The Josiah Macy Jr. Foundation spent the past year traveling the country to discover what different regions were doing to better align physician residency training programs with the many changes occurring in health care delivery. The model of graduate medical education (GME) in the United States is held in high esteem both here and around the world, but it needs to adapt to an environment of constrained resources coupled with expanding societal health needs.
The foundation partnered with six academic institutions (Vanderbilt University, in Nashville, Tennessee; University of Texas System MD Anderson Cancer Center in Houston; University of California, San Francisco (UCSF); University of Washington and the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) Regional Medical Education Program in Spokane, Washington; Partners Healthcare, in Boston, Massachusetts; and the University of Michigan, in Ann Arbor) to spotlight GME innovations happening locally to learn what’s working, capture lessons, and share what’s promising.
We held six regional convenings. Together, they drew more than 800 professionals from thirty-nine states and the District of Columbia. What they revealed was a robust GME innovation landscape catalyzed by strong local leadership and a desire to respond to local needs. We saw multiple innovations being pursued, but we captured some common themes that can help shape a new direction for GME.
GME needs to be more outward looking. The GME model is evolving to improve the public’s health, address health disparities, and affect the social conditions that influence how well and long people live (such as poverty, safe and affordable housing, and clean air). As we heard from one speaker, those of us who work with patients need to be “co-producing” improvements in health with the communities we serve and harnessing GME programs and residents as part of that co-production. This means more engagement with the people living in those communities. Examples of institutions taking these steps include Florida International University, where family medicine residents follow families over time to provide medical care and help address challenges that affect their health, and Southern California Kaiser Permanente’s community medicine fellowship, which allows residents to train on the frontlines as they care for underserved and homeless patients.
Residents should be part of the solution. Health system leaders need to see residents as assets and should empower them with skills needed to help achieve institutional goals to improve quality of care, safety, and efficiency. One example is a resident-led effort at Vanderbilt University Medical Center focused on identifying ways to reduce wasteful or unnecessary medical tests, treatments, and procedures that resulted in significant reductions in blood draws and overall patient testing. A resident-led interprofessional collaboration at UCSF to reduce medication errors when patients were admitted to the hospital led to cost savings and reduced readmission rates.
Residency programs and sponsoring institutions need new partners. We need to develop new clinical training sites, particularly in community-based settings that offer a much different learning environment than in traditional teaching hospitals. We met many GME leaders who are successfully making the case that GME is a public service that can help achieve better health care and community goals. For example, an Alaska pediatric residency program that is offered plants doctors in remote regions of Alaska to spend four months a year for three years in community-based settings to serve high-risk Alaska Native people. The Maine Medical Center offers a rural track to enable residents to learn about population health and how to work in rural areas where resources are more limited.
Training needs to be more tailored to the individual medical resident. Higher education in general is moving toward more individualized, personalized training that allows learners to have input into what they learn and how they learn it. Increasingly, we see residency programs assessing learners based on whether they have acquired the necessary skills, often at their own pace, rather than programs based on a standardized amount of time that they may have spent practicing those skills. We also heard concerns about resident burnout and the need to coach residents in self-care and stress management. An increasing focus on physician wellness is leading to a number of exciting innovations to make the training experience more humane.
Residency programs need to focus on teamwork and collaboration. More time in residency needs to be spent with practitioners and learners from other disciplines and professions with an explicit goal of developing team competencies. Efforts to develop interprofessional education (IPE) programs—where learners from two or more professions learn about, from, and with each other—have been steadily rising in health professions schools. For example, in the Rio Grande Valley of Texas, psychiatry residents are embedded in primary care clinics and are on teams with primary care doctors, social workers, and pharmacists. The Boise Center for Excellence in Primary Care, in Idaho, offers training opportunities for family medicine residents and engages teams of trainees to work together, including nurse practitioners, nurses, pharmacists, family medicine physicians, and psychiatrists.
GME needs new sources of funding beyond Medicare. Most of the nation’s 120,000 resident slots are funded primarily through Medicare. However, a number of states are using state funds to expand GME programs. In addition, a number of GME consortia are emerging to help develop and support residency programs to meet regional needs. For example, in Oregon, hospitals, health systems, physician groups, and medical schools formed a consortium to help develop new rural residency programs.
Without a national push to reform GME, local health care institutions, states, and regions are moving on their own to find new models for training and funding. Many view this as an opportunity to innovate. We know we can’t continue the status quo. It’s exciting to see so many communities seizing this moment and leading the way forward.
To learn more about efforts to improve GME at the local, regional, and national levels and what was learned at the 2016 conferences, here is a link to the report we just published.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/2hSg6cj
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