). METHODS AND MATERIALS: A porcine kidney was prepared and restructured to simulate the relevant anatomy of the human prostate. The restructured prostate was connected to an artificial urethra and bladder. Face, content, and construct validity of the model was carried out using a 5-point Likert scale questionnaire, and comparison in task performance between participants and experts was made using observational clinical human reliability analysis. RESULTS: A total of 24 participants and 11 experts who practiced TURP skills on this model from October 2014 to December 2015 were recruited. The mean score on specific feature of the anatomy and color, sensation of texture and feeling of resection, conductibility of current, and efficacy and safety of the model were 4.34 ± 0.37, 4.51 ± 0.63, 4.13 ± 0.53, and 4.35 ± 0.71, respectively, by participants whereas they were 4.22 ± 0.23, 4.30 ± 0.48, 4.11 ± 0.62, and 4.56 ± 0.77, respectively, by the experts on a scale of 1 (unrealistic) to 5 (very realistic). Participants committed more technical errors than the experts (11 vs 7, p < 0.001), produced more movements of the instruments (51 vs 33, p < 0.001), and required longer operating time (11.4 vs 6.2min, p < 0.001). CONCLUSIONS: A newly developed restructured animal tissue model for training TURP was reported. Validation study on the model demonstrates that this is a very realistic and effective model for skills training of TURP. Trainees committed more technical errors, more unproductive movements, and required longer operating time.

Integrative Medicine in Preventive Medicine Education: Competency and Curriculum Development for Preventive Medicine and Other Specialty Residency Programs.

During 2012, the USDHHS's Health Resources and Services Administration funded 12 accredited preventive medicine residencies to incorporate an evidence-based integrative medicine curriculum into their training programs. It also funded a national coordinating center at the American College of Preventive Medicine, known as the Integrative Medicine in Preventive Medicine Education (IMPriME) Center, to provide technical assistance to the 12 grantees. To help with this task, the IMPriME Center established a multidisciplinary steering committee, versed in integrative medicine, whose primary aim was to develop integrative medicine core competencies for incorporation into preventive medicine graduate medical education training. The competency development process was informed by central integrative medicine definitions and principles, preventive medicine's dual role in clinical and population-based prevention, and the burgeoning evidence base of integrative medicine. The steering committee considered an interdisciplinary integrative medicine contextual framework guided by several themes related to workforce development and population health. A list of nine competencies, mapped to the six general domains of competence approved by the Accreditation Council of Graduate Medical Education, was operationalized through an iterative exercise with the 12 grantees in a process that included mapping each site's competency and curriculum products to the core competencies. The competencies, along with central curricular components informed by grantees' work presented elsewhere in this supplement, are outlined as a roadmap for residency programs aiming to incorporate integrative medicine content into their curricula. This set of competencies adds to the larger efforts of the IMPriME initiative to facilitate and enhance further curriculum development and implementation by not only the current grantees but other stakeholders in graduate medical education around integrative medicine training.

[Further education: a core responsibility of the German Society for Rheumatology and the Rheuma Academy]. / Weiterbildung - eine zentrale Aufgabe für DGRh und Rheumaakademie.

The first further education training program of the German Society of Rheumatology (DGRh) was an important milestone in further training in rheumatology. The workshop presented approaches on how to interest and gain students and young physicians for rheumatology and presented the possibilities planned by the DGRh in cooperation with partner organizations and the Rheuma Academy for improvement of further training in rheumatology and the potential to benefit inpatient further training. Many of the projects are dependent on financial support especially by industry. In this article the most important theses and arguments from the individual lectures will be presented.

US residency training before and after the 1997 Balanced Budget Act.

CONTEXT: Graduate medical education (GME) determines the size and characteristics of the future workforce. The 1997 Balanced Budget Act (BBA) limited Medicare funding for additional trainees in GME. There has been concern that because Medicare is the primary source of GME funding, the BBA would discourage growth in GME. OBJECTIVE: To examine the number of residents in training before and after the BBA, as well as more recent changes in GME by specialty, sex, and type and location of education. DESIGN: Descriptive study using the American Medical Association/Association of American Medical Colleges National GME Census on physicians in Accreditation Council for Graduate Medical Education (ACGME)-accredited programs to examine changes in the number and characteristics of residents before and after the BBA. MAIN OUTCOME MEASURES: Differences in the number of physicians in ACGME-accredited training programs overall, by specialty, and by location and type of education. RESULTS: The number of residents and fellows changed little between academic year (AY) 1997 (n = 98,143) and AY 2002 (n = 98,258) but increased to 106,012 in AY 2007, a net increase of 7869 (8.0%) over the decade. The annual number of new entrants into GME increased by 7.6%, primarily because of increasing international medical graduates (IMGs). United States medical school graduates (MDs) comprised 44.0% of the overall growth from 2002 to 2007, followed by IMGs (39.2%) and osteopathic school graduates (18.8%). United States MD growth largely resulted from selection of specialties with longer training periods. From 2002 to 2007, US MDs training in primary care specialties decreased by 2641, while IMGs increased by 3286. However, increasing subspecialization rates led to fewer physicians entering generalist careers. CONCLUSION: After the 1997 BBA, there appears to have been a temporary halt in the growth of physicians training in ACGME programs; however, the number increased from 2002 to 2007.

Spirituality training for palliative care fellows.

INTRODUCTION: Spirituality is a major domain of palliative medicine training. No data exist on how it is taught, nor is there a consensus about the content or methods of such education. We surveyed palliative medicine fellowship directors in the United States to learn how they teach spirituality, who does the teaching, and what they teach. METHODS: A PubMed () search using the terms "spirituality" and "medical education" was completed. Thirty-two articles outlined spirituality education content and methods in medical schools and residency programs. From these articles, a survey on spirituality education in palliative medicine fellowship training was prepared, pilot-tested, revised, and then distributed by e-mail in June 2004 to the 48 U.S. palliative medicine fellowship directors listed on the American Board of Hospice and Palliative Medicine (AAHPM) website, but excluding the three fellowship programs represented by the authors. Follow-up requests were sent by email twice during the 6-week collection period. The Institutional Review Board at the Medical College of Wisconsin approved the study. RESULTS: Fourteen fellowship directors completed the survey (29% of all programs; 42% of those currently teaching fellows as indicated on the AAHPM website). All programs indicated they taught "spirituality"; 12 of 14 had separate programs for teaching spirituality and 2 of 14 reported they taught spirituality to their fellows but not as a distinct, separate program. All respondents taught the definitions of spirituality and religion, common spiritual issues faced by patients at end of life (which was not defined further), and the role of chaplains and clergy. Chaplains provided spirituality education in all of the responding programs, but other team members were frequently involved. The most common formats for education in the domains of knowledge and attitudes were small group discussion, lecture, and self-study. Small group discussion, supervision, and shadowing a chaplain or other professional were the most common methods used for skills. Faculty written or oral evaluations of fellows were the most common forms of evaluation, with little evidence of more robust assessment methods, such as structured role-play (none of the programs surveyed). CONCLUSIONS: Palliative medicine fellowship programs generally agree on the content of training on spirituality, but have not incorporated robust educational and evaluation methods to ensure that fellows have obtained the desired attitudes, knowledge, and skills to meet the Initial Voluntary Program Standards for Residency Education in Palliative Medicine of the American Board of Hospice and Palliative Medicine. Based on the survey data and results from the literature review, broad recommendations are made to enhance spirituality education.

[Further development of urology in the tension field of surgical and molecular medicine]. / Weiterentwicklung der Urologie im Spannungsfeld von operativer und molekularer Medizin.

Methods based on molecular biology and molecular medicine now have important practical applications in many areas of theoretical and clinical medicine, and it is no longer possible to imagine life without them. This means that in a largely surgical discipline, such as urology, completely new challenges are coming to the fore, which urology, as an academic and clinical discipline, now has to face up to, and to a much greater degree than hitherto. However, there is less and less freedom of action in any university department of urology, as a result not only of intensified legal outline conditions in the healthcare sector and tight public budgets, but also of faculty- and hospital-specific blocks to innovation. There is an urgent need for the creation of appropriate outline conditions and innovative structures that will allow efficient surgical care and also an efficient way of working scientifically.

Current threats to osteopathic graduate medical education.

The Balanced Budget Act of 1997 and continuing changes put into place by the Educational Commission on Foreign Medical Graduates (ECFMG) are altering the environment for graduate medical education (GME) in ways that threaten osteopathic graduate medical education in particular. Hospital revenue is decreasing due to declines in Medicare GME and patient-care reimbursements. The new 3-year rolling average methodology for counting "house staff" makes it likely that unfilled positions will be eliminated. With osteopathic GME positions unfilled and financial resources decreasing, osteopathic medical programs may shrink further. Additionally, the ECFMG has put into place policies that may restrict the number of international medical graduates entering the United States. Approximately 25% of all allopathic GME positions in the United States are filled by international medical graduates. If this applicant pool decreases, allopathic medical programs may turn to osteopathic medical graduates as the only other available pool of individuals to fill program positions. At a time when allopathic internship positions are already unfilled and 30% of osteopathic medical graduates enter allopathic first-year programs, further inroads by allopathic programs could severely impact osteopathic GME efforts.

Knowledge for improvement: who will lead the learning?

If we wish to improve the results of a system, what is needed to help health professionals learn about the redesign of that system? To create learning experiences that will attract good health professionals, a special blend of practical insight and critical thinking is required. To enjoy good standing in the academy, these leaders must be able to design, conduct, and disseminate knowledge-building activities subject to peer review. This is the story of the development of the United States Veteran's Health Administration Quality Scholars Program from those who designed and formed it to prepare health professional teachers and academics.

The social roles of Medicare: assessing Medicare's collateral benefits.

The Medicare program incorporates a number of functions that go beyond providing health insurance to its beneficiaries. These activities, which we refer to as "collateral" functions, may have important health consequences but are also an increasing source of controversy. In this essay we develop a conceptual framework for categorizing these involvements, introduce some additional options that might complement Medicare's current collateral functions, assess the reaction of policy elites and Medicare's current beneficiaries to these alternatives, and evaluate the role that collateral activities play for Medicare's core mission. A case can be made for expanding some collateral involvements, but only if the Health Care Financing Administration has the strategic direction and administrative capacity to effectively implement these activities.

A Fellowship in Quality Management.

The U.S. Healthcare Fellowship in Quality Management at Hahnemann University was developed by a managed health care organization and health science university in order to train physicians in the theory and practice of quality management and clinical outcomes measurement. This article describes in detail the program content and the characteristics of applicants.

Health care delivery systems: effects on surgical education in Italy.

Since 1989 a national health system (NHS) has been in effect in Italy based on the constitutional principle that health care is a right of all citizens. Until 1992 the NHS had a secondary role in medical education, as the 33 medical schools for postgraduate training are under the control of the Ministry of University. The European Community legislation allowing free movement of M.D.s and specialists between member countries has resulted in standardization of teaching programs and formative curricula in the European Community. Therefore beginning in 1992, every 3 years the Ministry of Health and University establishes the number of specialists that can meet the needs of the NHS and allocates funds to each school for the salary obligations. The actual number of paid residents for surgical specialties is 941 per year (192 for general surgery). Until recently surgical training in Italy was mainly theoretic, as no legislation guaranteed that physicians in training would perform surgery. New legislation, increased exchanges with European hospitals, and improved and loyal cooperation between universities and the NHS will certainly improve the situation in coming years.