The effect of Public Law 94--484 on pathology residency programs.

The Health Professions Educational Assistance Act of 1976 (Public Law 94--484) will affect graduate medical programs. The author surveyed directors of medical education in one major metropolitan area to study what the effects might be. With regard to pathology residency programs there are a number of important influences. For example, there will be fewer foreign medical graduates available to study in United States pathology programs. However, those who do come may be of higher quality. Also, owing to financial incentives to increase primary care, medical schools and hospitals may show less interest in the development of speciality programs such as pathology. The changing environment poses challenges to pathology directors to maintain or improve their programs.     

Residency directors' assessments of which selection criteria best predict the performances of foreign-born foreign medical graduates during internal medicine residencies.

In the summer of 1990, 102 directors of internal medicine residency programs from nine areas of the country with the largest numbers of foreign-born foreign medical graduates (FFMGs) were surveyed by mail to determine what criteria used to select FFMGs for residency positions best predicted performance. The directors felt that the most important predictors were performance on the Foreign Medical Graduate Examination in the Medical Sciences or the National Board of Medical Examiners examinations; performance during the interview; and postgraduate clinical experience in the United States. Recent graduation from medical school was felt to be a better predictor than postgraduate clinical experience in a foreign country. Seventy-three percent of the directors found letters of recommendation from a foreign country to be useless. The author suggests the results of this study may be useful to residency programs in evaluating FFMG applicants and to FFMGs in assessing their own credentials.     

The changing scene in graduate medical education: implications for pathology

During the past several years a number of unrelated events have occurred that will have a marked impact upon residency training in pathology in the United States. These factors include: (1) a twofold increase in the annual number of graduates from American medical schools, (2) Public Law 94-484, which will reduce the number of foreign medical graduates eligible for postgraduate training in this country by 70 to 80 per cent, and (3) increased emphasis on permitting Americans studying abroad to transfer to United States medical schools. Barring unforeseen changes, the culmination of these events is expected circa 1984 when the number of applicants for first year house office positions will equal or exceed the pool of available slots. Therefore, a significant proportion of graduates either will not be matched at all or will not be matched with the specialty(ies) of their choice. The implications of these trends with respect to residency training in pathology, with particular reference to the motives and motivation of persons seeking a first year slot, are discussed and alternative strategies for maximizing benefits discussed.     

Licensure, competence, and manpower distribution. A follow-up study of foreign medical graduates.

Medical statistics report United States medical graduates licensed at higher rates than foreign medical graduates. This difference is often interpreted to show greater medical competence of United States graduates. This study questions this interpretation by analyzing 1971 licensure rates for both groups who had been interns and residents in 1963. We found that factors unrelated to competence--namely, visa-citizenship status and state of examination--are associated with holding a license. Moreover, quality of medical education is not an accurate predictor of licensure. It follows that the use of licensure rates as measures of medical competence distorts understanding of the quality of medical care in the United States. More probably, the difficulties in obtaining medical licensure experienced by foreign graduates result from the use of such graduates to relieve specific medical-manpower shortages.     

Medical students trained abroad and medical manpower. Recent trends and predictions

Physicians trained in foreign medical schools, including U.S. citizens, are once again playing a larger part in the provision of medical are in this country. After a decrease in the numbers of such physicians from 1977 through 1980, the number of foreign nationals entering the National Resident Matching Program increased by 312 per cent, and the number of U.S. citizens from foreign schools increased by 273 per cent. U.S. graduates of foreign medical schools participating in Fifth Pathway programs appear to benefit from their extra year of clinical training by being more successful in the National Resident Matching Program and having a higher pass rate on state licensing examinations. These increases in physicians trained in foreign medical schools, together with an increasing number of students graduating from U.S. medical schools, have resulted in an insufficient total number of first-year postgraduate positions, regardless of the specialty, to accommodate all physicians seeking a first-year residency. Since the number of residency positions will probably not expand to meet applicant demand, an increase in the pool of physicians with neither residency training nor licenses to practice medicine is likely. Alien foreign medical-school graduates and U.S. students who go abroad to study medicine can no longer take for granted residency training and practice in the United Stages.     

Predicting performance using background characteristics of international medical graduates in an inner-city university-affiliated Internal Medicine residency training program

Background  

IMGs constitute about a third of the United States (US) internal medicine graduates. US residency training programs face challenges in selection of IMGs with varied background features. However data on this topic is limited. We analyzed whether any pre-selection characteristics of IMG residents in our internal medicine program are associated with selected outcomes, namely competency based evaluation, examination performance and success in acquiring fellowship positions after graduation.     

Adequacy of medical school gross anatomy education as perceived by certain postgraduate residency programs and anatomy course directors

In light of the many changes that have been made in medical gross anatomy instruction, an attempt was made to determine the adequacy of medical student preparation in gross anatomy upon arrival at a postgraduate residency program and whether the adequacy of preparation had changed in the last 10 years. To address these questions, a survey was mailed to all of the programs in four postgraduate residencies in the United States. This survey requested information about the importance of gross anatomy to the discipline, the adequacy of resident preparation, how today's residents compare to those of 10 years ago, and in what areas they are deficient. Another survey was mailed to all medical school anatomy departments to follow changes in curriculum, teaching methods, curriculum hours, and staffing in gross anatomy. Overall, of the surveys mailed, 79% were returned, 78% from the residency programs, and 81% from the anatomy departments. A majority of the residency programs report that gross anatomy is either extremely important or very important to mastery of their discipline and rank it as the most important basic science. Overall, 57% of the residency program directors felt that residents need a refresher in gross anatomy upon arrival, 29% felt that they were adequately prepared, whereas 14% felt they were seriously lacking. Fifty‐six percent of the residency programs indicated that the residents are as prepared as those of 10 years ago, 41% indicated that they are less prepared, and only 4% said that they were better prepared. There were significant differences in the responses between the different residency programs. The residency programs indicated that residents need to arrive more proficient in clinical applications, general knowledge, and cross‐sectional applications. Anatomy departments continue to modify their curriculum and teaching methods, decrease the curriculum hours and faculty devoted to gross anatomy, and foresee problems obtaining qualified gross anatomy teachers in the future. Clin. Anat. 12:55–65, 1999. © 1999 Wiley‐Liss, Inc.     

The research rotation: competency-based structured and novel approach to research training of internal medicine residents

Background  

In the United States, the Accreditation Council of graduate medical education (ACGME) requires all accredited Internal medicine residency training programs to facilitate resident scholarly activities. However, clinical experience and medical education still remain the main focus of graduate medical education in many Internal Medicine (IM) residency-training programs. Left to design the structure, process and outcome evaluation of the ACGME research requirement, residency-training programs are faced with numerous barriers. Many residency programs report having been cited by the ACGME residency review committee in IM for lack of scholarly activity by residents.     

Commentary: Coming to America: the integration of international medical graduates into the American medical culture.

This Commentary is a companion piece to two Research Reports appearing in this issue: "Behavioral Science Education and the International Medical Graduate," by Searight and Gafford, and "International Medical Graduates and the Diagnosis and Treatment of Late-Life Depression," by Kales et al. International medical graduates (IMGs) come to America from diverse cultures around the world to complete their graduate medical education (GME). These residents are and will continue to be a fundamental part of the American health care delivery system. IMGs' acculturation into the norms and standards of medicine as practiced in the U.S. is crucial to their education as well as to quality patient care. The time has come for GME to begin to systematically and effectively address the cultural challenges that IMGs face not only within the context of American medicine and GME, but in the larger context of American culture. Specific programs and strategies need to be developed and put in place early in the GME experience-or even before entry into GME-to assist IMGs in understanding the context for, and issues associated with, providing optimum health care in the United States. The author reflects on the findings of the two Research Reports, and calls for increased attention in the medical education community to acculturating and educating IMGs for optimal patient care.     

Perspective: Integrating research into surgical residency education: lessons learned from orthopaedic surgery

Orthopaedic research has advanced tremendously in parallel with accelerated progress in medical science. Possession of a fundamental understanding of basic and clinical science has become more essential than previously for orthopaedic surgeons to be able to translate advances in research into clinical practice. The number of medical graduates with prior education in scientific research who choose to pursue careers in orthopaedic surgery is small. Therefore, it is important that a core of research education be included during residency training to ensure the continued advancement of the clinical practice of orthopaedics. The authors examine some of the challenges to a comprehensive research experience during residency, including deficient priority, inadequate institutional infrastructure, financial strain on residency budgets, restricted time, and an insufficient number of mentors to encourage and guide residents to become clinician-scientists. They also present some strategies to overcome these challenges, including development and expansion of residency programs with clinician-scientist pathways, promotion of financial sources, and enhancement of opportunities for residents to interact with mentors who can serve as role models. Successful integration of research education into residency programs will stimulate future orthopaedic surgeons to develop the critical skills to lead musculoskeletal research, comprehend related discoveries, and translate them into patient care. Lessons learned from incorporating research training within orthopaedic residency programs will have broad application across medical specialties-in both primary and subspecialty patient care.     

Future directions in graduate medical education

Public perception that the challenges of meeting medical manpower and facility needs and of providing access to complex medical care have been met, coupled with concerns over mounting costs of medical care, will significantly reduce commitment to funding of graduate medical education. There will be reduced funding for longer educational programs and subspecialties and for foreign medical graduates, but not for primary care specialties and US medical graduates. The medical care system must ensure that each US medical graduate has access to the postgraduate education necessary as preparation for practice. The system will be challenged to develop necessary techniques for funding that education. An all-payor's system based on health insurance premiums, funds from the faculty practice plans, and sponsored programs carrying obligations of future service are reasonable possibilities for meeting funding needs.     

Training psychiatric residents to treat blacks

As only 600 of the 30,000 psychiatrists in America are black, it is apparent that black psychiatrists in the United States will not be able to meet the needs of all the mentally ill blacks in this country. In view of this situation, the authors feel that psychiatric residency training programs should prepare psychiatric residents to treat black patients. This paper describes some of the knowledge base and experience that residents need to treat black psychiatric patients.     

Financing graduate medical education.

The direct costs of residency training in the United States are over $1 billion per year. These educational programs have been organized predominantly around hospital services and supported by hospital revenues. Pressure has been increasing to reduce the rate of increase in hospital expenditures or costs or both. This article describes alternative methods for financing graduate medical education. Debate over the current sources of financing reveals several troublesome issues: the presence of residents allegedly decreases the productivity of professionals and leads to overusage of ancillary services, proposed methods to pay for faculty salaries and services have created confusion and concern, and the financing of ambulatory-care training has been insufficient and poorly coordinated. The medical-education community must resolve these professional and educational problems so that financing issues can be debated and properly defended.     

Internal medicine and general surgery residents' attitudes about the ACGME duty hours regulations: a multicenter study.

PURPOSE: To assess internal medicine and general surgery residents' attitudes about the effects of the Accreditation Council for Graduate Medical Education duty hours regulations on medical errors, quality of patient care, and residency experiences. METHOD: In 2005, the authors surveyed 200 residents who trained both before and after duty hours reform at six residency programs (three internal medicine, three general surgery) at five academic medical centers in the United States. Residents' attitudes about the effects of the duty hours regulations on the quality of patient care, residency education, and quality of life were measured using a survey instrument containing 19 Likert scale questions on a scale of 1 to 5. Survey responses were compared using the Student's t-test. RESULTS: The response rate was 80% (159 residents). Residents reported that whereas fatigue-related errors decreased slightly, errors related to reduced continuity of care significantly increased. Additionally, duty hours regulations somewhat decreased opportunities for formal education, bedside learning, and procedures, but there was no consensus that graduates would be less well trained after duty hours reform. Residents, particularly surgical trainees, reported improvements in quality of life and reduced burnout. CONCLUSIONS: Residents in medicine and surgery had similar opinions about the effects of duty hours reform, including improved quality of life. However, resident opinions suggest that reduced fatigue-related errors have been offset by errors related to decreased continuity of care and that the quality of the educational experience may have declined. Quantifying the degree to which regulating duty hours affected errors related to discontinuity of care should be a focus of future research.     

Perceptions of stress among pathology residents: survey results and some strategies to reduce them

We conducted a survey to attempt to identify stressors perceived by pathology residents. A comparison of survey results from pathology residents with stressors perceived by residents in other specialties was done to evaluate whether the stressors in pathology are unique. A confidential e-mail survey of residency programs in the United States generated a response rate from program directors of 23.3% and a resident response rate of 6.4%. Although the study is limited by response rates and the data are primarily from university-based residency programs, the concordance between the identifiable risk factors for stress by the resident and program director groups validates the importance of this issue among pathology residency programs. Both groups identified variability in faculty expectations and work overload that inhibits optimal learning as the top 2 stressors for residents. We discuss various factors that contribute to stress and some strategies that pathology residency programs can implement to address the stressors.     

Establishing a national clearinghouse on international medical education programs: an idea whose time has finally come.

In 2006, a special committee appointed by the Federation of State Medical Boards (FSMB) issued a report that evaluated undergraduate medical education in the United States and abroad. With accreditation systems that can provide reasonable and adequate assurance for the quality of medical education in this country, the committee focused its attention on international medical school programs. Because international medical graduates (IMG) comprise a quarter of the physician workforce, U.S. medical licensing boards continue to seek useful and appropriate information on the medical schools of their licensees.Among the report's recommendations is one calling for the establishment of a national clearinghouse of information and data on international medical schools. A workgroup with representation from the FSMB, the Educational Commission for Foreign Medical Graduates, and state medical boards has been formed to establish this clearinghouse. The clearinghouse workgroup is considering various quality indicators suggested by the special committee report such as admission requirements, policies relative to advanced standing, and aggregate performance data on the United States Medical Licensing Examination. The challenges facing the clearinghouse are significant (e.g., gaining cooperation from multiple parties in the United States and abroad, prioritizing data collection efforts). One likely means for facilitating success may be to concentrate data-collection efforts primarily on the 8 to 10 schools currently supplying the largest number of IMGs seeking medical licensure in the United States. In this way, the clearinghouse will provide licensing boards with a resource for standardized information on those medical schools commonly presented by their IMG licensees.     

The potential of the academic medical center to shape policy-oriented rural health research.

Rural communities continue to have problems in gaining access to basic health care services, a problem exacerbated by persistent shortages of physicians, financially threatened rural hospitals, and weak local economies. Academic health centers can help to address these issues, not only by increasing the flow of their graduates to rural areas, but also by supporting health services research designed to shape public policy that affects the rural United States. Examples of such research include experiments designed to influence the locational decisions of medical students and residents, studies of the quality and cost-effectiveness of care in rural hospitals, and the testing of new ways to provide emergency medical care in rural areas. Such policy-oriented research is compatible with both the intellectual and the service missions of most medical schools; in addition, lessons learned in rural areas may be relevant in more urbanized areas.     

Teaching medical residents about teenagers: an introductory curriculum in adolescent medicine.

OBJECTIVE: Adolescents in the United States have high morbidity rates, which are attributable to injuries, behavioral disorders, sexually transmitted diseases, and unplanned pregnancies. This has led to a call to action for health care educators to better prepare future practitioners to meet adolescent health care needs. Although pediatrics residency programs have required one-month curricula dedicated to adolescent medicine, many internal medicine (IM) residency programs do not have such requirements despite an American College of Physicians position paper recognizing the importance of internists' providing health care to adolescents. Thus, an introductory curriculum in adolescent medicine was developed for a community hospital IM residency program. The curriculum was designed to train IM residents to effectively interview, provide preventive care for, and evaluate common medical problems of older adolescents (ages 16-21) in an outpatient setting. DESCRIPTION: The curriculum was based on the results of an extensive needs assessment, which included surveys sent to practicing internists and current IM residents. It included three units, each a series of one-hour lessons delivered via morning report or grand rounds sessions. The first unit was interviewing, which covered specific interviewing questions, communication methods, and confidentiality issues. The second unit was preventive medicine care, which addressed immunizations, injury prevention, and adolescent drug and alcohol use. The third unit was diagnosis and management of common problems, which focused on topics frequently encountered during adolescent outpatient visits, including acne, sexually transmitted diseases, reproductive health care needs, and menstrual abnormalities. Other topics pertinent to the care of adolescents, notably depression, eating disorders, and sports medicine, were covered by previously established curricula, and thus omitted. This curriculum was created through the support of the Michigan State University Primary Care Faculty Development Fellowship Program, and was reviewed by curricular and adolescent medicine content experts. The residency program director supported its implementation over the course of two academic years. The pilot unit interviewing was conducted in February 2001, during two one-hour morning report sessions. In the first session, a short lecture outlining interviewing concepts and principles was given, followed by several case-based studies describing office presentations of adolescent patients. In the second session, an actual office visit was simulated; the residents observed adolescent volunteers being interviewed, and were then given an opportunity to ask the patients further questions. Residents completed a brief quiz and evaluation survey at the end of the pilot unit. DISCUSSION: Twenty-one of 40 residents participated in the pilot unit. Evaluations were overall very positive. Quiz scores confirmed that the residents achieved the desired learning objectives. Given these results from the pilot unit, the remaining two units of the curriculum have been integrated into the residency curriculum. Additional faculty members have been selected to deliver future sessions and support this important educational activity. The adolescent medicine curriculum can be used as an model by other IM residency programs for teaching adolescent health care, with an emphasis on both the knowledge base of adolescent issues and awareness of the unique skills necessary for the establishment of a physician-patient relationship between internists and older adolescents.     

Preparing graduates for the first year of residency: are medical schools meeting the need?

PURPOSE: Changes in graduate medical education associated with full implementation of the Balanced Budget Act of 1997 have required medical schools to review and revise their curricula. As limited funding increases pressures to streamline training, residencies will potentially expect an entry level of skill and competence that is greater than that which schools are currently providing. To determine whether medical school curricular requirements correlate with residency needs, this multidisciplinary pilot study investigated expectations and prerequisites for postgraduate specialty training. METHOD: A questionnaire about 100 skills and competencies expected of new first-year residents was sent to 50 U.S. residency directors from surgery, internal medicine, family medicine, pediatrics, and obstetrics-gynecology programs. Each director was asked to state expectations of a first-year resident's competence in each skill at entry to residency and after three months of training. Skills deemed most appropriately acquired in residency were also identified. Competencies included diagnosis, management, triage, interpretation of data, informatics and technology, record keeping, interpersonal communications, and manual skills. RESULTS: A total of 39 residency directors responded, including seven surgery, nine medicine, seven family medicine, eight pediatrics, and eight obstetrics-gynecology. In addition to physical examination skills, 13 competencies achieved more than 70% agreement as being entry-level skills. There was wide variability as to the relative importance of the remaining skills, with residency directors expecting to devote significant resources and time in early training to ensure competence. CONCLUSIONS: Medical schools should consider the expectations of their students' future residency directors when developing new curricula. Assuring students' competencies through focused curricular change should save both time and resources during residency.