How do we educate residents with todays restrictions .... (part III)

“It is a miracle that curiosity survives formal education.”

~Albert Einstein

So the next question is how do we, educators, teach our audience, the learners, our craft with in the restrictions of different governing bodies, while appropriately meeting the specific needs of the current generation?

As we look at the need of the current generation, we can see that there is an emphasis on the individual yet they want to be mentored. They are in touch with the newest technology and may require different ways of communicating. You may be required to give them instant feedback. Heck, we have cell phone and the text messaging. I want to know now. Why didn't you pick you your phone? I think we, educators, must keep in mind that everyone’s time is important. The learners do not need to learn all of the information in one sitting. People learn and think best when well rested and fed. This progression to a kinder gentler medical training is a change in philosophy. It will make less bitter people.

The learners, on the other hand, must understand that they will be required to be active participants in their own education. Because less will be learned directly from the educator, the learner must be facile with the other learning media. Learners must seek out knowledge. There is not enough time to do passive learning; the learner must seek out the opportunities to gain clinical skill. This is something in the past that was provided by shear volume; now, it must be sought out and learn through alternative means. Unlike many things that can be learned by reading, those who are in clinical specialties must learn from patients. Patients and their diseases do not always follow the rules. The more patients you see, the better understanding of the possible variations in presentation. This can not be learned by computer simulation or by reading in a text book. There is no algorithm will incorporate every clinical scenario. So, the patients must be seen and evaluated. With all of the new technology, one of the key skill set of the physician is slowly being lost, the physical examination.

There are some significant changes coming in the future that will effect resident education. Many current residents and medical students harp on the 80 work week and the low pay. There are the arguments that say that the hospitals and universities get 100+ thousand dollars for each resident and the resident should get more money or have to work less hours. I say, be careful what you wish for. Let's go into some basic changes that will effect resident education directly and indirectly.

NEED TO INCREASE PHYSICIAN NUMBER

Although there are some that believe that,

There has been a systematic attempt to limit the number of spots in medical schools. With a limited supply of training institutions, there was insufficient supply to meet demand.

There have been some significant changes over the past few years to actually increase the number of physicians. Here is a little history.

In 1992, the Council on Graduate Medical Education (COGME) issued a series of reports expressing concern with potential surpluses of physicians and recommending an increase in the percent of physicians trained and practicing as generalists. These concerns led the Council to develop a recommendation that 110 percent of the number of U.S. medical graduates in 1993 should enter residency training each year (or about 19,750 physicians) and that half of these physicians should be generalists. This recommendation became known as the “110/50-50” goal for the physician workforce in the U.S.

Recently put out in the COGME's 16th report, they assessed the future supply, demand, and need for physicians in the United States (U.S.) through 2020 for both generalist and non-generalist physicians will exceed what we are currently producing.

Summarizing some of their findings:

1. Under current production and practice patterns, the supply of practicing physicians in the U.S. is expected to rise from 781,200 full-time equivalent (FTE) physicians3 in 2000 to 971,800 in 2020, a 24 percent incease.

2. At the same time, for a number of reasons and under a number of scenarios and models, the demand for physicians is likely to grow even more rapidly over this period than the supply.

3. The need for services, reflecting primarily the use of services under universal insurance and increased utilization review processes, is also expected to increase over the period.

4. The models and alternative scenarios used to make the predictions included a number of factors that could have a major impact on supply, demand, and need and, consequently, on a potential gap in the physician supply. Many of these factors are likely to add to the shortage of physicians.
> Changing lifestyles for the newest generation of physicians, with the possibility that new physicians will work fewer hours than their predecessors;
>Continuation of the rate of increase in the use of physician services by those over 45, which has been increasing for the past 20 years, and increased use of services by the baby-boom generation compared to prior generations
> Expected increases in the Nation’s wealth that would contribute to continued increases in the use of medical services.

Other factors could also lead to larger shortages and are not included in the baseline projections or alternative scenarios. These include the following:

> A potential increase in non-patient care activities by physicians, including research and administrative activities;
> A potential change in practice patterns for physicians over 50, including a reduction in hours worked before retirement and earlier retirement patterns;
> Possible increases in departures from practice due to liability concerns of physicians;
> Decreases in hours worked by physicians in training;
> Possible decreases in immigration of graduates of foreign medical schools;
> Possible increases in the number of physicians limiting the number of patients on their panel (sometimes referred to as “boutique medicine”);
> Advances in genetic testing that could lead to increases in the use of services as individuals learn they are at risk for certain illnesses or conditions; and
> Additional medical advances likely to keep individuals with chronic illnesses alive longer without curing their illnesses.

THE MEDICAL SCHOOL RESPONSE

In response to the findings of COGME, medical schools have started the process of increasing the class sizes to help with predicted future needs. This is in contrast to the past where there was a decrease in both medical school classes, as well as a push towards the primary care specialties. With the current findings, there will be a need across the board. There is less of a push for those primary specialties. In June of 2006, AAMC came out with a Statement on the Physician Workforce. They recommended:

1. Enrollment in LCME-accredited medical schools should be increased by 30% from the 2002 level over the next decade. This expansion should be accomplished by increased enrollment in existing schools as well as by establishing new medical schools.

2. The aggregate number of graduate medical education (GME) positions should be expanded to accommodate the additional graduates from accredited medical schools.

3. The AAMC should assist medical schools with expanding enrollment in a cost effective manner; assuring appropriate medical education for traditional and non-traditional students; and increasing the number and preparedness of applicants.

4. The AAMC should continue to advocate for and promote efforts to increase enrollment and graduation of racial and ethnic minorities from medical school; and promote the education and training of leaders in medical education and health care from racial and ethnic minorities.

5. The AAMC should examine options for development of: (1) a formal, voluntary process for assessing medical schools outside the U.S.; and (2) a mechanism for overseeing the clinical training experiences in the U.S. of medical students enrolled in foreign medical education programs.

6. The AAMC should undertake a study of the geographic distribution of physicians and develop recommendations to address mal-distribution in the U.S.

7. National Health Service Corps (NHSC) awards should be increased by at least 1,500 per year to help meet the need for physicians caring for under-served populations and to help address rising mdical student indebtedness.

8. Studies of the relationship between physician preparation (i.e., medical education and residency training) and the quality and outcomes of care should be conducted and supported by public and private funding.

RESIDENCY FUNDING

Residents are mostly funded by Centers for Medicare and Medicaid Services (CMS) and this is for taking care of Medicare patients. That funding is split into 2 parts: DGME and IME. The DGME (Direct Graduate Medical Education payment) is the direct cost of the resident (salary, benefits, malpractice, etc). The IME (Indirect Medical Education) is the indirect cost of medical education (teaching, supplies, cost of personnel for each residency and GME, and the increased cost of training institutions because of trainees). The dollar amounts vary based on an algorithm, but the gist is that the DGME is about ~$70-90,000 and the IME is ~$30,000. In the near future, like next year, the IME is being decrease by about 1/2. Another change that will affect residencies is that if a resident goes to a course for education, the government will not pay for those days, unless they were vacation days. If a resident is in an outpatient setting, unless approved by CMS, the hospital or facility will have to cover the residents salary for that given time. Every hour of a resident’s day has to be accounted for and reported to the government. If there is a question, that time will have to be covered by the institution. Many would have you believe that the hospital make a mint of of the residents. They get money from the government and then they are able to bill for facility fees and attendings bill for their work. There are actually some articles that are coming out to dispute this.

Along with the CMS guidelines the numbers of medical graduates will be increasing but the residency "cap" has not. Therefore the number of residencies paid for by CMS will not change. There have been some policies to change this, but they are not currently in place. Hospitals have responded to the lack of governmental GME funding by funding residency positions themselves.

Why do I say be careful what you wish for? I can see in the future requiring tuition for residency. When the government pulls most or all of the funding, this may be happening.

TIME

Time is going to be an issue. With many of the newer generation wanting a "life", they are going to spent less time learning in the hospital. We have run into this problem with trying to fit in a curriculum that is considered a necessity by the RRC. When do you find time to have didactics? In today’s world, the didactics must be taught between the hours of 630 am and 6pm, Monday through Friday, no weekends, no holidays. This makes things tough in the surgical specialties. Yes, we can hire PA's and NP's to cover floor work; and yes, the attendings can start the cases by themselves (I actually prefer this because I get to operate). The problem is that this is education time too. In the surgical specialties, noon conferences don't work. That means it must be at the beginning or the end of the day.

Hospitals are being crushed by decreases in reimbursements so they are pushing to get more done with less. More cases are done in less time. Start the cases early and on time so that they can get more done before the end of the day shift. They don't want to pay overtime. Many hospitals want to push the OR time back to 7am. Hospitals administrators know that residents slow down many attending surgeons and would rather not have them operate to decrease OR time. So how are we going to prevent monetary problems from effecting the education of our needed practitioners?

WHAT'S THE ANSWER?

In the end, this question I wanted to solve has only brought more questions. I will continue to reevaluate my on education styles. I hope to keep this generations eyes open. I want them to look not only at how they are affected, but at how their choices and actions affect those who will follow them. As an educator, my ultimate goal is to put out a good product (physician/surgeon) in the end. The means of doing that may vary but hopefully the outcomes will be the same.

"In youth we learn; in age we understand.”

~Mari Von Ebner-Eschenbach