Graduate medical education funding mechanisms,challenges, and solutions: A narrative review

BackgroundWith increased attention on the federal budget deficit, graduate medical education (GME) funding has in particular been targeted as a potential source of cost reduction. Reduced GME funding can further deteriorate the compensation of physicians during their residency training.MethodsIn order to understand the GME funding mechanisms and current challenges, as well as the value of the work accomplished by residents, we searched peer-reviewed, English language studies published between 2000 and 2019.ResultsDirect and indirect GME funding is intended to support resident reimbursement and the higher costs associated with supporting a teaching program. However, policy efforts have aimed to reduce federal funding for GME. Furthermore, evidence suggests that residents are inadequately compensated because their salaries do not reflect the number of hours worked and are not comparable to those of other medical staff.ConclusionsOur review suggests that creative solutions are needed to diversify GME funding and improve resident compensation.     

Attrition of categoric general surgery residents: results of a 20-year audit

Background

Attrition of general surgery residents is of continued concern in graduate medical education. It results in loss of morale and resources and often leaves programs scrambling to find replacement residents. The aim of this study was to evaluate the incidence of attrition of categoric general surgery residents as well as the fate of those who left the general surgery training program among a defined cohort of categoric general surgery residents in a university hospital residency training program.

Methods

We retrospectively reviewed the files of all general surgery residents at the Yale University School of Medicine-Yale New Haven Hospital Surgery Program who began as categoric interns from July 1, 1986 to June 30, 2006. Ninety-nine residents were identified. Attrition of residents was divided into withdrawals (changed specialty or left graduate medical education), transfers (transferred to a different program in general surgery), and dismissals (dismissed from the program).

Results

Among the 99 residents who began as categoric interns from 1986 to 2006, 66 of 99 (67%) were men. Thirty of 99 (30%) failed to complete the general surgery training program. Of these, 21 of 30 (70%) withdrew, 5 of 30 (17%) transferred, and 4 of 30 (13%) were dismissed. Attrition occurred before entering the third clinical year in 23 of 30 (77%). Two of 30 (7%) left graduate medical education. Thirteen of 21 (62%) who withdrew entered primary care or another nonsurgical specialty, whereas 7 of 21 (38%) matriculated into a surgical subspecialty. The attrition rate was 40% (12 of 30) since the academic year 2000. The overall annual attrition rate for the past 20 years was 6.7%.

Comments

Attrition in our general surgery training remains low. Most who leave remain in graduate medical education and transfer to a different specialty. The overwhelming majority leave before beginning their third clinical year. Although our 6.7% annual attrition rate remains favorable (national attrition rate in general surgery 5.8%), we must continue to analyze the root causes and solutions.     

Differences in operative self-assessment between male and female plastic surgery residents: A survey of 8,149 cases

BackgroundPrevious studies show female residents tend to underrate and male residents to overrate their own performance. We sought to determine if plastic surgery resident trainee self-evaluations differ by resident sex.MethodsWe extracted Operative Entrustability Assessment (OEA) data for plastic surgery programs from MileMarker?, a program capable of storing assessment data for CPT-coded procedures. Complete OEAs contain a trainee self-assessment and attending surgeon assessment. We used simple statistics and linear regression to assess differences, stratifying by trainee sex and post-graduate year (PGY).ResultsWe analyzed 8149 OEAs from 3 training programs representing 64 residents (25% female) and 51 attendings. Compared to attending assessments, both male and female residents significantly underrated their performance during PGY1. However, during PGY2-6 male residents’ self-evaluations were significantly higher and female residents’ self-evaluations significantly lower than their attending evaluations.ConclusionsResults demonstrated female plastic surgery residents underestimated and male residents overestimated their performance. Further studies are needed to determine reasons for these differences.     

Education in obstetric anesthesiology: an international approach

Competency-based training and active teaching methods are increasingly becoming accepted and utilized in medical schools and hospitals, and obstetric anesthesiology training is expected to follow this process. This article summarizes current modalities of obstetric anesthesiology training in five countries from various parts of the world.Analysis of these curricula shows that implementation of new educational methods is variable, incomplete, and lacking in data related to patient outcomes. Research in assessments and practical applications are required to avoid wide ranges of educational strategies.     

Accreditation Council for Graduate Medical Education competencies and the American Board of Anesthesiology Clinical Competence Committee: a comparison

We compared the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project to the long-standing requirement of the American Board of Anesthesiology for a Clinical Competence Committee Report. There are many similarities between these two systems of resident evaluation. However, the ACGME Outcome Project requires the use of more numerous and diverse metrics when compared with the traditional global evaluation alone. In addition, the Clinical Competence Committee Report is primarily a summative evaluation for the purpose of assigning credit for training. The ACGME Outcome Project may be used as a component of a summative evaluation, but the primary emphasis is on formative assessment.     

Meeting the Accreditation Council for Graduate Medical Education competencies using established residency training program assessment tools

BACKGROUND: Most existing residency evaluation tools were constructed to evaluate the Accreditation Council for Graduate Medical Education (ACGME) competencies. METHODS: Before ACGME's six competency based assessment requirements for resident performance were developed, we created a residency evaluation tool with 5 domains important to successful surgical resident performance. Reliability was determined after 6 months of use. Factor analysis assessed whether the evaluation tool was a construct-valid measure of the ACGME competencies. RESULTS: Three hundred forty-three evaluations for 36 surgical residents were tested. The original evaluation tool was highly reliable with an overall reliability of 0.97. Factor analysis defined 4 new combinations of questions analogous to 4 of the ACGME competencies: professionalism (reliability 0.95), patient care (reliability 0.93), medical knowledge (reliability 0.92), and communication (reliability 0.92). The new competency clusters were correlated with each other to a moderate degree. CONCLUSIONS: Our locally developed tool demonstrated high reliability and construct validity for 4 of 6 ACGME competencies. The correlation between factors suggests overlap between competencies.     

An historical review of graduate medical education and a protocol of Accreditation Council for Graduate Medical Education compliance

PURPOSE: A brief history of American graduate medical education is discussed to provide a context for understanding the new standards set forth by the Accreditation Council on Graduate Medical Education (ACGME). The evaluation protocol of the University of Washington, which is structured around the 6 core competencies, is described. MATERIALS AND METHODS: Historical events regarding American graduate medical education, national conference information and recent ACGME recommendations according to the Outcomes Project are reviewed and summarized. These materials were used to design a reasonable program that would comply with ACGME recommendations. RESULTS: ACGME tools that represent the 6 core competencies have been incorporated into our program and should provide metrics that will demonstrate improvement in residency training and education. CONCLUSIONS: A key factor to the success of residency training and ACGME accreditation will be the education of residents and faculty about the new ACGME regulations. The University of Washington Department of Urology is poised to engage the new model by creating new call coverage strategies, applying new metrics to old teaching models and using electronic database systems.