I began my career as a residency program director some 35 years ago when I founded a new general internal medicine training program. Despite my experience as a program director, I discovered I still had much to learn when the organization I now lead, the Association of Academic Health Centers (AAHC), decided to move beyond the contentious issues of funding and allocation of residency slots to take a look at the deeper complexities “inside graduate medical education (GME).”
Graduate Medical Education refers to the period of specialized training, known as residency, between medical school and medical practice and largely based in hospitals. It is an intense period of education and training ranging from three to seven or more years.
We convened seven regional roundtables across the U.S. Each roundtable consisted of a variety of stakeholders with different interests and perspectives. The regional series was, in part, a response to the far-reaching July 2014 Institute of Medicine Report on the subject; in addition, AAHC members felt it would be useful for the organization to serve as a neutral convener for what is for many an emotionally charged topic.
This post discusses some of the lessons learned from the roundtables. It identifies key priorities that must be addressed by a new 21st Century paradigm for GME, one that will help us build the new health care workforce that we need.
Lessons Learned From The Regional Roundtables
AAHC’s report can be found on our website, but I would like to share here my perspective as a former residency program director on these issues.
Inherent Organizational Conflicts
While I was not surprised to learn that organizational conflicts—between the medical schools that administer the residency programs and the teaching hospitals where the residents train—are inherent within the GME structure, it is important to note that this was the case even when the same institution owned both the hospital and medical school. The way the GME funding stream works is a bit paradoxical: funds flow to the teaching hospitals to pay residents’ salaries and related expenses, while the academic programs in medical schools that manage the residencies (in terms of curriculum, evaluation, and accreditation) are not the direct recipients of this funding.
As a result, an organizational conflict between the hospital and medical school may arise which can create a pattern of cognitive dissonance that reflects the competing pressures of providing patient care and education at the same time. An example of this “service-education conflict” is the push-pull of patient needs versus attendance at education programs and rounds.
Adequate Health Service for Local Populations
I learned that issues surrounding the provision of care for rural and underserved populations were a significant point of discussion in every region. Not surprisingly, discussions in certain regions focused on the provision of health care to rural areas (and, in some, on specific concerns relating to “frontier” areas). For example, in New Mexico, there is only one academic health center, the University of New Mexico in Albuquerque, that also is home to the only Level 1 (or 2) Trauma unit in the entire state. This has huge implications on survival rates of unexpected medical traumas, such as car crashes.
Many participants in other regions discussed substantial concerns about the rural areas of each region and/or the underserved populations in urban areas. The challenges are similar — not just providing a physician, but the right physician, in terms of language, culture, and background, to best meet health needs. For example, a participant at the western regional roundtable commented that while Latinos comprise 36 percent of the current population in California, only 5 percent of GME residents are Latinos.
Issues of Stress and Mental Health
I was struck by how much concern there is for the mental health of residents and the faculty who teach them. Given the requirements in recent years to limit residents’ working hours, one might readily conclude that this is an illogical observation. Yet it appears that stress during training has increased rather than decreased.
Why might this be the case? The roundtable discussions suggest a major reason: the increasing pace of patient care in today’s hospital environment and the resultant need to get the work done in a shorter time frame. We heard many examples from residents and faculty who struggle to find the right balance between time constraints and thoroughness. Residents have less time to get to know their patients, and in an environment where “throughput” tends to dominate, they are simply under more pressure.
Looking Forward: Building The New Health Care Workforce
As our health care system undergoes rapid evolution, the loss of critically important thought leadership resulting from the unfunded National Health Care Workforce Commission is compounded with each passing year. Our health care system is changing so rapidly that it is not even possible to determine with precision the future shape of health care delivery and to project the workforce needed. Even if we could make reasonable predictions, simply adding more physicians is not a thoughtful solution.
The number of health professionals needed is less critical than their geographic and specialty distributions. And all of this could be said for other health professions. Arguably, there is a growing mismatch between health professions supply and demand. There is also a mismatch between the skillsets health professions trainees possess at the completion of their education and training versus the full complement of skills necessary for their careers. This is a market failure that suggests market-based solutions.
In our view, there are a least four essential market dynamics—there may be more—that need to be addressed to achieve the paradigm shift demanded by 21st Century health care:
- Forge a close working relationship between the academic institutions that educate and train health professionals and the health care delivery systems that will employ them. The major stakeholders on the supply side (academic institutions) and demand side (hospitals, large group practices, health systems, insurers) in local health workforce markets must work together cooperatively and strategically to ensure there is a far better match between health workforce supply and demand. Similarly, they must work together to place far greater emphasis on post-graduate continuing education and retraining for health professionals who suffer career dislocation as a result of health system transformation.
- Redistribute the cost of health professions education across a wider financial base so student debt is less likely to distort where health professions graduates choose to start their careers and what specialties they choose to pursue. The stakeholders who rely on the output of health professions schools and programs for their workforce should make a tangible investment in health professions education and training if they expect their workforce needs to be met.
- Strategically integrate pre-medical collegiate, medical school, and residency education to reduce the time and expense for health professionals to complete their education and training. Redundancy and lack of coordination across the different phases of health professions education and training undermines efficient and cost-effective health workforce development.
- Accreditation and licensing bodies must embrace their responsibilities to serve as agents of transformation, not simply as guardians of the status quo. Failure to foster the disruptive innovations necessitated by the rapid evolution of the health care system could entrench health workforce market dislocations.
It is important to ensure that health professionals (both those entering and those already in the workforce) are educated and trained so they possess the new skillsets needed for a 21st century health care workplace that embraces team-based patient and family-centered care, personalized and precision medicine, diagnosis and treatment augmented by artificial intelligence, pay for performance, population health, and all the other changes that place new demands on how we educate and train health professionals.
Consider the demands on future physicians, who will need new skillsets for their changing roles, including:
- Management and oversight of delegated responsibilities within multiprofessional and multidisciplinary care teams;
- Monitoring and managing large amounts of patient data generated by ubiquitous wearable health technology and large biobanks;
- Integrating artificial intelligence and big data into day-to-day clinical practice;
- Adapting clinical practice to performance measurement and value-based payment; and,
- Proactively promoting population health in addition to treating individual patients.
As a nation, we need to be thinking strategically about how to improve health workforce market efficiency by ensuring that major stakeholders are, in effect, all rowing in the same direction. Simply increasing the number of physicians and other health professionals will be a redundant effort unless we transform how we educate and train them, and what we educate and train them to do.
Stakeholders in some markets are trying to make headway on these health workforce challenges, but the results they are able to achieve are limited by the absence of a consensus vision for change. The longer we wait to articulate that vision, the greater the task becomes.
The author thanks Anthony Knettel for his contributions to this post.