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.

The Graduate Medical Education (GME) Gold Rush: GME Slots and Funding as a Financial Asset.

The unprecedented displacement of more than 550 trainees that occurred because of the closure of Hahnemann University Hospital has demonstrated that the medical education community, Centers for Medicare and Medicaid Services, and the Accreditation Council for Graduate Medical Education were unprepared for a graduate medical education (GME) crisis of this scale. The authors offer a first-hand perspective of the chaotic environment that ensued following the announcement of the hospital's closure and of the challenges faced by trainees and program leadership looking to ensure trainees found a landing program that was a good fit for them. The authors review the complexity of GME funding and how the owners of Hahnemann University Hospital leveraged this in an attempt to offset debt. The lessons learned from the authors' experience can help inform the medical education community's response to this type of crisis in the future.

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.

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.

Integrative Medicine in a Preventive Medicine Residency: A Program for the Urban Underserved.

The Preventive Medicine Residency Program collaborated with the Department of Family Medicine's Program for Integrative Medicine and Health Disparities at Boston Medical Center to create a new rotation for preventive medicine residents starting in autumn 2012. Residents participated in integrative medicine group visits and consults, completed an online curriculum in dietary supplements, and participated in seminars all in the context of an urban safety net hospital. This collaboration was made possible by a federal Health Resources and Services Administration grant for integrative medicine in preventive medicine residencies and helped meet a need of the program to increase residents' exposure to clinical preventive medicine and integrative health clinical skills and principles. The collaboration has resulted in a required rotation for all residents that continues after the grant period and has fostered additional collaborations related to integrative medicine across the programs.

Project ASPIRE: Incorporating Integrative Medicine Into Residency Training.

Griffin Hospital, a community hospital affiliated with Yale School of Public Health and Yale School of Medicine, received Health Resources and Services Administration funding to strengthen and improve its combined internal medicine and general preventive medicine residency program by incorporating an integrative medicine curriculum. The purpose of project ASPIRE (Advancing Skills of Preventive medicine residents through Integrative medicine Education, Research and Evaluation) was to create, implement, and evaluate a needs-based, innovative training curriculum in integrative medicine. Through this robust new training, the authors aimed to produce preventive medicine-trained physicians with competencies in integrative medicine to collaboratively work with other integrative medicine practitioners in interdisciplinary teams to provide holistic, patient-centered care. The multifaceted collaborative curriculum was composed of didactics, grand rounds, journal club, objective structured clinical examinations, and two new practicum rotations in integrative medicine. The new practicum rotations included block rotations at the Integrative Medicine Center at Griffin Hospital and the Yale Stress Center. Between 2012 and 2014, three cohorts participated in the curriculum; two of these cohorts included three advanced preventive medicine residents each and the fourth included four residents. Project faculty conducted 14 lectures and journal clubs, and two grand rounds. Six of the ten participating residents (60%) completed integrative medicine clinical rotations. Residents' attitudes toward integrative medicine were evaluated through self-assessment using the Complementary, Alternative, and Integrative Medicine Attitudes Questionnaire; data were analyzed in 2015. This article describes the results of this prospective observational study based on single-institution experience over the course of the 2-year project period.

Creating an effective and efficient publicly sponsored health care delivery system.

An effective and efficient publicly sponsored health care delivery system can increase access to care, improve health care outcomes, and reduce spending. A publicly sponsored health care delivery system can be created by integrating services that are already federally subsidized: community health centers (CHCs), public and safety-net hospitals, and residency training programs. The Patient Protection and Affordable Care Act includes measures that support primary care generally and CHCs in particular. A publicly sponsored health care delivery system combining primary care based in CHCs with safety-net hospitals and the specialists that serve them could also benefit from incentives in the Patient Protection and Affordable Care Act for the creation of accountable care organizations, and reimbursement based on quality and cost control.

Evaluating the need for alternative didactic learning options in pediatric dental residency training.

The need for an alternative means of delivery of a didactic curriculum to pediatric dental residents is described. It is our hope with this project to encourage a much-needed didactic curriculum for programs lacking faculty and to endorse other programs in which academicians exist but cannot cover all the material with which a resident needs to become familiar in the two years of postgraduate residency training. A decrease in faculty number due to retirement, debt burden, or marginal recruitment techniques along with an increase in positions in pediatric dentistry residency programs poses a unique educational dilemma. Using a mixed-method research methodology, we sent a twelve-question survey to 105 pediatric dentistry residency program directors and department chairs, followed by eight telephone interviews. Results from a 55 percent return rate show that the debt burden of most pediatric dental residents is well over $100,000 and that this affects a resident's decision to enter academia, as does the relative lack of positive recruitment techniques and poor faculty remuneration. The survey results affirm the need for improvement in the didactic curriculum of pediatric dentistry residents and show that program directors and department chairs also feel that an alternative delivery method using DVD or online/web-based programs would be welcomed. Despite their extremely heavy workloads, educators are willing to contribute by providing lectures or reading lists in their area of expertise.

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.

Reasons for student debt during medical education: a Michigan study.

The authors address the need for a better understanding of the reasons for greater indebtedness among today's osteopathic medical students. In May 2000, a survey was mailed to all 219 osteopathic interns at participating institutions in Michigan. The self-administered survey contained 19 questions designed to gather basic financial information, demographic characteristics, and subjective perceptions of student debt loads from participating interns. One hundred seventy completed surveys were returned, for a response rate of 78%. The authors attempted to focus on demographic predictors of debt and found that although there is no indication that such predictors have a significant effect on a student's total debt load, financial support from the student's family remains the single most important factor in predicting low levels of student debt. The authors suggest that the higher debt rate of students entering specialty fields may reflect the fact that students incur these debts with the knowledge that those debts will be more easily repaid once the student has begun to practice medicine.

Characteristics of civilian postdoctoral general dentistry programs.

U.S. civilian (non-VA/non-military) Advanced Education in General Dentistry (AEGD) and General Practice Residency (GPR) programs were identified (n=208) and surveyed. The assessment evaluated infrastructure support, populations served, services provided, and trainee stipends. One hundred thirty-one programs responded (thirty-two AEGD, 64 percent/ninety-nine GPR, 63 percent). Sixty-nine programs were HRSA-funded (53 percent), and sixty-three (47 percent) were nonfunded. One hundred and five responses identified hospital/medical center resources; fifty-six indicated dental school support. Mean faculty support was similar regardless of program type or HRSA funding. Mean first-year positions in AEGDs were greater than GPRs. Mean first-year GPR positions were greater in funded than in nonfunded programs. A comparison of AEGD and GPR programs showed that residents in GPRs treated more children, medically intensive, economically/socially disadvantaged, and in-patient/same-day surgery patients (p<0.05). Residents in AEGDs treated more healthy adults (p<0.05). GPRs treated more lower fee (no pay, Medicaid, welfare/general relief, Medicare, and capitation/HMO) patients. AEGDs treated more insurance/private pay patients (p=.0001). No differences existed in comprehensive care and emergency visits between AEGDs and GPRs. GPRs treated more hospital-based patients. The mean stipends for GPRs ($32,055) and AEGDs ($22,403) were different.

Residency training in dental public health: assessment of status, needs, and issues.

The opportunities for public health training have declined over the years while the need for public health skills is likely to increase. This paper reports the results of a project, sponsored by the Health Resources and Services Administration, which answers the question of "how best to invest in the dental public health education system so as to fulfill the profession's responsibilities to protect and improve the oral health of individuals and society." An information base on dental public health education, practice, and specialization was developed from an extensive review of the literature and a survey of dentists concerning employment and practice requirements for public health dentists. An advisory group considered this information, met to discuss the issues involved in dental public health training, and provided advice to the project staff. Based on the information gathered as part of the project, recommendations were made to: (1) develop a grant program to support advanced education in dental public health; (2) increase the competencies of dentists who are working in public health positions and not eligible for board certification via off-site residencies; (3) develop model programs in areas of great need, such as general public health, management, policy, prevention, environmental health and research, that in conjunction with a basic public health core, could satisfy the eligibility requirements of the American Board of Dental Public Health; (4) develop student loan forgiveness programs for dentists and dental hygienists working in public health; and (5) develop additional credential recognition programs for dental public health workers.