Resident Concerns, Part 2: Fellowship Applications

So, continuing on with resident concerns I heard about during conversations at the 2014 CAP Residents Forum and Annual Meeting, let’s move on to the fellowship application process.

One nice offering by the Residents Forum for the past two years at the Annual Meeting is a mock fellowship interview. The process was simple in that I only needed to fill out a brief application prior to the meeting with my fellowship interests and I was matched up with a member of the CAP Board of Governors or another CAP national leader who either practiced or had experience in my area of interest (or as close to it as CAP could find out of the available pool of mock interviewers). Once matched, I emailed my personal statement and CV to my mock interviewer (who turned out to be someone I already knew from my work on a CAP Council). I also participated in the mock interviews last year with a pathologist who I didn’t know beforehand. Both times, I received valuable feedback on my submitted materials and advice for the actual interview as well as an open invitation to contact them in the future if I had questions or needed more advice. I highly recommend these mock interviews if you are attending a future CAP Annual Meeting.

Obtaining fellowships can be even more competitive than getting into a residency. There are far fewer spots in that some may only offer one position per year in that subspecialty, programs may have already filled their positions with internal candidates, and the majority of residents (96%) apply for at least one fellowship (85% of third and fourth year residents according to the 2014 ASCP Fellowship and Job Market Survey had already accepted fellowship positions by the time of this survey during the RISE).

The trend these days is to complete at least one fellowship (56% answered yes to this question on the ASCP survey) and many often complete two (39% on the ASCP survey indicated that they would pursue two fellowships). I personally also know individuals who completed three although they are in the minority.

And it’s currently fellowship application season. Even though the suggested deadline is December 1st, we all know that most programs start accepting applications in September. I called some programs in August with questions and they had received applications already! Suffice it to say, from totally anecdotal evidence that I’ve heard, it seems that there are two periods for interviews: Oct/Nov for those accepting applications early and Jan/Feb for those who wait until December 1st to look at their applications. Even from friends in other specialties also going through this process, it seems that the process actually begins the year prior to application.

For those who want to be ahead of the game, at least start getting your CV and personal statements together. Since I’ve been updating my CV whenever something new came up since college, the CV was no problem. But I can tell you that I wished that I had started on the personal statement as a second year. I thought that I was being a semi-early bird to write my initial draft in August. But it took about a month of back-and-forth feedback from people who I asked to read it for me to whittle it down to less than one page. Turns out that most programs want something short and sweet (one page or <500 words). One program even wanted <250 words so I gave them a super abridged version of what I submitted to other programs. So, second years, start now so that you can submit everything in complete form on September 1st. The other part of applications are letters of recommendation. I’ve only heard residents from one program tell me that their letter writers will give them a letter within a day after being asked. If you’re like me, you’ll probably need to ask your letter writers way in advance and sometimes, give quiet reminders. So start early if you want letters ready by the time you submit.

The controversial issue that I always hear whispers about at the three Residents Forums I have attended is that of a standardized fellowship match like we had when we applied for residency. There are pros and cons for and against a standardized match. I was speaking with someone from the Association of Pathology Chairs (APC) and he supported a match. I would agree that it would deter residents from being subjected to undue pressure from programs to decide quickly once an offer is made (most 4th year residents who I spoke with said that they had up to 1 week at most to decide). It would also eliminate the situation that many of them found themselves in where they had accepted a position but later interviewing programs encouraged them to still interview and disregard their previous acceptances (which I think is unethical and I’d politely decline to interview at that program). But I can understand the conundrum that the later interviewing programs that follow the suggested CAP deadlines are subject to when many of their desirable candidates have already signed by the time they interview.

Unlike when the NRMP decided to go a match system for residencies, and later on, to bar pre-matching from participating institutions, the incentives and ability to leverage are very different when it comes to fellowships. Most fellowship programs offer a small number of single digit positions which they can usually easily fill without a centralized application service. And fellowships are a quasi-limbo state between school and our first “real” job. The job market does not cater to regulation and it is hoped that free competition is enough to ensure that everyone ends up where they are meant to be (although we know that connections and word of mouth still matter, especially in the small world of pathology). Programs (supposedly 51% from one study) will also often fill their spots with internal candidates and residents often feel the need to apply earlier and undertake audition rotations for the most competitive fellowships (eg – 2nd year for dermatopathology). While a standardized match may alleviate some of the aforementioned pressures, it does provide some of its own. Residents often have to spend more money to interview at a larger number of programs to feel secure that they will match somewhere and they also need to wait until later in the year to learn their fate. They also would likely have difficulty if they are trying to match for two successive fellowships which is not that unheard of, especially when those fellowships are related.

So, in terms of a standardized match, even though I usually have an opinion on most topics, I’m not sure which is better and the jury is still out. But I do know that the ability to incentivize programs into such a match process is much more difficult than it was for residency programs. It does seem though that residents do prefer a standardized application timeline according to multiple ASCP surveys even if they don’t support a match process. APC and PRODS (program directors section) tend to support a pan-pathology fellowship match while other organized groups within pathology and most residents remain skeptical that one would solve all the issues on both the resident and institution sides of the equation.

Well, for my compadres who are wading in these murky waters this interview season as I will also be, it’s a moot point. So I leave you with this: CAP had a great webinar last year by two pathologists-in-training who had survived this process as well as a program director. The webinar can be accessed here as well as a Q&A FAQ PDF from that webinar.

References:

  1. KD Bernacki, BJ McKenna, and JL Myers. Challenges and Opportunities in the Application Process for Fellowship Training in Pathology. AJCP, 2012; 137: 543-552. Accessed at http://ajcp.ascpjournals.org/content/137/4/543.full.pdf+html
  2. WS Black-Schaffer and JM Crawford. The Evolving Landscape for Pathology Subspecialty Fellowship Applications. AJCP, 2012; 137: 513-515. Accessed at http://ajcp.ascpjournals.org/content/137/4/513.full.pdf+html
  3. JM Crawford, RD Hoffman, WS Black-Schaffer.Pathology Subspecialty Fellowship Application Reform, 2007-2010. AJCP, 2011; 135: 338-356. Accessed at http://ajcp.ascpjournals.org/content/135/3/338.full.pdf+html
  4. RE Domen and A Brehm Wehler. An examination of professional and ethical issues in the fellowship application process in pathology. Hum Path, Apr 2008; 39(4): 484-488.
  5. N Lagwinski and JL Hunt. Fellowship Trends of Pathology Residents. Arch Path Lab Med, Sept 2009; 133(9): 1431-1436. Accessed at http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165-133.9.1431
  6. JL Myers, SA Yousem, BR DeYoung, ML Cibull (on behalf of ADASP). Matching Residents to Pathology Fellowships: The Road Less Traveled? AJCP, 2011; 135: 335-337. Accessed at http://ajcp.ascpjournals.org/content/135/3/335.full.pdf+html

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

Resident Concerns, Part 1: Boards Prep

So I’m writing this blog while taking a break from the 2014 CAP Annual Meeting (I hate high heels and my feet are killing me from standing by my poster). As a resident, one of the most enjoyable parts of every conference that I attend is meeting and speaking with other residents. It’s even better if the conference planners organize specific events, networking receptions, or a resident lounge where residents can meet and socialize with each other and other trainees and pathologists. The CAP Annual Meeting is always good in terms of providing residents such outlets.

The best part for me is hearing stories of other resident experiences different than my own in addition to making new friends and colleagues. So my next couple blog posts will be about some of the topics that came up as the most important from the residents I spoke with: boards preparation, the fellowship application process, and networking/engagement opportunities for residents.

So, in terms of the boards, two themes seemed to emerge. First, many felt that the Resident-In-Service-Exam (RISE) does not correlate well with what we need to know to prepare for boards. For instance, this example was given to me: a decent percentage of questions on the RISE focused on forensics while most had heard that the boards have very questions dealing with forensics. My opinion on this topic is that it depends on what your expectations are concerning the RISE. If you are hoping that the breakdown of the RISE is a simulation of the boards in mini-form, then you might be disappointed. But if you like to advocate change for a different focus for the RISE, then I’d encourage you to bring your concerns to the RISE committee at rise@ascp.org and provide a cogent argument for your views…my motto is always, “you never know, the worse that they can say is no, so it’s better to try.” It certainly is not irrational to want our in-service exam to reflect what we need to know most for the boards and for real-world practice so let the RISE committee know.

Secondly, the topic came up of what is tested on the boards in terms of breakdown. I also wondered the same thing since I need to prepare chemistry and molecular pathology podcasts for for ASCP’s Lab Medicine Podcast Series and had no clue what would be high-yield topics that I could focus on (if you have a specific topic or test in these areas that you’d like a podcast on, please feel free to let email me and I’ll try my best).

So, I asked someone I know at the American Board of Pathology (ABP) about this issue. She directed me to the APCP Exam Blueprints which outlines the overall breakdown of number of questions in specific topic areas on the most recent board exam. I’ve also been told that they will post category codes for the various exams (ie – something like a “table of contents”) to the ABP website soon.

Looking at the blueprints, I have a better idea of some of the board topic areas that I will need to concentrate on (although there is nothing listed for molecular pathology but maybe there isn’t that much yet on the boards or it’s included within other AP/CP areas like soft tissue or hematology). And apparently, this is much more info than has been previously provided. But again, if you want a more detailed breakdown or other information that you can’t find on the ABP website, I also encourage you to communicate your concerns to Dr. Rebecca Johnson, the CEO of the ABP. Remember, positive change only occurs if there is a stimulus for change, and that stimulus can be you! As attendings, we need to be pro-active in questioning and changing the status quo for the better, so why not start practicing or acquiring those skills while a resident.

 

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

 

Generation Gap from a Resident’s POV

I was talking with my attending and fellow this week and was struck by the generation gap in terms of how we were/are trained. When my attending was in residency, he had to handle over 100+ CP calls in a week – he even keeps one of his call sheets to back up his stories. In some ways, we are spoiled because we can just say that there is an APP to do many of the calculations he had to do then and so we’re not even paged on these types of calls. These days, I may average 10+ CP calls/week at the same institution where he trained at. He also said that they didn’t have PAs back then and it wasn’t unusual to gross until close to midnight…and the grossing resident also covered all frozen sections at the same time, too. His is not the first attending story that I’ve heard like this. Obviously, this was before we had work hour reform. But I wonder what we’ve lost in training since his time?

I’ve often heard residents complain that we have too many service duties and that they feel that service duties supersede our education. Most of the time these complaints revolve around not having enough time to read and too much “scutwork” including grossing routine specimens. I’m no expert by any means but I feel that for me, I’ve learned more when I’ve had to do things as opposed to reading textbooks. And by doing things, I mean performing those duties that are required of my attending as close as possible to the real experience. And yes, that does include lots of reading, not just textbooks but also journal articles and other resources, but is not limited mainly to reading.

Gone are the days where I could skip (or attend) my medical school classes and watch a video of the lecture and read the textbook and do well on exams. The more important difference is that now the consequences of my actions can more directly harm patients so it’s vitally important to gain “attending skills” as well and as soon as I can. And even after graduation, I know that it will still take a few years before I am comfortable in my clinical competency. I know that I’ll be more stressed and OCD about details because it will be my name at the end of the report that is responsible for patient care decisions and also liable for medico-legal action. But I want to be as prepared as possible when that time comes.

Residency is the time when we should transition from passive learning (ie – learning mostly by reading textbooks) to active “on the job” learning. Sure, if no one at your program wants to teach you, then you may be stuck with textbooks and online resources. But I’ll take a bet that even at the most “malignant” programs, there is always at least one golden mentor (including non-attendings) who wants to teach. And remember, that during fellowship, your attendings will expect that you have most of these skills in your portfolio and that you have good time management skills. No one expects that we have knowledge of everything (even our attendings don’t have that), but they will expect that we know how to approach that situation if we find ourselves unsure.

Anyway, that’s not my most important point. I find that complaining just wastes my energy that can be directed to a more useful endeavor. Yes, if I feel something is truly unjust, I will be one of the first to say something. But I realize that the patient is the center of my training and not me, their needs supersede mine, and yes, there will always be scut but it depends on how I approach it what I get out of it. Plus, I realize that compared to other specialties, I didn’t have an intern year and don’t have to do overnights, so I’m thankful that my residency experience is not as bad as it could be.

A generation gap exists where our attendings can’t understand why we complain and where we don’t feel our attendings understand us. But I think that there is a middle ground. I don’t think that we should go back to unregulated work hours where we are dangerously fatigued and never get to see our family and friends. But I also don’t believe that residency training is there to spoon-feed me. It is the time for me to spread my wings (with supervision, of course) and learn how I’d navigate my clinical duties as a future independent attending.

For those going into surgical pathology, you may still end up working at a hospital where you may need to gross or at least, look at specimens or teach how to gross. The end of residency doesn’t necessarily mean the end of grossing (or insert you least favorite aspect of residency here). A friend was telling me that he overheard attendings at a networking reception complaining about a new hire they had who didn’t know how to gross. If that was at a private practice, I would expect that after a short time allowed for remediation, that if that new hire didn’t improve, s/he would be fired. There may be more leniency at an academic or VA institution, but I also believe that if a better replacement could be found, that person would still be fired.

So residency is the time to make sure we gain competency in skills like grossing, lab management, billing, CLIA regulations…even if these are usually the things that we find to be boring. Sign-out is not even half of what will be required of us when we are full-fledged attendings, especially if you want to work in private practice, which is where most of us end up since the compensation is greater.

Getting involved in leadership positions, whether at your hospital, state society, or within a national advocacy organization in my experience opens doors to many practical opportunities as well. For instance, I’ll be going with my hospital’s CAP lab accreditation inspection team this month to help inspect the hematology section of a lab in another state. Because my department chair knows I have an interest in hematopathology and because I performed well on my first CP rotation here, I was given this great opportunity. I’m now certified as a CAP inspector and will have a better idea of lab management issues after this experience. Due to my involvement as the junior member on CAP’s Council on Education, I’ve also been given the opportunity to serve as the ACCME/AMA compliance monitor at a joint CME activity of CAP and a state pathology society in the near future. I see this as active learning and a step toward gaining the competencies that I will need.

Right now, we are buffered from much more than we realize. Probably as a fellow, we will understand the end game better, just how much our attendings’ days are filled with more than just sign-out. I suggest reading the article, “Adequacy of Pathology Resident Training for Employment: A Survey Report from the Future of Pathology Task Group” that outlines specific competencies that employers wanted and that residents did not possess adequate competencies in. It goes on to state that 50% of employers felt that new graduates that they hired needed more support and guidance than was required 10 years ago. So what can we do now during training to ensure that we are not those new graduates who are perceived as needing “more” supervision at our first job?

 

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

Radiologic and Pathologic Correlations

So last night I stayed later than usual after work to prepare for an interdepartmental conference that I will be giving next Friday before I fly out that night to attend the CAP Residents Forum and Annual Meeting. A radiology resident and I will be presenting two cases together to correlate their radiology and pathology, two specialties that have much in common, at least on the surface.

Both radiologists and pathologists, at least pre-ACA era and except for subspecializations like interventional radiology and transfusion medicine, do not often interact with patients directly. Therefore, both fields rely heavily on clinical observations and notes written by the primary care doctors caring for “their” patients. Both also require a broad knowledge of disease differentials, and frequently, understanding the prognostic and treatment considerations of the disorder under examination even though they are not involved in direct care of the patient. Additionally, both fields require good communication with primary care physicians.

Senior radiology residents attend a month-long course correlating radiology with the corresponding pathophysiology of diseases at the Armed Forces Institute of Pathology (AFIP) now known as the American Institute for Radiologic Pathology (AIRP). I remember during medical school trying to set up an elective at what was then called AFIP but was not able to since it is only open to radiology residents.

At both my previous and current institution, the “rads-path conference” as it is affectionately called, is informal and driven by the radiology department in terms of case choices. It’s meant to be a learning experience but generally the only pathology residents who attend are the one(s) presenting while all the radiology residents available have to attend. Seems somewhat ironic that the learning is mostly one-sided, and it’s bad that our two departments don’t do this more as a true inter-departmental conference.

Pathology and radiology are two fields that also often get left out when publications are written even though our final diagnoses, and sometimes, even images are used within publication submissions. As residents in these fields, we should make an active effort to interact with our primary care counterparts frequently. We should do this not only to be included in such scholarly endeavors but also to show that we are also equal members of the patient care team and are not forgotten when treatment discussions take place.

It also happens with tumor boards as well that most of the choice of cases and topics for discussion come from the non-pathology department. So what are your opinions on how we should interact with other departments for patient care discussions and inter-departmental conferences?

 

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

The Importance of Supportive Mentorship and “Junior Attending” Experiences

Over the last few weeks I have spent more time revising my fellowship application personal statements than I would like. While my attendings have been a great source of feedback, it’s hard to know what fellowship directors would like to see highlighted. But going through this process, I have realized even more palpably than I had previously thought before, that two things have been important in bringing me to this point: supportive mentorship and “junior attending” experiences.

Let’s start with supportive mentorship and the definition of mentor. The word Mentōr derives from the Greek name of the friend of Odysseus and advisor to his son, Telemachus, in Homer’s Odyssey. Therefore, first and foremost, a mentor is an advisor: someone who is more expert and who guides you. But what I’ve found is that a professional mentor is more than a mere advisor.

I have been extremely blessed and grateful when it comes to my mentors. Not only do they advise me but they also think of me when opportunities arise such as a possible research project or publication or to be a member of their CAP lab accreditation team that inspects another institution’s lab. Besides building up my CV, these activities also help me to acquire skills that I will need in my future professional capacity. I at first didn’t necessarily think of including some of these experiences on my CV but after a talk with a fellowship director, realized that these are the types of experiences that they would like to know about – if I’ve had previous experience where I gained a skill, then they feel I will be faster to train in terms of skills that build on that initial skill.

This brings me to my second point: the importance of “junior attending” experiences. What I mean by this term is the opportunity to participate in patient care or directorship duties in as close to a capacity as your attending would have. This could mean initial sign-out without direct supervision (of course, attending review has to occur prior to true verification) in terms of patient cases, whether it be AP or CP cases, or the initial preview of a frozen section. In terms of lab management, this could mean participating in preparation for a CAP inspection or serving on a CAP inspection team that goes to another institution. And in terms of most CP rotations, serving as the primary consultant for primary physicians about lab tests and discussing evidence-based and cost-effective ordering of appropriate tests or developing, troubleshooting, or validating a new assay.

Whatever the attending does in the course of their daily workload is where we should focus on acquiring skills. While writing my personal statement and CV, I talked with fellowship directors, and this became clearer to me. It’s all about having the proper attitude. Yes, there can be a lot of “scut” during our training but in comparison to other specialties (and those who have to do an intern year), we are fortunate to have less of it. Either way, the work has to get done, “scut” or not, so might as well learn from it and you might be surprised how it helps you later. Our attendings are not free from “scut” in their daily work either. If we think of the “scut” as attached to a patient who is waiting for their diagnosis, it makes the work go easier and faster in my opinion.

Having a positive attitude, working hard, and becoming known for certain qualities and skills only help in terms of developing strong relationships with mentors (who will one day be your colleagues) and being given those “junior attending” opportunities. Strive to be the first person they think of in those situations. Remember we are no longer in school and the faster you acquire the characteristics, knowledge, and skills of an attending, the better off you will be when it comes to progressing to the next phase.

 

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

 

Ebola Information for Laboratory Professionals

While it’s unlikely you will ever encounter a case of Ebola, it’s best to be prepared. The CDC has a health advisory page full of information, including specimen requirements for Ebola testing. The laboratory’s first step is to contact their state health department.

 

 

The State of Graduate Medical Education and Meeting Our Nation’s Health Needs

The Institute on Medicine (IOM), the health arm of the National Academy of Sciences that provides analysis and advice on national health issues, released its report “Graduate Medical Education that Meets the Nation’s Health Needs” on July 29, 2014. Citing a lack of transparency and accountability in our current system and discordance with producing the types of physicians necessary to meet our nation’s health needs, the IOM recommended a significant overhaul of our current system of graduate medical education (GME) financing and governance over the next ten years.

Since the creation of Medicare in 1965, the federal government has provided the majority of funding for the post-graduate training of physicians with about two-thirds provided by Medicare. Originally intended as a temporary measure until a more suitable one could be found, this system has financed GME since 1965. Approximately, $15 billion ($9.7 billion from Medicare) was spent in 2012 to support GME funding.1 The IOM’s report remain recommendations unless enacted into law by Congress so aggressive lobbying efforts are expected in the forthcoming months.

In fact, there has already been quick and varied response by multiple academic medical organizations: the American Association of Medical Colleges (AAMC), the American Hospital Association (AHA), and the American Medical Association (AMA) vehemently opposed and warned that the IOM’s recommendations would destabilize our current GME infrastructure while the American Association of Family Physicians (AAFP) supported the recommendations and the American College of Physicians (ACP) falls somewhere in between. If we break down the major recommendations of the report, the reasons for each organization’s opinions become more apparent but this does not necessarily help us to determine the best way to distribute GME funding to address our future healthcare workforce needs.

Currently, there are two components to GME funding from the federal government: direct and indirect. Direct graduate medical education (DGME) funding provides for the “direct costs” of teaching hospitals for the training of residents: the salaries and benefits of residents and the faculty who supervises them, the salaries of GME administrative staff, and allocated institutional overhead costs such as electricity, space rental, and maintenance. Each hospital receives DGME funding as a per-resident amount (PRA) which is hospital specific and calculated as the DGME costs in 1984 (or 1985) divided by the number of full-time equivalent (FTE) residents per year.2 This PRA is updated annually with an inflation factor and adjustment for that hospital’s resident count, limited, of course, by that hospital’s resident cap (number of allowed total residents) set by the Congressional Balanced Budget Act (BBA) of 1997.

The Medicare portion of DGME is calculated by a ratio based on the number of total in-patient days in that hospital spent by Medicare patients divided by the total number of in-patient days by all patients. There are separate PRA’s for primary care and non-primary care residents with those in primary care specialties (family medicine, general internal medicine, general pediatrics, OB/Gyn, preventative medicine, geriatric medicine, general osteopathic medicine) receiving a slightly higher amount. This is due to a congressional freeze on PRA inflation updates on non-primary care residents in 1994 and 1995.

Indirect graduate medical education (IME) funding are additional amounts paid to teaching hospitals for the “indirect costs” of being a teaching hospital. They generally incur more costs than non-teaching hospital settings due to having a sicker patient load and more “non-quantifiable” costs (eg – residents ordering extra tests).3 This payment is based on a formula that takes into account the ratio between the number of interns and residents and the number of patient beds (IRB ratio) adjusted with a variable multiplier and IRB ratio caps that are set by Congress. IME funding is not weighted like DGME funding where the number of residents in their “initial residency period” (IRP) are counted as 1.0 FTE and those beyond this period as 0.5 FTE.

Of course, these funding formulas can get very complicated and are adjusted with each new Congressional legislative action on GME. But now that you have a rudimentary idea of how the federal government and Medicare fund our education as residents, let’s consider the recent IOM recommendations.

IOM Recommendation #1: aggregate GME funding should remain at current levels ($15 bil/yr) with adjustments only made for inflation over the next ten years while the recommended new GME policy is implemented; the bulk of funding ($10 bil/yr) will continue to come from Medicare.

Supporting Argument: the current GME system is unsustainable and needs to become more performance- and value-based as healthcare system evolves under healthcare reform; this would provide stable (albeit not increased) funding over this transitional period.

Opposing Argument: for years, academic medical associations and their allies have recommended an increase in GME funding stating that the rate of increase has not kept up with inflation and the expense of educating our nation’s future healthcare workforce; additionally, they have consistently recommended lifting the GME cap with little success.

IOM Recommendation #2: a new GME Policy Council should be established within the Office of Health and Human Services to provide guidance on GME issues and a new GME Center within the Centers for Medicare and Medicaid Services to administer GME funding.

Supporting Argument: more transparency and accountability is needed to make sure that our dollars are well spent to produce more efficient use and better health outcomes for patients.

Opposing Argument: more bureaucratic and inefficient “red tape” and hoops to jump through without added benefit.

IOM Recommendation #3: eliminate the DGME and IME structure and replace with an Operational Fund to finance existing GME programs; the other portion of funding would support a Transformational Fund focused on innovation and programs in needed and underserved areas.

Supporting Argument: the Operational Fund would provide for currently existing programs so as not to destabilize GME funding during the proposed transition; the Transformational Fund would be targeted to address the current geographic and subspecialty maldistribution that exists.

Opposing Argument: the geographic and subspecialty maldistribution is nothing new but merely funneling more money toward these areas will not necessarily provide more healthcare professionals in these underserved areas or specialties, especially as long as student loan financing structures remain as they are currently. This recommendation also will significantly affect the funding amounts currently received by teaching hospitals, especially urban based hospitals, where the majority of GME takes place.

IOM Recommendation #4: provide funding based on PRA only with geographic adjustments and end payments based on Medicare in-patient days, IRB ratio, and other factors currently in the funding formula. These PRA funds would be directed to the GME sponsors who are responsible for the actual educational content for the training of interns and residents rather than to teaching hospitals alone. GME sponsors can be teaching hospitals, educational institutions, community health centers, or GME consortia.4

Supporting Argument: funding would go directly to those responsible the actual educational content which may be a non-teaching hospital setting; studies do not support a physician workforce shortage, especially in primary care specialties.

Opposing Argument: this recommendation again will disproportionately hurt teaching hospitals as they tend to have a sicker patient load, have more patient beds, and have access to more expensive tests and treatments than more community-based and/or non-teaching hospitals; teaching hospitals often are the main settings for GME, although not necessarily the only settings, and may need to make cuts based on resident education versus operational costs of the hospital with reduction of resident slots as the outcome when a physician workforce shortage is looming.

The IOM recommendations assert to support a more targeted, performance-based investment in the training of our future healthcare workforce but do they really? Obviously, GME funding has been a hotly debated topic for the past 50 years so there are no simple solutions and everyone has their own biased opinion. Even though I have some health policy and advocacy training from my MPH and grassroots organizing background, I don’t profess to be a health policy wonk by any means so I encourage you to become more informed and decide your own opinion. And if so inclined, become more involved in health policy advocacy with the political action committees (PAC) of your affiliated academic medical organizations to lobby for your beliefs.

You can read or download an electronic copy of the report free online at: http://www.iom.edu/Reports/2014/Graduate-Medical-Education-That-Meets-the-Nations-Health-Needs.aspx

References
1. Institute on Medicine (IOM). Graduate Medical Education that Meets the Nation’s Health Needs. July 29, 2014. 256 pages.

2. American Association of Medical Colleges (AAMC). Medicare Direct Graduate Medical Education (DGME) Payments; accessed on 8/8/14 at https://www.aamc.org/advocacy/gme/71152/gme_gme0001.html

3. T Johnson and TW Coons. Recent Developments in DGME and IME Payments. American Health Lawyers Association. Updated by Laurie Garvey on 3/16/10; accessed on 8/9/14 at http://www.healthlawyers.org/Events/Programs/Materials/Documents/MM10/coons_johnson.pdf

4. E. Salsberg. IOM Graduate Medical Education Report: Better Aligning GME Funding with Healthcare Workforce Needs. Health Affairs Blog. July 31, 2014; accessed on 8/10/14 at http://healthaffairs.org/blog/2014/07/31/iom-graduate-medical-education-report-better-aligning-gme-funding-with-health-workforce-needs/

 

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.