Deborah L. Benzil, MD, FACS, FAANS, AANS (left)
Chair, AANS/CNS Communications and Public Relations Committee
Mount Kismo Medical Group
Columbia University Medical Center
Mt Kisco, New York
Guest Post from Clemens M. Schirmer, MD, PhD, FAANS, FAHA (right)
Vice-Chair, AANS/CNS Communications and Public Relations Committee
Geisinger Health System
Wilkes Barre, PA
During the month of March, much of America gets swept up in “The Dance” — the last four in and the last four out of the National Collegiate Athletic Association (NCAA) basketball tournament. Not televised or featured in the headlines of news sites, senior medical students are anxiously awaiting phone calls and emails that quite literally determine their future. March is the month when medical students on their way to earning their medical degrees learn where they will begin their post-graduate training — the next step towards becoming independent and board certified physicians. For both the students and the training programs, the “match” happens on one day across the country and evokes similar anticipation as an Academy Award or an NCAA bid, as students open an envelope and learn where they will spend their next three to seven years of their medical career. Neurosurgery Blog designated March as GME month (#GMEMonth) in an attempt to feature all aspects of graduate medical education — a process that in some way begins for the individual on “Match Day” in mid-March.
We intend this post to reflect a Grand Rounds presentation with a sweeping overview of some of the issues of GME as they relate to Match Day. Grand Rounds are an esteemed, long-standing component of residency education. These sessions are considered the pinnacle of the educational experience and bring together the greatest talent on a critical topic. March Madness, thus, honors this tradition across the health policy blogosphere. By way of introduction, excellent data on GME trends across the spectrum of programs is available through Health Affairs.
Conference Championships (All about Medical School)
Before embarking on tournament play (post-graduate education), physicians must first navigate the many challenges of medical school. Being well prepared for a GME season requires optimizing pre-tournament play. This is an ongoing challenge, with medical school debt, choosing the right medical students and adapting educational models which are all key issues.
An in-depth assessment of the cost of medical education is available through the Association of American Medical Colleges (AAMC). Pauline Chen, MD, a Plastic Surgeon, applauds the efforts of David Geffen, MD, “fighting the fact that medical education in the US is paid for largely by student debt.” These efforts are challenged by Danielle Ofri, MD, who points out some of the less savory messages medical students receive when the name of a medical school is acquired. Other paths to debt free medical school have been offered up as reported by the American Medical Association (AMA). In Training relates early angst about residency funding and the importance of advocacy on this topic (see below for more on this critical subject). Harvard’s Dean is leading another charge, intent on transforming medical education to meet the pace of change in health care. At Stanford, Sarah Greenberg, executive director of the d.school, has also been working on a complete redesign of medical education. Another unique program has been ongoing at Sidney Kimmel Medical College on medical students’ role in quality and safety. Meanwhile, diverse opinions about topics such as cultural competence and work-life balance are explored in depth at In-Training.
How Malcolm Gladwell would choose the right medical students for the future of health care is explored through the Jefferson Leadership blog. In a related topic, David Silbersweig, MD, from Harvard espouses the value of liberal arts and philosophy in teaching physicians how to think as a highly undervalued but essential trait for doctors.
The Bids, Please (The Match)
“Match Day” has evolved as one day in March when medical students learn which residency they will enter. As GME became more complex, this system evolved to protect medical students, balance programs and provide fairness. By its design, The Match strives to give each student his or her highest choice on a rank list of training programs they submit, matching their choices with similar rank lists of applicants the training programs submit. However, not all agree that The Match continues to provide this service efficiently and effectively, although most would not want to return to the system of old where individual applications, phone calls between faculty and insider knowledge about open positions were essential to obtaining a training position.
Given the impact of the “Match” on medical students and their families, it is no surprise that medical student blogs are awash in reflections. You can listen and viscerally experience what Match Day is like courtesy of Newsworks. In-Training (the agora of the medical student community) has a series of advice pieces on choosing a specialty, senior specialty rotations, and Match Day commentary. Ryan, a young father, waxes poetic on the stress of Match Day via the Loma Linda University Student Blog along with Josh Kaplan, PhD via OHSU Student Speak. A poignant memoir of choosing otolaryngology is given by Shabnam Ghazizadeh, MD. This piece is also an excellent overview of how the system works and how medical students navigate it. A look back at the traveled road just after Match Day is well delivered by Josh Diaz, MD, for The Doctor’s Tablet (Albert Einstein College of Medicine).
68 Teams In and the Bracket (GME Slots and Financing)
The NCAA Tournament limits team selection to just 68, ultimately leaving out some great talent. Perhaps surprisingly to most not involved in the system, similar principles apply to GME slots, limited by Federal caps placed on funding. Despite the looming physician shortage, the Balanced Budget Act of 1997 froze the total number of Medicare-funded training spots in the U.S. at 1996 levels. While we have successfully increased the number of medical school students who will ultimately become graduates, we must continue to make the case that these MDs require the additional postgraduate training to become board certified physicians with sufficient skills and experience to care for patients. This looming crisis is the focus of a broad spectrum of publications and has become so pressing the AMA established a Save GME campaign!
The AAMC delves into “The Complexities of Physician Supply and Demand: Projections from 2013-2025,” and note a widening gap. Danielle Ofri, MD, cogently details how the Affordable Care Act (ACA) makes the physician shortage even more acute. The New England Journal of Medicine (NEJM) also weighs in noting the increase in medical students won’t alleviate the physician shortage if there are insufficient GME positions. The match is an algorithm that through its inception addressed the shortcomings of the previous way of giving out training slots via individual wheeling and dealing with a general lack of transparency. While theoretically ideal and completely efficient, it does not always work in practice. Leaving medical school grads on the sidelines is profiled in MedialXpress, and Modern Healthcare notes the one percent growth in residency positions at the same time as a two percent growth in medical students, leaving nearly a 1,000 residents unmatched in 2015.
Healthcare Economist states simply, “one thing that is certain is that the fight over funding the education of the nation’s physicians is likely to continue.” The Hill provides an outstanding summary of the problem, noting the chilling effect on physicians and discusses potential legislative solutions. The strong advocacy efforts of the AAMC on the topic of the link between GME positions and the doctor shortage are outlined through a letter from Atul Grover, MD, PhD. An Institute of Medicine (IOM) report was released in July 2014 with analysis and recommendations for new policies. A Health Affairs commentary challenged some of the findings and the foundational rationale of the report through a discussion with IOM co-Chair, Gail Wilensky. In a related piece, analysis of the report is offered including the strong statement, “We do not support the IOM conclusion that current Federal funding levels of residency positions are adequate to meet our future health system needs.” An alternative is proposed giving the Council on Graduate Medical Education (COGME) an enhanced leadership position. Meanwhile, some states are starting innovative programs to try and address geographical workforce issues as reported by Pew Trusts.
At least one neurosurgery GME program, Mayo Clinic in Jacksonville, has the incredible fortune to have John H. and Carolyn O. Sonnentag as generous benefactors to endow the residency. Nationwide and across all GME positions, relying on donations for funding, however, is neither possible nor optimal.
Early Rounds (Duty Hour Restrictions)
The initial rounds of the GME tournament (known as PGY for post-graduate year) have radically changed in the last decade because of regulatory mandates. For GME, the early round debate is not bracketology, but rather the resident duty hour restrictions instituted in 2003 (further revised in 2011), which have changed the GME game. Since implementation, the delicate balance between patient care and education has been much discussed; from the clinic watercooler where old-timers (like the authors) who trained before the current regulations express their personal opinions to the blogosphere, op-eds and the academic literature. Studies, including a randomized, controlled study of work-hour restrictions and patient care, reported by the NEJM, have demonstrated no benefit to the educational component of these restrictions. An avalanche of commentary has been unfurled since this publication including a comprehensive look at KRQE. Also weighing in is The Washington Post with a careful consideration of the results.
A thoughtful and balanced discussion comes from resident Dhruv Khullar, MD, who stresses the need for data, the challenge in all outcomes and well-being assessments and ultimately wisely concludes that answers, “may be more nuanced that we’ve been willing to accept.” An increase in patient handoffs and potential for error is poignantly related in the New Yorker.
Clearly within neurosurgery, there is evidence that work-hour regulations have an adverse impact on resident education and productivity as published by Dr. Jagannathan and colleagues. Another recent study reported by Dr. Fargen and others noted that the 2011 regulations had a negative (35 percent) or negligible (33 percent) impact on residents, especially the PGY-1 rules. These results are especially poignant since Neurosurgery as a specialty has long stated that the current one-size fits all approach does injustice to the vastly differing requirements and needs of different specialties.
Beyond the contentious duty hour restriction debate, some even question whether residents provide a positive or negative impact on patient care. But have no fear Mark Adelman, MD, on Clinical Correlations (NYU Langone) debunks the myth of “The July Effect.”
Sweet Sixteen (Innovation)
There can be some big surprises in the early rounds of the tournament. Top coaches often are the difference in success or failure. In the same way, societies, institutions and, in particular, imaginative individuals who strive to infuse GME with innovation are helping to ensure better training for residents and ultimately better patient outcomes. Neurosurgery is leading the way in this through simulation programs. Senior author Dr. Ed Benzel reported work on “Establishing a surgical skills laboratory and dissection curriculum for neurosurgical residency training.” Another notable enterprise uses a gaming device to help plan and execute brain surgery, as eloquently detailed in the Smithsonian. Another neurosurgical contribution that enhances resident education and patient safety was the development of Boot Camps (through the Society of Neurological Surgeons) that enhance knowledge retention and provide critical hands-on learning as reported by Dr. Nate Selden, et al.
Wing of Zock provides the forum for several excellent articles on innovation in GME programs. Michael Decker, MD (orthopedic resident) states, “Educating residents and students on upcoming changes to payment models is in the direct interest of practicing physicians.” His goal is to improve GME so physicians will be better prepared to influence the health care environment for the benefit of patients. A medical resident, Nilay Patel, MD, initiated a pilot program to help residents more clearly understand “the knowledge between cost and value…and consideration of cost-value during daily patient care.”
Dr. Ricardo Nuila espouses the value of teaching storytelling as a crucial aspect of becoming a good doctor in a TEDxRICEU talk from Baylor College of Medicine. Through AMRounds, David Sklar, MD, remains enthusiastic about the GME system but has collected ideas for meaningful innovation to improve further the system and also developed a thoughtful podcast.
Halftime Show (Humor Helps)
A little levity and entertainment are always an important part of any good championship tournament, usually presented as the halftime show. While GME may not be the equivalent of a wardrobe malfunction and pompoms are not customarily used when doctors treat patients, there is no greater homage paid to the importance of this topic than the energy devoted to it via the satirical GomerBlog. Dr. Wangmeister extols the secretarial skills acquired in addition to the medical knowledge during most stages of training. The value of coffee in promoting quality patient care is the subject of another cheeky post and the stress of Match Day gets a sarcastic twist. But let us return to serious action.
Elite Eight and Final Four (The Best and Brightest)
Few know their championship role in GME development. They have established an Education Grand Rounds program to reach a broad interprofessional audience to promote networking and collaboration. Neurosurgery training programs are also leading the way with initiatives like one at UC San Francisco in which residents worked to improve quality and reduce costs.
Others are also weighing in on various trends critical to current and future success of GME programs to meet the challenges of today’s health care system. Dhruv Khullar, MD, reflects on his current experience as a resident and an opportunity too often lost when ignoring the potential value of team learning and teaching medical team leadership skills. Nash on Health Policy relates a program at Jefferson used for a unique resident training program targeted toward “fluency in the language of measuring and improving the quality and safety of healthcare.”
Another significant trend is the increase in doctors seeking MBAs. The LA Times note that this combination of skills may prove increasingly valuable as health care is transformed and those that straddle both worlds can use insights gained to improve both.
Post Game Wrap-up (GME and Our Health Care Systems)
Ultimately, GME remains the primary way we train tomorrow’s physicians, and it must fit into the wider health care system on all levels. A huge move toward assuring a smooth connection between the quality of GME programs and the health care system should result from the merging of MD and DO training standards as explained by KevinMD. There is a great deal of mutualism and benefit to the cooperation of GME, academics and health systems says Dr. James McDeavitt (Baylor College of Medicine). He also discusses the connection between 15th century Renaissance painting and modern health care in detailing the move toward Learning Health System. Lessons from the education world, authored by Stephen Klaski, MD, MBA, relates a need, “to seek the same emotional intelligence,” building creative partnerships, something counterintuitive to many who complete the arduous years of medical training. He also created a thoughtful video with a hypothetical look back from 2024 of the positive potential of medical changes.
Finally, poignantly noted by Joyce Copeland, MD, (Duke University School of Medicine) is that GME never actually stops. “The process of learning has evolved over the years, but the purpose of learning has not. We want to be better doctors.” A real championship idea, indeed!
With this we close, and congratulate all the participants in the 2016 Residency match, especially all future Neurosurgery residents and call for help to improve our GME system to continue to train the best – these will be the doctors of tomorrow to take care of us!
The authors gratefully acknowledge the work completed by Christine Hammer, MD, that provided the foundation for completion of this piece.