November 5, 2013
Welcome to Philadelphia! It’s another great day at the AAMC Annual Session – and Election Day! If you are local, don’t forget to vote, and if you are not, we hope you remembered to send in your absentee ballot! We’re still learning a lot still here…
Leadership Plenary: Embracing Changes in Culture – Driving Organizational Success by Building a Culture of Contributors
A strong session to start Tuesday morning (and the last of the plenary sessions) brought Adam Grant, PhD to the group to discuss givers, matchers, and takers – and which type is best for organizations. Happily, it Dr. Grant’s work appears to have shown that “givers” are, in the long run, the best type for both individual and organizational success (although perhaps NOT in the short term, surprisingly). The most important points not only were to encourage givers (who can influence matchers and even takers to give more), but to prevent takers from “getting on the bus.” Tips for recruitment were discussed, and opportunities to bring out the “giver” in all were suggested. Uplifting, energetic, and informative start to the day!
MedEdPORTAL and MedAPS Update
Great resources for staff, faculty and students. Check out the websites!!
RIME Invited Address
This was an excellent invited dress by Clarence Braddock, vice Dean at UCLA, about patient centeredness as an organizing framework for medical education research. He made a strong case that patient outcomes should be a principal measure of the success of our medical education program. He said a good medical education program graduates excellent doctors, but a great one improves health outcomes for patients and populations.
Digitized poster session: Curriculum
This session offered seven posters related to curriculum innovations or daily practice in UME. Topics for this session covered LCME as a vehicle for continuous quality improvement through an innovative obesity curriculum for M2 students that incorporated an SP encounter to discuss weight loss options for patients. Great ideas for all of us to consider!
Light Years beyond Flexner: Academic Medicine in 2033
Discussed team based models of care for patient needs, training structure and continuum of med education, technology in medicine and impact on patient physician relationship. Beyond….Information science, decision science, social science and art back into medicine??
In the future, most of what physicians do today will be done by others. Physicians will deal with complexity and ambiguity, become the designer, innovator and navigator as well as the leader or coordinator. Other possibilities- “ultrasound on steroids”, holographic and lifelike robotic mannequins and situational simulation with telepresence. Leaders will need both critical and creative thinking, competency based evaluation will take on another look and individualized medical education will be what occurs including self phased curriculum and blurring of UME and GME
November 4, 2013
AAMC Town Hall
Dr. Kirch again took us through a variety of audience generated topics, including global health (GHLO - https://www.aamc.org/services/ghlo/), GME, MOOCs, and one that generated lots of buzz online and off… this conference, and what it should look like. Should the AAMC annual session split out educational focus from other topics (lots of concern about this one) – or research, etc.? No one wants to give up the opportunities to network, learn about areas a bit peripheral to one’s own expertise – all available in a large, multi-focus conference. However… conference is super-sized and getting unwieldy for some (and venue can be challenging – as we have all seen these past few days). Chicago AAMC meeting next year is shorter, different formats (more broad, user driven) and there will be more targeted conferences separately. More info and more feedback is certainly needed!
GME: What next?
A hot topic at this year’s conference. Attendees heard a variety of viewpoints – health sciences VP, medical student (arguably the best speaker!), and DIO. If we focus on just the student views – paints a challenging picture. Students come to medical school NOT as pluripotent stem cells, but as individuals with already molded expectations of careers in medicine. Can we expect them to create “parallel paths” to residency in less-competitive specialties if that is not what they are cut out to do? As it was so perfectly put by the Dartmouth student, “If you take 100 competitive people and put them in a room together, you should expect that they are going to compete.” Flip side is that some of those “competitive” students are not going to be able to compete, and options will be lots of debt and no ability to become a physician… No easy answers generated today…
Innovative Organizational Models in a Time of Rapid Change
Heerad Sabeti took the audience through his perspective on an emerging new, fourth sector (after business/for profit, government, and not-for-profit) – the “for-benefit” organization. This type of organization melds the income-generating/revenue-earning focus of the business sector with the societal benefit focus of the not-for-profit and governmental sectors. Unlike govt and not-for-profits, these organizations are not funded primarily by grants, taxes, or donations, but by earning their income. However, unlike the business sector, their goal is not income/wealth for their owners, but societal benefit. Current legal and other structures are challenged by this model; we need new regulatory and legal approaches to this type of organization to make it work. AMCs already have some of the characteristics of the for-benefit corporations, but need to push further along the spectrum.
Enhancing the Sustainability of Postbaccalaureate Programs in Medical Education: outcomes and collaboration
This fairly recent national collaborative described the development of the group with the AAMC. The types of postbacc programs that exist, as well as the student groups most likely to benefit from their curricula were outlined. The goals of the collaborative include the development of shared resources, support for the development of new programs, collaboration in research efforts, and sharing best procedures.
This session went over the updates of the various student surveys including the MSQ. Student wellness is now a focus of these surveys including time management and use of stimulants. The survey is anonymous but the response rate was only 18 percent. There are sexual identity questions for the first time. Females noted generally higher social support and the answers were more positive than other groups. 13 to 20 percent report using stimulants and alcohol use is even higher – obviously a very concerning statistic for us.
Innovative Uses of Clinical, Research, Education, and Multipurpose Space: A Virtual Tour
Six terrific virtual tours of new and reconstructed spaces were reviewed, including:
The Change Imperative Plenary Session: Embracing Changes in Culture
Daphne Koller, co-founder of Coursera, discussed the work in MOOCs. Presented a variety of fascinating strategies and actual data on outcomes and benefits of the pedagogy. Of interest –
Also discussed the potential to use technology to replace and/or supplement individual tutoring (which has best outcomes to learning).
Questions – what about massive offering of medical content for medical schools!
November 3, 2013
Welcome to Philadelphia! Day 3 of the 2013 AAMC brought a fascinating array of topics – and lots of great ideas for the present and future!
Plenary Session: Envisioning Changes in Health Care
Fascinating, frustrating, and somewhat frightening session on the future of the health care system in the age of ACA and HIX. Futurist Ian Morrison took us on a tour of the potential futures, with his prediction that the US will end up with massive healthcare provider consolidation, ultimately ending up with 100-200 large regional centers. The question is will all AMCs be in that group, just some, or none? Private exchanges are likely to take off, and healthcare is likely to go the route of pensions: defined contribution instead of defined benefit.
Four potential scenarios were proposed:
Khan Academy for PreHealth Preparation, the MCAT 2015 and Beyond
This session provided some history of the joint effort between the Khan Academy, AAMC groups, and the Robert Wood Johnson Foundation to produce high-quality, open access educational materials specific to concepts tested on the new MCAT. The work to create a freely accessible content library for premedical students is part of the larger effort to remove barriers to medical school, and has been strongly supported by The AAMC and the general academic medicine community. The balance between fact retention and problem solving within a conceptual framework on the new MCAT was a point of question, but no clear answer emerged during the session.
Many admissions officers spoke of their concerns regarding the removal of the recruitment activities from future AAMC national meetings. Future recruitment events and related logistics will require all involved groups to work together.
Social media experts from med ed discussed approaches to online media and the new AAMC “Toolkit” (available at https://www.aamc.org/members/gir/gir_resources/359492/digitalliteracytoolkit.html) for digital literacy. The group reviewed several of the case studies and had a lively discussion on the “right” answers… and discussed the ongoing and dynamic nature of how physicians and their patients communicate – both online and in person. Educators have an obligation to prepare our students for the world of communication with patients – beyond the one-on-one.
This session discussed research leading to the potential use of a new medical schools admissions test that is comprised of situational judgment tests that address interpersonal and interpersonal competences. There is also potential to use this as a measure of ability to move from one level of medical education to another – i.e., from preclinical to clinical training.
All around a wonderful (and jam-packed) session. Journalist Anna Quindlen compared the gap between providers and consumers to that between newspapers and consumers. Neither have met the changing needs, but unchanged wants, of readers/patients.
She challenged the notion of “MDieties” and asked the profession to focus on “just being kind.” Patients ask their doctors, “Do you know who I AM?” We need to be able to answer yes.
We must teach quality improvement across the curriculum. Schools can combine didactic and experiential learning, link with health system improvement efforts, assess education outcomes in this area, and have role models for quality improvement in educational processes.
A task force has identified 13 core Entrustable Professional Activities for entering residency. The project was initiated to address the international focus on transitions (UME to GME to CME) and the gaps that were identified between expectations of program directors and entering resident skills, and what residents were asked to do without supervision and what was documented that they were competent to do.
Entrustable is defined as “without direct supervision” which is different from a practicing physician. Activities should be viewed as a floor (minimum competency ), not a ceiling, and should not replace mission-critical activities.
EPAs were selected as they represent day to day activities of residents, and are observable. Competencies are abstract and granular. However, there is a connection between EPAs and competencies. All selected EPAs spanned more than one competency.
The task force document identifies the EPA, aligns the EPA with competencies, and provides vignettes of “entrustable ” and “nonentrustable” students.
The longitudinal integrated clerkship was viewed as a better organizational structure for documenting EPAs.
The site team went through a demo of the site. It can now be offered to accepted students prior to arrival using their AMCAS number with school assignment at the time the SRS is complete. We can also now offer the site with tools to our faculty mentors and greater tools to Advisory College Directors. The new site is easier to access and integrates the newsletters and sites for further information on specialties. There are plans for further expansion as well.
Transformative student initiated innovations and developments in medical education.
This session focused on five innovative student led projects in medical education that immersed students in the healthcare of their communities. CMSRU’s own CCCP Ambulatory Clerkship is already at the forefront of best practice. One idea presented was the concept of students as health coaches – with students empowering patients with chronic health conditions to navigate the health care system. This is very similar to what CMSRU does in Ambulatory Clerkship and what we plan for our CLIC. Add in our commitment to service learning and our students are learning and serving our community as part of our innovative curriculum!
The Future of Healthcare and the Learning Environment
This session saw four presentations from panelists discussing new programs for quality improvement and GME expansion. Wayne State and Duke both instituted QI programs that involved UME and GME that also aligned with the hospital’s needs. Duke’s program financially incentivized housestaff to achieve specific metrics. Both programs found success through aligning educational program targets with goals that the health systems desired. FIU and the University of Georgia discussed programs to increase GME in their own states through partnerships/funding from managed care (in FIU’s case) and the state (in UG’s case). Both were in the early stages – more to come!
State healthcare exchanges launched fairly well, but there were very few. Estimates are that 10,000 people will be added to Medicare rolls per day for the next 19 years. Emphasis will need to be on quality, efficiency, and cost reduction. Expected M&A activity will raise anti-trust concerns. With GME, teaching hospitals will no longer be able to count the time residents spend at critical access hospitals for IME or DME purposes.
Personal Competencies: the SJT
The AAMC has a project underway to create a test to measure skills and attributes not seen in the MCAT and in grades. The test will be a balance between cognitive and behavioral issues. This is a aimed at the selection step and is at least five years from implementation. The concerns surround the effects of coaching and faking on outcomes over time and the difficulty in creating enough scenarios.
Keynote Address: Joe Scarborough and Mika Brzezinski
An entertaining hour of political discourse ranging from the adversarial but still collegial relationship between Ronald Reagan and Tip O’Neill to the full-on war between the parties in Washington today. Mika and Joe talked about their own upbringings – including Mika’s dinners with the Pope and Deng Xiaoping, and Joe’s father’s refusal to vote for him when he ran for Congress. Finally, a few predictions for the 2016 elections (with a lot of hedging)… an entertaining evening presentation!
October 31, 2013
Welcome to Philadelphia! We are looking forward to this year’s AAMC Annual Session – a little closer to our home across the Ben Franklin Bridge this year. Follow us as we live blog and learn together!
Saturday, November 2
Leadership Plenary: Our Moment of Truth
AAMC President & CEO Dr. Darrell Kirch discussed his own “moments of truth” through his career, and asked us to consider our own – and how we made decisions in tough situations. And how sometimes we avoided making decisions – and how this was a decision itself.
We will have shared moments of truth together over the coming years – when we must make the difficult decisions that will impact the health of the nation.
Leadership Plenary: Leading the Dance of Change
Dr. Valerie Williams took the crowd through the options of the pace of change by way of a tour of dancing: The Waltz (traditional, stable, organized – as long as everyone moves in the same direction); The Twist (all about personal style – no matter if everyone dances on their own – but inefficient and non-cooperative); the Line Dance (structured and orderly, but one misstep by an individual impacts everyone else – structure and order are necessary, but not adequate); The Tango (powerful, fearless – a combination of order and risk-taking).
We must adapt our leadership skills to the challenges – we must be prepared for “sustained disequilibrium”, ongoing experimentation, and a changing environment.
Annual Address on the State of the Physician Workforce
The past ten years have seen a decrease in the number of rural and African Americans entering medical schools. If the current increase in residency slots of 1% per year continues we will have 2000 less positions than graduates by 2021. 35% of the IMGs applying for residency slots are now from Carribbean schools. There has been an increase in nurse practitioners by 60%. Studies show that 50% of patients do not mind seeing an extender and that number increases if it means being seen sooner. The prediction is that 50% of the physician shortage will be in primary care areas. Schools should give students good role models in primary care. The decline in interest in primary care may be ending. The ACA will amplify the physician shortage numbers.
Education meets Analytics
What we need from analytics: Competency verification (of students AND faculty); Counseling for individual learning needs – help students self-assess; Behavior Modification – help students/faculty see how and why different areas are important in the curriculum; Accreditation – of course; Curriculum evaluation
Hazards: Overwhelming people with data; Unhealthy competition among students; Heisenberg effect
Colleges are great at collecting data, but not very good at dispensing that information back to the students. What data should be shared with students, and who makes that decision? In a perfect world, students should be able to have access to their data (it is their data after all) whenever possible.
Preparing Your Institution for a Post Fee-For-Service World
Provided an interesting set of principles to lead health care organizations from fee-for-service to a value-based system. An emphasis was placed on communications, preparing systems, empowering people, customized strategic planning, and rewards and recognition. The value of visiting places that are innovators in this area was emphasized. The importance of getting an idea of true costs vs charges was presented. Accurate knowledge of costs unlocks opportunities in process improvement. Some articles from Harvard Business Review were cited and discussed.
Evidence-based approaches to promoting diversity in the academic medicine workforce
Great session presenting three different studies examining factors that impact career trajectories for clinical and research faculty. Controlled studies/analyses of existing mentoring approaches, academic milestones, and implementation of new “coaching” models all addressed current successes and failures in building diverse faculty at academic medical centers. One study highlighted that actual conversations are central to promoting change, and virtual or distance efforts to address practices/attitudes do not effectively pave the way for true discussions regarding culture change.
A healthcare delivery model that integrates legal care directly into patient healthcare, and uses three levels of legal intervention: 1) at the patient, 2) at the clinic, and 3) at policy levels — to address and prevent health-harming legal needs. Concepts for interprofessional education of medical and law students were discussed. An outline for a 4 year curriculum was presented. Great ideas for our schools
Six year elections are typically difficult for the party in power in the white house – so, expect loss of democratic seats in both houses of Congress. Very few house seats will be likely to change due to redistricting/gerrymandering and the resulting “safe” seats for both parties – only around 15% of seats are up for grabs. Polling shows that 47% of respondents thought ACA was a bad idea, but only 24% thought it should be completely repealed.
As Ohio goes, so goes the Nation: Shift in statewide elected officials from Democrat -> Republican in 2010 – Democrats lost ability to control redistricting… Gerrymandering created the model of “safe districts” for parties – heavily weighted towards R.
Efficiency, Accountability, and Sustainability: Alternative Models of Medical Education
Buzzwords in this session title were expanded upon – presenting three models of med ed that addressed combining M4 with residency in primary care, an accelerated back to MD, and an accelerated PhD in basic science to MD. Each presented possibilities that are creative and sustainable, but are complicated by the current structure of GME. Key to success in med ed innovation begins with the ACGME. “Competence, not time, should be the benchmark of med ed” — a Sal Khan-esque approach to medical education! We must continue to be innovative in our approach – particularly to the M4 year.
The Jaws are closing on Unmatched Students: Engaging National and Local Perspectives
Lively and busy session today!
Unfilled positions are decreasing as more students are applying. Students don’t match for a short list of reasons: 1) competitiveness (didn’t rank enough programs, too competitive specialty), 2) USMLE scores too low, 3) poor interview/interpersonal issues, 4) overly aggressive rank order list. Schools must counsel students – especially those “at risk” (competitive specialty, below average performance, couples match, etc.) to have a “parallel” plan for less competitive specialty or other option (MPH, etc.). VCU uses match survey, identifies students by red/yellow/green with regard to risk of not matching – identify EARLY and counsel on options, etc.
Council of Faculty and Academic Societies (CFAS)
The inaugural session of this group was held today. CFAS was created to provide a voice for medical school faculty (128,000 strong nationwide!) within AAMC. A few key issues affecting faculty that were identified in today’s session:
1) Increased emphasis on faculty clinical productivity over research and teaching
2) Effects of health system aggregation on the role/value of academic faculty
3) Federal fiscal crisis impact on sustainable research agenda
Implementing the Health Care and Diversity Imperatives in the Post-Fisher World
Successful policy development includes the following: sound educational basis, support by key stakeholders, clear mission/goals, and is lawful. The goal should be preparing effective, culturally competent physicians. Institutions need to develop metrics and track the benefit of a diverse, inclusive student body, in order to demonstrate efficacy of holistic admissions measures. Evidence can include student surveys, alumni surveys, patient outcomes, etc. Metrics matter!
Bridging the industry-academia divide to advance discovery
84% of drug discovery over last decade is from academia. There is a revenue stream from this – and institutions must manage the conflict of interest. Implicit in the push for translational research is commercialization (per the NIH). The curriculum must include instruction in conflict of interest. (and CMSRU has this embedded in our Scholar’s Workshop course!)
Health Care Improvement: effecting and Studying Change Thru Continuing Education, Professional Development, and Lifelong Learning
Important link all three of these approaches. The new equation is Value = Quality/Cost + Pt Centeredness. Consider changing “CME Office” to “Office of Integrated Professional Development”. It’s critically important to focus on the continuum of medical education – undergraduate, graduate, and continuing.
Friday, November 1
Working Within a Team: Navigating Difficult Conversations
This session dealt with preparing students for difficult conversations in the health care setting. How should they respond as members of the health care team when they observe something that isn’t standard of care or something occurs that is a patient safety issue? How do we empower students to speak up without fear of reprisal? Simulation would be a good venue to learn and practice having crucial conversations. OSCEs would a good way to assess student skill in this area.
Future of Medical Education: Opportunity, Innovation, and You—Sponsored by the GRMC.
Regional campuses may be ideally suited for innovation. A variety of innovations were discussed: LIC implementation at regional campuses, interprofessional education, early learners as patient navigators, restructuring the fourth year, faculty development in 10-15 minute sessions posted on U tube, and partnering with other schools to develop a digital library of lectures by premier faculty.
The four sections of the new MCAT for 2015 were reviewed. A validity study is in progress. In 2013 there were 48,014 applicants to allopathic schools in the US and for the first time enrollment was > 20,000. Applicants apply to 15.4 schools on average. Applications from Hispanic/Latino students have increased to 1826 and women comprise ~47% of the pool. 26% of enrollees are socio-economically/ educationally disadvantaged based on parental education and occupation. 19% are first generation college graduates.
October 10, 2013
The last two weeks have indeed been interesting ones nationally and locally. The all too familiar Washington gridlock leading to the government shutdown and the launch of the Affordable Care Act (ACA) highlighted the political turmoil surrounding access to care and how it is funded. While enrollment data are scant so far, the federal health insurance marketplace website (www.healthcare.gov) had over 8.5 million visits during the first week; this should remind us that, in order to care for these patients entering the healthcare system, we must address the present and looming physician and health care provider shortage.
As a quick refresher, we face a 90,000-doctor gap in the year 2020. Despite the appropriate recent focus on primary care, half of this number is specialists. This deficit is projected despite the number of new U.S. schools (of which CMSRU is proud to be one) and the expanded enrollment in most existing schools – even so, we still won’t get there. (In my last blog, I wrote about the collision of the increase in medical school graduates and the insufficient number of graduate medical education positions which will further complicate the issue). Not surprisingly, the physician shortage worsens the challenges of access to care among underserved citizens, both urban and rural.
In New Jersey, we won’t fare any better; New Jersey is 2,800 physicians short of what is needed, most of whom – 1,800 – are specialists. The Garden State, now with four medical schools and 26 hospitals and health systems with residency/fellowship programs, has disturbingly poor retention of these physicians once they complete their education. We rank 30th among states in keeping these groups – not a reassuring statistic in terms of meeting the looming provider shortfall.
Why stop here? Let’s layer another problem on top of this – medical student debt, a topic that’s also appeared in this space. The numbers are staggering: 85% of medical students graduate with an average debt of $162,000. These graduates may feel forced to select higher paying specialties and choose practice locations where the cost of living may be lower or where insured patients predominate.
An option that is gaining popularity nationally is a loan repayment program – after completion of training, physicians with debt can agree to practice for a certain number of years in a state in return for a reduction in debt. In New Jersey, we currently have a program, the “Primary Care Loan Redemption Program of New Jersey”. This plan allows primary care physicians who are NJ residents to obtain $120,000 of loan forgiveness by practicing full time in an underserved area for four years. Some have felt that this program is too restrictive in terms of practice sites and populations, and it has not had the anticipated effect on access to care.
And now, a bill has emerged from the NJ Senate Education Committee, S162. “Physician Loan Redemption Program”, will create a program with greater impact on reaching those citizens most in need of care. The bill will allow graduates of the state’s medical schools and residency programs to have full loan repayment after ten years of practice in New Jersey in underserved urban and rural locations. The bill, co-sponsored by Senators Singer and Vitale, prorates the percentage of loan repayment over the ten years – lower percentages early (5%) and higher proportion (20%) toward the end of the time frame, thereby encouraging participants to continue in the program until completion.
An added, and I believe intended, goal of this plan is this: physicians who remain in plan for the full time will be more likely to stay in the region, serving those same populations most in need of care. And while the sponsors are aiming for approval in 2014 rather than this year, this needs to happen as soon as possible. Every day, more of our citizens are seeking access to care and we must respond.
It’s awfully hard not to like this bill, although some have suggested that this should be left to “the market.” However, it is clear that “the market” has not effectively provided adequate physician coverage for the growing demand. Yes, the state will have to fund the loan repayment, but imagine how much money the state will save in costs of care, especially when these physicians improve the health status of our citizens?
We need this program; we need this bill to get to Governor Christie’s desk for signature. The physicians who enroll in this pay back plan, the patients for who they provide care and the state will benefit. I urge every Garden State citizen to support this bill. Let’s make this happen.
Paul Katz, MD
Cooper Medical School of Rowan University
August 27, 2013
In previous blogs (February 6 and April 15 of this year) I’ve written about the challenges this country faces in graduate medical education (GME) – that is, too many U.S. medical school graduates for too few available residency positions. The physician shortage in our country is accelerating, and despite the projections of a 90,000 doctor shortfall in 2020, many areas of the country and many specialties are already feeling the crunch.
The medical schools have responded – 15 new M.D.-granting schools have started since 2008, and many existing schools are increasing their class size. But the challenge remains at the GME level; most residency positions are supported by Federal funding through Medicare and Medicaid – almost $12 billion annually – but the number of residency positions funded through this program was “capped” at 1996 levels with the passage of the Balanced Budget Act of 1997. Currently, approximately 10,000 residency positions are funded from non-Federal sources—generally by hospitals and health systems eager to expand the GME workforce.
This year’s “match” – the process by which fourth year medical students apply for residency through the National Residency Matching Program and are “matched” by the program that ranks them the highest – showed an increase in applications of 5.8% from M.D. degree schools to a total of over 17,000, constituting half of the total number of applicants (the rest of the applicants are from osteopathic schools and non-U.S. medical schools). After the match, 528 U.S. grads (MDs and DOs) were without residency positions – that is, they did not match. These applicants then enter the Supplemental Offer and Acceptance Program (SOAP), whereby unmatched students vie for unfilled residency positions, a process facilitated by their medical school.
At the end of the SOAP this past year, there remained 61 unfilled residency positions, with 42 in the core disciplines of family medicine, internal medicine, pediatrics, psychiatry and neurology (child and adult). What does this mean for the future of primary care? One can imagine that in certain highly competitive specialties, American graduates may have to travel overseas to receive training. Or perhaps pay “tuition” to enter U.S. programs. Even today, it is likely that some graduates choose primary care residency positions only because they are available, not because that’s what they really want to do. This does not bode well for a long-term career in primary care.
So what awaits us? The intersection – or perhaps more descriptive, the collision— between an increasing number of medical school graduates and an insufficient number of residency positions is upon us, only to worsen as even more students graduate (see this article from John Iglehart from a 2013 NEJM). The obvious response is more Federal funding of GME positions. However, the Obama Administration’s recommended reduction in GME support of more than $11 billion in the next ten years is not a cause for optimism. Alternative mechanisms of funding (for example, contributions by insurers; new legislation) seem unlikely.
The Council on Graduate Medical Education (COGME) released its twenty-first report this month (here); COGME is an almost 30-year old group authorized by the Congress to address physician workforce issues. Its 17 members issued this report recognizing the looming crisis in GME, not just in terms of number of physicians but also with regard to the nature of the training, the primary care shortage and the remarkable changes that are occurring in care delivery. COGME developed six recommendations – increase GME funding; focus funding on those specialties currently under represented in the workforce; improve the efficiency of training; revise criteria for recruiting medical students and GME training based on populations served; revise curricula for students and residents maximize quality and safety; and increase the funding in medical education research.
COGME should be commended for these recommendations – we can only hope that they are taken seriously by those in a position to effect these changes and support them with the requisite funding. Ironically, since 1997, the funding of new GME slots has largely been due to the response of states, communities, and hospitals and health systems rather than the Federal Government. This decentralized approach has not resulted in growth of nationally underrepresented specialty workforce, and has also missed the mark on educating students and residents on critical issues of patient safety and quality.
In order for the COGME’s recommendations to be followed (as one example), Medicare funding for residency positions could be weighted – that is, more funding for a family medicine resident than an orthopedic resident. To push the agenda of patient safety and quality, GME sponsoring institutions could be required to demonstrate outcomes for their trainees based on quality measures, efficiency of care and post-residency practice location. Each of these methods would not require more Federal funding but rather would effect a redistribution of the current allocation.
Historically, GME funds have been provided without concomitant insistence upon demonstration of utility and efficacy. Now is the time for a change.
Paul Katz, MD
Cooper Medical School of Rowan University
July 8, 2013
It’s been a busy year at CMSRU, and many topics worth discussing have arisen – both internally and externally. As a bit of an end of year “clean up” – some thoughts on a few of these items:
The End of Year One – On June 7th, the Charter Class completed their first year! They were very happy as were we, needless to say. This year went extraordinarily quickly – it seems like just yesterday that we celebrated the Grand Opening of the Medical Education Building (it was actually July 24, 2012!). About half of the first class is staying in Camden for the summer, mostly working on research projects.
In mid-June, the senior leadership team held a day-long “Year 1 in Review” Retreat. Each unit (e.g., Academic Affairs, Student Affairs, etc.) did an internal review of the year – what worked well, what needed some tinkering and what was the plan in response to these findings. In a large group session we reviewed and discussed each of the reports. Our team arrived at some unit-specific tasks to complete and, equally importantly, we identified some overarching areas on which we wish to focus; things such as new program development and research expansion. The corollary benefit of this process was the open dialogue among all members of the attendees – a dialog on how CMSRU can become even stronger. I’ll be talking about some of these in future blogs.
The Challenges in Graduate Medical Education (GME) – In previous blogs (February 6 and April 15), I wrote about the impending (and realized) crisis in GME; that is, too many U.S. medical school graduates and too few residency positions. Much has been written about this recently (“The Residency Mismatch” Iglehart, N Engl J Med Online June 27, 2013; “Should Hospital Residency Programs Be Expanded to Increase the Number of Doctors?” WSJ Online, June 16, 2013) and I refer you to these articles as good updates. As previously promised, I’ll soon be posting a new blog about possible Federal responses to this conundrum.
Fisher v. Texas – Back in November, I wrote about this case that was pending before the U.S. Supreme Court. What was fundamentally at stake was whether higher education could use applicant race in admission decisions. Especially worrisome was that the Court might overturn the Grutter ruling that supported the use of this criterion. On June 24th, the 7-1 ruling (Justice Kagan was recused) sent the case back to the lower courts, thereby preserving the Grutter decision (at least for now).
For CMSRU, given our commitment to inclusion and diversity, this was an extremely important decision. We applaud the Court for preserving our ability to continue our holistic admissions process which we believe will help foster the cultural competence of our students as well as contributing to creating a diverse workforce. Much work remains to achieve these goals and we will redouble our efforts to do so.
CMSRU’s internal quality improvement, challenges in GME, and the ongoing national discussion on the importance of diversity – all of these conversations are of importance locally or nationally. Expect to hear more on all of these in the coming academic year.
Paul Katz, MD
Cooper Medical School of Rowan University
May 31, 2013
“Study the past if you would divine the future.” -- Confucius
Many months ago in this blog, plans for the CMSRU Time Capsule were revealed. Beginning back in the spring of 2011, the project began to unfold. We wanted to capture a bit of the past – the events and the people that, four decades ago, initiated the concept of a medical school in southern New Jersey. Building from this, we looked to the present and more recent events, starting with the Executive Order in 2009 that launched our school. And, finally, projections of the future – the future of CMSRU and of Camden.
A Time Capsule Committee was established last year consisting of members of the Charter Class, staff and faculty, all of whom saw this literally as a once-in-a-lifetime opportunity – a chance to entomb for 50 years the artifacts and memorabilia that will be part of our legacy. (See here for more details of the Time Capsule Event).
The committee appropriately titled the Time Capsule interment ceremony “Past, Present & Future”. They carefully selected items that captured the journey – photos, documents, newspapers and mementos that told the story, our story, of CMSRU. A number of letters from our team were entombed; letters written to loved ones who will hopefully read and reflect in 2063 on the thoughts, wishes, hopes and goals of the authors.
Those of us at CMSRU view our school as the place where we have the opportunity to create something new and different – not a carbon copy of the other medical schools in this country, not a “me too” institution. And we strive to be different, not to just be different; not innovative just for the sake of “innovation”. But “different” because the present and the future demand it. Our mission, vision and core values are woven through all that we do: our admissions process, our curriculum, the selection of our faculty, and very importantly, our community. We are mission-focused. We are mission-driven.
Our goal is to pay it forward, to keep the promise that we and those before us made. We pledge to educate a new type of physician – one who will be recognized as a ”CMSRU Physician,” not merely because of competency, but because of the type of person they are – driven to service, committed to humanistic care, and determined to be the kind of physician who each of us would want to care for our families.
As has been often written in this blog, the City of Camden – our classroom, our home – is always on our mind. A community with a celebrated past, a challenged present and a hopeful future. In “The Lion King”, the king’s Grand Vizier, Rafiki, says, “Oh yes, the past can hurt. But the from way I see it, you can either run from it, or… learn from it.” How we are ultimately judged as a medical school should in large measure be based on what happens to this city. Let us help it return to its past glory, let us pledge to make this a city that is prosperous, safe, healthy and well-educated. A city about which the poet Walt Whitman wrote – “I dreamed in a dream, I saw a city invincible”. A city that is recognized for its re-ascent to glory.
The day of the Time Capsule interment, the speakers spoke of the elements that were heralded in the title, “Past, Present & Future” – How did we get here? What and who are we now? Where will we go? While difficult to put all of these journeys – bygone and yet to be – into words, the mementos that were placed in the capsule will help tell the story.
But our hope is that those artifacts will be treasured by those who open the capsule in 2063 – and we hope that many members of the Charter Class will be among those present at the opening. With good health and good luck, most should be able to re-assemble to open the small reliquary and remember the day in 2013 when these reminders of the past were enshrined.
Let us hope that the course that has been set is true.
Paul Katz, MD
Cooper Medical School of Rowan University
May 14, 2013
Dean Katz and I recently attended the last meeting of the New and Developing Medical Schools funded by the Josiah H. Macy, Jr. Foundation. The group was first convened in 2009 when the Association of American Medical Colleges (AAMC) sponsored a conference of “new and developing medical schools.” In 2010, the Macy Foundation provided a generous grant to support meetings and activities of the 16 new schools. Over the years, the group has served many functions beyond merely giving advice and support on Liaison Committee on Medical Education (LCME) accreditation. It has served as a support group and sounding board for those with like experiences; a place to network; and a forum for innovation and problem-solving. CMSRU has been a beneficiary of the largess and camaraderie of the group. On a personal level, friendships have been forged. This particular meeting was somewhat bittersweet because it was the last meeting that will be funded by the Foundation.
George E. Thibault, MD, President of the Macy Foundation, made opening remarks that called for the need to make more of a “push for innovation.” He also proposed that this is an opportunity for us to change educational models and, in essence, take advantage of the uncertainties in healthcare to advance education. His messaging resonated with the group. Dr. Thibault outlined six areas for focus and change in medical education:
The group went on to hear various reports including observations from Warren D. Anderson, PhD, the ethnographer who visited several of the new schools and gave us new insights into the relatively unique phenomenon of creating a culture de novo. We brainstormed about various writing projects and spoke about our future as a group. While this particular chapter is ending, it is just the beginning of our story.
We will be forever grateful for the support of the Josiah H. Macy, Jr. Foundation and the spirit of collaboration that has been fostered among the new schools. On to the next chapter!
Annette C. Reboli, MD
Cooper Medical School of Rowan University
April 23, 2013
After a week of Spring Break, our Charter Class began gross anatomy. Traditionally, anatomy has heralded the start of one’s medical school career and adds to the “shock and awe” of beginning a career as a physician.
The CMSRU curriculum is different, as chronicled in this blog. In the fall curriculum, when our students traveled through the aptly named Fundamentals course (among others),they were exposed to the basic elements of cell biology, genetics, physiology and the related material typical of the first year.
With the new year began the transition to the organ system blocks that will extend into the second year. With Infectious Diseases and Hematology/Oncology now complete, Skin and Musculoskeletal System coincides with the start of gross anatomy, where dissection will parallel the remaining organ system experiences.
Some three years ago, as the CMSRU curriculum was being planned (concurrent with the design of the Medical Education Building), our discussions focused on whether dissection and anatomy as most of us experienced in the past were still necessary. With the associated costs, required infrastructure and regulatory requirements, as well as the increasing availability of skilled prosections and elaborate virtual tools, there has been a trending away from “classical” gross anatomy.
Ultimately, we at CMSRU decided to retain this traditional model of student dissection (albeit with a very different timing and integration with organ-based courses). We believe that only part of what occurs and is learned in the gross anatomy laboratory is really about anatomy. If one thinks about what should occur in the lab, the opportunity to learn about professionalism, dignity, respect, teamwork, communication and personal reflection clearly trumps the memorization of the branches of the facial nerve or the location of the Ligament of Treitz. And it is those “competencies” that are learned during this time that will hopefully long endure in our graduates, far beyond their recollection of most anatomical details.
As has become customary at many medical schools, CMSRU held a ceremony to mark the start of gross anatomy. As has been the case with all of our “first time” events, there was much anticipation about this session for students, staff and faculty. And, like our other inaugural gatherings, we wanted to make it special and memorable. I was asked by our faculty director of gross anatomy to make some opening remarks that prompted considerable thought on my part.
Much has been written about the significance of this course. Phrases such as the “humanity of anatomy” and “dissect with respect” are frequently found. As I have toured guests through our building over the past nine months, I always talk about a physician’s medical school anatomy experience as one that is never forgotten – it is a defining moment of becoming a practitioner. The sites, the sounds, the textures and the smells remain with us forever, as well they should.
I asked the students to think about those people, now deceased, who will leave an indelible imprint on them. They were mothers, fathers, sister, brothers and parents. They are now “paying it forward” by serving as a resource for the education of those who will spend hours and hours with them over the ensuing months. I suggested to the students that the term “cadaver” was impersonal and somehow commoditized those who now lay before them at the dissection table. Their hopes, their dreams, their failures and successes, were unknown to all of us, but no less tangible than those of the next “real” living patient each class member will encounter.
An unintended consequence of this ceremony was visible of the faces of the physician faculty in attendance – this event, this CMSRU event, crystallized for each of us what it has meant to have the privilege of being in our profession. Of course, we recalled our experiences in our own gross anatomy labs. But more important for me at least, was thinking about the wonderful, magical careers that await our students and the special moments that they will share with those for whom they provide care. I wish them well.
Paul Katz, MD
Cooper Medical School of Rowan University
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