Academic Medicine and Rural Health System Partnerships: Enhancing Education While Advancing Physician Workforce Priorities.

ABSTRACT: A worsening shortage of rural physicians paralleling increasing health disparities demands attention. Past and ongoing efforts to address this shortage have had positive effects and can inform new strategies to achieve even greater impact. Interventions have included the development of regional medical school campuses and rural-focused tracks to recruit medical students from rural areas, expansion of rural-based graduate medical education (GME) programs and tracks, and use of institutional and individual financial incentives for rural-based training and/or practice. National policy has also taken aim at this challenge with provisions aimed at expanding rural GME in the Medicare, Medicaid, and State Children's Health Insurance Program Balanced Budget Refinement Act of 1999 and the Consolidated Appropriations Act of 2021. Additionally, several states have funded growth in GME, and supportive pathways for Medicare reimbursement and for Veterans Administration funding have been implemented. The authors recommend a new strategy for bolstering the rural physician workforce, focused on using academic-rural partnerships to incorporate rural rotations as a routine part of GME. They explain how the current health care landscape supports this approach and outline additional steps toward implementation. Centralized data collection and analysis are noted as essential to guide future efforts.

Promotion in Place: A Model for Competency-Based, Time-Variable Graduate Medical Education.

PROBLEM: Competency-based medical education is increasingly regarded as a preferred framework for physician training, but implementation is limited. U.S. residency programs remain largely time based, with variable assessments and limited opportunities for individualization. Gaps in graduates' readiness for unsupervised care have been noted across specialties. Logistical barriers and regulatory requirements constrain movement toward competency-based, time-variable (CBTV) graduate medical education (GME), despite its theoretical benefits. APPROACH: The authors describe a vision for CBTV-GME and an implementation model that can be applied across specialties. Termed "Promotion in Place" (PIP), the model relies on enhanced assessment, clear criteria for advancement, and flexibility to adjust individuals' responsibilities and time in training based on demonstrated competence. PIP allows a resident's graduation to be advanced or delayed accordingly. Residents deemed competent for early graduation can transition to attending physician status within their training institution and benefit from a period of "sheltered independence" until the standard graduation date. Residents who need extended time to achieve competency have graduation delayed to incorporate additional targeted education. OUTCOMES: A proposal to pilot the PIP model of CBTV-GME received funding through the American Medical Association's "Reimagining Residency" initiative in 2019. Ten of 46 residency programs in a multihospital system expressed interest and pursued initial planning. Seven programs withdrew for reasons including program director transitions, uncertainty about resident reactions, and the COVID-19 pandemic. Three programs petitioned their specialty boards for exemptions from time-based training. One program was granted the needed exemption and launched a PIP pilot, now in year 4, demonstrating the feasibility of implementing this model. Implementation tools and templates are described. NEXT STEPS: Larger-scale implementation with longer-term assessment is needed to evaluate the impact and generalizability of this CBTV-GME model.

Improving Graduate Medical Education by Aggregating Data Across the Medical Education Continuum.

ABSTRACT: Meaningful improvements to graduate medical education (GME) have been achieved in recent decades, yet many GME improvement pilots have been small trials without rigorous outcome measures and with limited generalizability. Thus, lack of access to large-scale data is a key barrier to generating empiric evidence to improve GME. In this article, the authors examine the potential of a national GME data infrastructure to improve GME, review the output of 2 national workshops on this topic, and propose a path toward achieving this goal.The authors envision a future where medical education is shaped by evidence from rigorous research powered by comprehensive, multi-institutional data. To achieve this goal, premedical education, undergraduate medical education, GME, and practicing physician data must be collected using a common data dictionary and standards and longitudinally linked using unique individual identifiers. The envisioned data infrastructure could provide a foundation for evidence-based decisions across all aspects of GME and help optimize the education of individual residents.Two workshops hosted by the National Academies of Sciences, Engineering, and Medicine Board on Health Care Services explored the prospect of better using GME data to improve education and its outcomes. There was broad consensus about the potential value of a longitudinal data infrastructure to improve GME. Significant obstacles were also noted.Suggested next steps outlined by the authors include producing a more complete inventory of data already being collected and managed by key medical education leadership organizations, pursuing a grass-roots data sharing pilot among GME-sponsoring institutions, and formulating the technical and governance frameworks needed to aggregate data across organizations.The power and potential of big data is evident across many disciplines, and the authors believe that harnessing the power of big data in GME is the best next step toward advancing evidence-based physician education.

Prevention of COVID-19 Following a Single Intramuscular Administration of Adintrevimab: Results From a Phase 2/3 Randomized, Double-Blind, Placebo-Controlled Trial (EVADE).

Background: The prevention of coronavirus disease 2019 (COVID-19) in vulnerable populations is a global health priority. EVADE was a phase 2/3 multicenter, double-blind, randomized, placebo-controlled trial of adintrevimab, an extended-half-life monoclonal antibody, for postexposure (PEP) and pre-exposure prophylaxis (PrEP) of symptomatic COVID-19. Methods: Eligible participants (vaccine-naive, aged ≥12 years) were randomized 1:1 to receive a single 300-mg intramuscular injection of adintrevimab or placebo. Primary efficacy end points were reverse transcription polymerase chain reaction (RT-PCR)-confirmed symptomatic COVID-19 through day 28 in the PEP cohort (RT-PCR-negative at baseline) and through month 3 in the PrEP cohort (RT-PCR-negative and seronegative at baseline) among participants randomized before emergence of the severe acute respiratory syndrome coronavirus 2 Omicron variant (November 30, 2021). Safety was assessed through 6 months. Results: Between April 27, 2021, and January 11, 2022, 2582 participants were randomized. In the primary efficacy analysis, RT-PCR-confirmed symptomatic COVID-19 occurred in 3/175 (1.7%) vs 12/176 (6.8%) adintrevimab- and placebo-treated PEP participants, respectively (74.9% relative risk reduction [RRR]; standardized risk difference, -5.0%; 95% CI, -8.87% to -1.08%; P = .0123) and in 12/752 (1.6%) vs 40/728 (5.5%) adintrevimab- and placebo-treated PrEP participants, respectively (71.0% RRR; standardized risk difference, -3.9%; 95% CI, -5.75% to -2.01%; P < .0001). In a prespecified exploratory analysis of 428 PrEP participants randomized after the emergence of Omicron, adintrevimab reduced RT-PCR-confirmed symptomatic COVID-19 by 40.6% (standardized risk difference -8.4%; 95% CI, -15.35% to -1.46%; nominal P = .0177) vs placebo. Adintrevimab was well tolerated, with no serious drug-related adverse events reported. Conclusions: A single intramuscular injection of adintrevimab provided prophylactic efficacy against COVID-19 due to susceptible variants without safety concerns. Clinical trial registration. NCT04859517.

Reimagining the Clinical Competency Committee to Enhance Education and Prepare for Competency-Based Time-Variable Advancement.

Assessing residents and clinical fellows is a high-stakes activity. Effective assessment is important throughout training so that identified areas of strength and weakness can guide educational planning to optimize outcomes. Assessment has historically been underemphasized although medical education oversight organizations have strengthened requirements in recent years. Growing acceptance of competency-based medical education and its logical extension to competency-based time-variable (CB-TV) graduate medical education (GME) further highlights the importance of implementing effective evidence-based approaches to assessment. The Clinical Competency Committee (CCC) has emerged as a key programmatic structure in graduate medical education. In the context of launching a multi-specialty pilot of CB-TV GME in our health system, we have examined several program's CCC processes and reviewed the relevant literature to propose enhancements to CCCs. We recommend that all CCCs fulfill three core goals, regularly applied to every GME trainee: (1) discern and describe the resident's developmental status to individualize education, (2) determine readiness for unsupervised practice, and (3) foster self-assessment ability. We integrate the literature and observations from GME program CCCs in our institutions to evaluate how current CCC processes support or undermine these goals. Obstacles and key enablers are identified. Finally, we recommend ways to achieve the stated goals, including the following: (1) assess and promote the development of competency in all trainees, not just outliers, through a shared model of assessment and competency-based advancement; (2) strengthen CCC assessment processes to determine trainee readiness for independent practice; and (3) promote trainee reflection and informed self-assessment. The importance of coaching for competency, robust workplace-based assessments, feedback, and co-production of individualized learning plans are emphasized. Individual programs and their CCCs must strengthen assessment tools and frameworks to realize the potential of competency-oriented education.

Is Resident-Driven Inpatient Care More Expensive? Challenging a Long-Held Assumption.

PURPOSE: The financial impact of graduate medical education (GME) on teaching hospitals remains poorly understood, while calls for increased federal support continue alongside legislative threats to reduce funding. Despite studies suggesting that residents are more "economical" than alternative providers, GME is widely believed to be an expensive investment. Assumptions that residents increase the cost of patient care have persisted in the absence of convincing evidence to the contrary. Thus, the authors sought to examine resident influence on patient care costs by comparing costs between a resident-driven service (RS) and a nonresident-covered service (NRS), with attention to clinical outcomes and how potential cost differences relate to the utilization of resources, length of stay (LOS), and other factors. METHOD: This prospective study compared costs and clinical outcomes of internal medicine patients admitted to an RS versus an NRS at Massachusetts General Hospital (July 1, 2016-June 30, 2017). Total variable direct costs of inpatient admission was the primary outcome measure. LOS; 30-day readmission rate; utilization related to diagnostic radiology, pharmaceuticals, and clinical labs; and other outcome measures were also compared. Linear regression models quantified the relationship between log-transformed variable direct costs and service. RESULTS: Baseline characteristics of 5,448 patients on the 2 services (3,250 on an RS and 2,198 on an NRS) were similar. On an RS, patient care costs were slightly less and LOS was slightly shorter than on an NRS, with no significant differences in hospital mortality or 30-day readmission rate detected. Resource utilization was comparable between the services. CONCLUSIONS: These findings undermine long-held assumptions that residents increase the cost of patient care. Though not generalizable to ambulatory settings or other specialties, this study can help inform hospital decision making around sponsorship of GME programs, especially if federal funding for GME remains capped or is subject to additional reductions.

Parenting While in Training: A Comprehensive Needs Assessment of Residents and Fellows.

BACKGROUND: Parenting issues can affect physicians' choice of specialty or subspecialty, as well as their selection of individual training programs, because of the distinctive challenges facing residents and fellows with children. Specific information about how residents perceive these challenges is limited. OBJECTIVE: We sought to better understand the challenges associated with parenting during residency and fellowship training in order to inform policy and research. METHODS: In 2017, a voluntary online questionnaire was distributed to all 2214 Partners HealthCare graduate medical education trainees across 285 training programs. The survey queried attitudes of and about trainees with children and assessed needs and experiences related to parental leave, lactation, and childcare. Responses were compared between subgroups, including gender, surgical versus nonsurgical specialty, parental status, and whether the respondent was planning to become a parent. RESULTS: A total of 578 trainees (26%) responded to the questionnaire. Of these, 195 (34%) became parents during training. An additional 298 (52%) planned to become parents during training. Respondents overwhelmingly agreed that their institution should support trainees with children (95%) and that doing so is important for trainee wellness (98%). However, 25% felt that trainees with children burden trainees without children. Childcare access, affordability, and availability for sufficient hours were identified as key challenges, along with issues related to parental leave, lactation facilities, and effect on peers. CONCLUSIONS: This survey highlights trainees' perspectives about parenting during their clinical training, signaling parental leave, lactation facilities, and childcare access and affordability as particular challenges and potential targets for future interventions.

Characteristics of Paid Malpractice Claims Among Resident Physicians From 2001 to 2015 in the United States.

PURPOSE: Limited information exists about medical malpractice claims against physicians-in-training. Data on residents' involvement in malpractice actions may inform perceptions about medicolegal liability and influence clinical decision-making at a formative stage. This study aimed to characterize rates and payment amounts of paid malpractice claims on behalf of resident physicians in the United States. METHOD: Using data from the National Practitioner Data Bank, 1,248 paid malpractice claims against resident physicians (interns, residents, and fellows) from 2001 to 2015, representing 1,632,471 residents-years, were analyzed. Temporal trends in overall and specialty-specific paid claim rates, payment amounts, catastrophic (> $1 million) and small (< $100,000) payments, and other claim characteristics were assessed. Payment amounts were compared with attending physicians during the same time period. RESULTS: The overall paid malpractice claim rate was 0.76 per 1,000 resident-years from 2001 to 2015. Among 1,194 unique residents with paid claims, 95.7% had exactly 1 claim, while 4.3% had 2-4 claims during training. Specialty-specific paid claim rates ranged from 0.12 per 1,000 resident-years (pathology) to 2.96 (obstetrics and gynecology). Overall paid claim rates decreased by 52% from 2001-2005 to 2011-2015 (95% confidence interval [CI]: 0.45, 0.59). Median inflation-adjusted payment amount was $199,024 (2015 dollars), not significantly different from payments made on behalf of attending physicians during the same period. Proportions of catastrophic (11.2%) and small (33.1%) claims did not significantly change over the study period. CONCLUSIONS: From 2001 to 2015, paid malpractice claim rates on behalf of resident physicians decreased by 52%, while median payment amounts were stable. Resident paid claim rates were lower than attending physicians, while payment amounts were similar.

Illuminating Graduate Medical Education Outcomes in Order to Improve Them.

Optimizing clinician education is an essential step toward enhancing health outcomes, and graduate medical education (GME)-as the pipeline for producing the nation's physicians-is an appropriate target for improvement. This Invited Commentary focuses on the need to clarify the specific goals of GME and measure achievement of those goals, using consistent metrics. The authors report on an October 2017 National Academies of Sciences, Engineering, and Medicine (NASEM) workshop focused on this agenda. A broadly representative group of participants reflected strong consensus in support of using GME outcomes data to develop better approaches to education and related policy. Implementation challenges include identifying meaningful metrics, minimizing administrative burden, addressing privacy concerns, and recognizing variability in institutional mission and capabilities. The authors recommend creating a national inventory of current data sources and initiating a pilot program to collect and share common metrics, while advancing a national effort via a "neutral" convener, such as the NASEM. The authors assert that measuring and reporting GME outcomes is a professional responsibility that must now be tackled.

Use of an objective structured clinical exam (OSCE) for early identification of communication skills deficits in interns.

INTRODUCTION: There is limited information about whether OSCE during GME orientation can identify trainee communication deficits before these become evident via clinical performance evaluations. METHODS: Ninety-seven interns matriculating to eight residency programs in six specialties at four hospitals participated in a nine-station communication skills OSCE. Ratings were based on the "Kalamazoo, adapted" communication skills checklist. Possible association with intern performance evaluations was assessed by repeated-measures logistic regression and ROC curves were generated. RESULTS: The mean OSCE score was 4.08 ± 0.27 with a range of 3.3-4.6. Baseline OSCE scores were associated with subsequent communication concerns recorded by faculty, based on 1591 evaluations. A 0.1-unit decrease in the OSCE communication score was associated with an 18% higher odds of being identified with a communication concern by faculty evaluation (odds ratio 1.18, 95% CI 1.01-1.36, p = 0.034). ROC curves did not demonstrate a "cut-off" score (AUC= 0.558). Non-faculty evaluators were 3-5 times more likely than faculty evaluators to identify communication deficits, based on 1900 evaluations. CONCLUSIONS: Lower OSCE performance was associated with faculty communication concerns on performance evaluations; however, a "cut-off" score was not demonstrated that could identify trainees for potential early intervention. Multi-source evaluation also identified trainees with communication skills deficits.