Proceedings of the 25th National Conference: April 14, 2014 – Second Plenary Session, Part 2 (Hansen)

This session immediately follows: Proceedings of the 25th National Conference: April 14, 2014 – Second Plenary Session, Part 1 (Allen)

We gratefully acknowledge the sponsorship of the Wright State University Boonshoft School of Medicine (Dayton, Ohio) for funding the transcription and editing of this section of the Proceedings of the Twenty-Fifth National Conference:

 

Thomas Hansen, MD; Chief Academic Officer, Advocate Healthcare, Downers Grove, Illinois
Thomas Hansen, MD; Chief Academic Officer, Advocate Healthcare, Downers Grove, Illinois

Thomas Hansen, MD, Advocate Healthcare, Downers Grove, Illinois (Dr Hansen is a Fellow of the National Conferences on Primary Health Care Access): Good morning, my name is Thomas Hanson, Until last July I was at Creighton University in Omaha, Nebraska, where I was the associate dean for medical education. Now I’m at Advocate Healthcare in Chicago,where I’m the chief academic officer.

We have 12 hospitals in our system, of which four of which are teaching hospitals, where we have residency programs. There are 31 fellowship and residency programs, comprising about 850 residents and fellows.

We are affiliated with three of our local medical schools, with about 2,000 medical students coming through our system. My position helps oversee all of that training as well as the research library and the CME programs.

Today I will give a brief update on some of the changes in the AOA and ACME accreditation standards, reviewing them very briefly. I’ll present some data from this year’s match and will discuss what I consider to really be potential crisis coming up with regard to undergraduate medical education.

Safeguarding American Osteopathic Education Program Principles

Andrew Taylor Still in 1914 (age 86), founder of osteopathic medical education
Andrew Taylor Still in 1914 (age 86), founder of osteopathic medicine

Many of you are aware of the possibility that like American Osteopathic Association’s accreditation process and the Accrediting Council on Graduate Medical Education (ACGME) will be combining. I think there’s still a vote of AOA’s Board of Delegates, but eventually it appears that there will be a combined process for accrediting residency education.

In the hospital system I represent, we currently have both strictly AOA programs and ACGME residency programs, and then we have those that are dually accredited.

I have talked with my colleagues who are in osteopathic medicine, and know of their real concern that the values and the values principles of osteopathic medicine, envisioned by its founder, A. T. Still, who had phenomenal ideas, are going to disappear with the learner as they are going through a residency program.

As we make changes in undergraduate medical education we are reflecting how we make sure that we’re protecting the values, so our governing principles give close attention to iyr responsibilities for these three positions.

Faculty, currently in the standards is making sure that, at least in primary care, that the chair of the clinical department is an osteopathic physician. But now they’re wanting to say that lets make sure that in all the clinical areas that wherever a students are receiving their education that they have someone who is competent as an osteopathic physician and can demonstrate the competency leading them and then research, really focusing research on those principals of osteopathic medicine.

Liaison Committee on Medical Education Accreditation Process Changes

LCME Requirments beginning July 1, 2015
LCME Requirements beginning July 1, 2015

Regarding LCME, there will be a big change, but it’s really a format change, and this takes place July 1, 2015.

If you’ve ever gone through an institutional self-study for LCME, you’ll recognize these five areas.

The institutional setting – the educational program, medical students, faculty and educational resource – and then you’d have all these standards behind them, with education program being the largest with 51 standards included.

Current Number of  Accreditation Standards per Category
Current Number of Accreditation Standards per Category

But if you’ve gone through a self-study, you know there’s a lot of redundancy.

Thus, I’d be answering a question in one standard and then the same answer might apply to another question either within medical education, or in medical students or elsewhere.

There are some of those standards where the form might have a response one, then 1A and then skip to three, then five, suggesting that they really wanted to try to clean this up.

Reducing (although rearranging) standards
Reducing (although rearranging) standards

Depending on how you count as of right now there are 133 standards. How LCME is stating this is that they’re going to reduce the number of standards from 132 to 13. In fact the 132 standards don’t go away, they are categorized as different elements within this new format.

But in that process they are reducing a lot of the redundancy, so that it will  be a much cleaner approach for those who go through self-studies after July 1.

These are now the 12 standards, if you will. And really if you look at the category “medical selection” –  the last three, those are already there, it’s just that now they’re separating them out so that now we have elements that are specific to each one of these 12 areas.

So again, nothing’s really changing much with as far as what the standards are with the expectations; it’s just the format. They did tweak a few of them and that’s where people are really paying attention to what has really been tweaked.

So for instance, this is just an example. In the old system, they would state that medical education programs “should ensure that its medical students have adequate study space, lounge areas, personal lockers and secure storage facilities”. Now they have added, and “if they are on call, they have to have a secure call room”:.

This is where the changes are. They’re very minor, They’re being tweaked. But this is what the associate deans of education and student affairs are really paying attention to.

The Residency Match

And then for the match, this is where that everyone thought that this year was going to be the crisis situation, because we know that we now would have more students graduating from medical schools than we have capacity in the system. Last year we had the phenomenon of 1,000 students not matching into a program.

American Osteopathic Association Match Results
American Osteopathic Association Match Results

There was the fear that this year was going to be the crisis year, when in fact it didn’t turn out to be this year. I think it’s still eventually going to happen.

But if we look at the AOA match, so this is, AOA students going into an AOA residency program; overall, in general they’re still were 38.9% positions that were not filled within the AOA programs, family medicine 41% of positions that are still unfilled, including one of mine.

National Residency Matching Program Aggregate 2014 Match Data
National Residency Matching Program Aggregate 2014 Match Data

When we look at the NRMP, we see a decrease of 113 students from last year who graduated from US allopathic medical schools. Their match rate rose by 0.7%. 975 did not match. That number is down, though from last year, when 1,097 did not match.

Medicare “Caps” on Funding Physician Positions

There were 500 more first and second year positions offered this year. I think it’s important to keep that number in mind, because what everyone’s been focusing on are the “caps”, those residency positions which teaching hospitals have funding from Medicare to pay for residents to be in their programs.

These 500 positions are not funded by Medicare. So there is another system that is developing on funding graduate medical education. Of those 500, 319 positions were offered in family medicine. So we have more positions to absorb the increase students that are graduating from our educational systems.

The number of allopathic seniors choosing primary care continues to modestly increase. The osteopathic students tend to be more interested in primary care than the allopathic.

When we just look at some of the other key groups. So those who did not match last year or they got a preliminary spot, but nothing beyond the first year, the match rate actually rose 7.2% for them.

Osteopathic students who were successfully matched in this year’s match program rose 2.9%. US citizens’ graduates of international medical schools, that rate also rose, and then non US citizens’ students graduates in international medical schools, there were fewer students this year, but their match rate was actually better than last year.

So again, the positions are out there. We still have openings in primary care throughout the system and so we’re not at that crisis situation yet.

And when we look at the primary care specialty trends, we still 131 slots unfilled in family medicine; 72 positions more offered this year than last year. But we still have slots that are left unfilled. Internal medicine and pediatrics did pretty well this year in the match.

What’s fascinating is this year there are 1,000 more fellowship positions offered in the match than last year. Again, these are not funded by caps. So programs are finding ways to fund graduate medical education without having to rely upon Medicare.

In my remaining time I will talk briefly about what I think is the biggest challenge facing undergraduate medical education. I can only speak from my experience at Creighton University and now at Advocate, but I think that this is something that’s happening across the US.

We all know that there’s been a significant increase in the number of medical students in our system, you know based on concerns that we’re not going to have enough primary care physicians in the future.

Most medical schools have increased their enrollment. Many medical schools have started regional campuses. (I did the same when I was at Creighton University, starting a regional campus in Phoenix.) And there is simultaneously an increase in the number of new medical schools.

What has not kept pace with that increase is an equal increase in the number of traditional teaching hospitals. You may have a medical school that’s affiliated with one teaching hospital. And so there’s been a lot of partnering with healthcare systems in trying to find those placements for medical students needing clinical education, especially in the third and fourth year.

The medical schools are trying to find sufficient clinical settings to educate medical students in the first and second year. Identificaion of new clinical settings for these students has not kept pace, so that we now have more students, but we don’t have necessarily the same number of slots to teach those students in the clinical environment.

  1. There are projections that in 2020 we might be down to just down to 100 or 200 healthcare systems in the United States. Whether that is going to happen or not still remains to be seen, but those are projections. I saw at Creighton and other places that healthcare systems are buying up and merging those teaching hospitals,

Oftentimes the health systems really don’t understand medical education, so decisions are based purely on what seems right financially, but not on whether we are we providing a good educational environment for our students and our residents.

When teaching faculty at a traditional teaching hospital are merged into a health system, often they are no longer faculty members with a contract with a medical school or university in which part of the contract is for their clinical activities and part is for research and education. They’re now part of a healthcare system where the contract is their relative value units (RVUs) that generate patient care revenues.

They are told that this is how much you must produce if you’re going to get this amount of salary. If there’s a residency program, and If they’re lucky, the residency faculty in those systems, will also include an amount for teaching residents, but usually there’s nothing in the contract with regard to teaching medical students.

And so physicians are saying that they have a contract, and know what they are required to produce their income. If the contract require, but reimburses them to teach residents; who will pay them to teach medical students? “If it’s no longer a requirement for my contract; it’s no longer part of my job”.

A; Looming National Crisis for Training Physicians

I think this is the crisis that we need to start looking at and talking about nationally. The fact is that we’re not going to have enough physicians teaching our medical students in which we’re pouring out into the system in larger and larger numbers. This is really creating a “free market economy”.

When we look at supply and demand, and we’re looking at physicians who are expecting to be paid to teach medical students, we are confronted with the question as to who’s going to pay for the medical education?

Iin general – and there are exceptions, but U. S. allopathic schools still have the mind set they physicians have the privilege of teaching our medical students and therefore medical schools don’t have to pay them anything because they may have access to our library, or whatever privileges there may be. Usually there’s no compensation for teaching the medical students, even though the medical students are paying to be taught.

U. S. osteopathic schools, because many of them do not have their own teaching hospital on site have done a better job of reimbursing hospital systems or physicians for teaching. Oftentimes it does go to the hospital. And so the hospital will allow their physicians to teach, but sometimes I’m hearing from physicians that they never see that money.

The offshore Caribbean schools are the ones that have done the best job in this free market economy, offering to pay hospitals and physicians to teach.

in Chicago, where many healthcare systems, hospitals that are still fairly small are facing very dire financial situations, even though they may be wanting to educate medical students from a local medical school, but they’re saying, “You know, if I have to look at this list of your students, and I’m being approached from an offshore Caribbean school who’s willing to pay so that we can still educate students because we want to, but this is going to help our bottom line,”

They’re choosing the Caribbean schools and they’re getting very good students to educate. But they’re displacing students who would be there from the local schools.

And again I have three regional affiliates, two MD schools, one DO school. One of our hospitals, starting in July 2014 is going to take on a whole cohort of students from one of our Caribbean colleagues, and they’re displacing all them from one of our local schools. One of our local schools still has 81 students who have absolutely nowhere right now to start rotations July 1.

They’re coming to me and saying well we need you to take our students into your system because you’ve got 12 hospitals, and I’m saying my physicians aren’t interested in teaching unless they’re at an academic medical center.

Those at the academic medical centers, they’re saying, you know we love teaching medical students, but because of the changes with accreditation, with the milestones that Dr Suzanne Allen was just talking about, there’s a lot more requirement for supervision, there’s a lot more requirements for monitoring. We can’t do this, and maintain the productivity levels that we’re required to do. We’re having to decrease the number of students that we can take into our systems.

So I’ve had to decrease those in our system from the local schools and now am telling the schools whose students have been displaced we can’t educate your students as well.

I think that this is happening in other locations as well. I may be wrong, but this is kind of one of the elephants in the room that has not been discussed nationally, how are we going to continue training our medical students for the future?

So this is my summary, few new changes to accreditation standards, slight increase to US students going into family medicine, still a large number of unfilled spots in the match this year but overall and in family medicine, and then the potential crisis with the significant increase in US osteopathic and allopathic medical students and insufficient faculty in medical sites.

This section is followed by: Proceedings of the 25th National Conference: April 14, 2014 – Second Plenary Session, Part 3 (Herman)