Foreign medical graduates and the issue of substantial disruption of medical services

Provisions of the 1976 Health Professions Educational Assistance Act may result in a substantial disruption of medical services provided by foreign medical graduates in United States residency training programs. Estimates of the effect of the Act indicate that between one third and two thirds of foreign graduates receiving visas annually will not qualify for admission, under the new provisions. Results of a recent study show, furthermore, that foreign medical graduates constitute a majority of the residents in 23 per cent of the hospitals with residency programs. Transition to a decreased dependence on foreign graduates may be facilitated through the waiver of two provisions relating to exchange visitors. Projected numbers of United States medical graduates and citizens receiving medical education abroad will not be enough to fill the gap created by the ultimate reduction in alien physicians. United States residency programs will have to develop alternative sources of residents to continue operating at current levels.     

The role of nonphysician consultants as health-care educators in postgraduate programs of anesthesiology

Many physicians believe that the tasks of postgraduate medical education and faculty development are best carried out by senior physicians trained in the appropriate specialty. However, many also will admit that, as physicians, they have received too little training for such an educational role, and that the practical demands of medical practice, scientific research, and administration make it difficult if not impossible to allocate time to continuing medical education program development, curriculum design for residency training, teacher training, and other key aspects of postgraduate medical education. Many medical disciplines have attempted to alleviate this problem by using nonphysician health-care educational consultants in their training programs. However, little attention has been paid to the possibilities of using such consultants in anesthesiology residency education and faculty development. Such consultants in postgraduate medical education and training programs in anesthesiology could perform a wide variety of functions and roles because they possess skills and technical expertise in teaching, training, curriculum design, evaluation, program planning, and interpersonal communications that faculty members often lack. The successful use of a nonphysician consultant in the Department of Anesthesiology at Hahnemann University in Philadelphia, Pennsylvania, is described.     

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.     

Translating exercise biology into the Venezuelan medical education and health care system

In the absence of pharmacological agents, physical exercise was widely used by physicians in the late 19th century to treat a number of maladies. In the 1950's, epidemiological evidence suggested an association between physical activity and health, and increased interest in clinical exercise biology. By the 1990's, sufficient research data was accumulated on the benefits of exercise, such that North American medical associations, government agencies, and the World Health Organization have published guidelines on exercise for public and clinical populations. Despite this, leaders in medical education have remained reluctant to incorporate exercise biology into the core medical curriculum, or to systematically implement it in graduate medical education. This work reviews Venezuelan exercise biology literature, and its medical applications. Venezuelan scientists and clinicians have invested efforts in cardiopulmonary exercise testing, skeletal muscle adaptations to training and exercise cardiovascular pharmacology in patients, sedentary subjects and athletes. It is suggested here, that there is a need to develop education and research programs in basic and clinical exercise biology in the formal training of medical students, physicians in residency programs, and allied health care professionals. Tentative steps to initiate this process are proposed.     

The meagerness of physicians' training in emergency psychiatric intervention

This study was undertaken to determine how much training physicians receive in emergency psychiatric intervention (EPI) during their residency programs. In 1988 the author mailed a questionnaire to 256 program directors of residencies in the major nonpsychiatry specialties. A total of 236 (92%) responded. Their responses indicate that emergency medicine and family practice residency programs provide the most training in EPI, followed by pediatrics, internal medicine, obstetrics-gynecology, and surgery. But overall, EPI training was meager. The findings indicate that 75% of the programs never assigned EPI-oriented readings to the residents and 70% of the programs never gave lectures or seminars on that subject. The author concludes that EPI skills are frequently absent in current medical practice because physicians have not been taught these skills; he recommends that more training is essential and indicates what it might consist of.     

From concept to culture: the WWAMI program at the University of Washington School of Medicine.

Shortages of primary care physicians have historically affected rural areas more severely than urban and suburban areas. In 1970, the University of Washington School of Medicine (UWSOM) administrators and faculty initiated a four-state, community-based program to increase the number of generalist physicians throughout a predominantly rural and underserved region in the U.S. Northwest. The program developed regional medical education for three neighboring states that lacked their own medical schools, and encouraged physicians in training to practice in the region. Now serving five Northwest states (Washington, Wyoming, Alaska, Montana, and Idaho), the WWAMI program has solidified and expanded throughout its 30-year history. Factors important to success include widespread participation in and ownership of the program by the participating physicians, faculty, institutions, legislatures, and associations; partnership among constituents; educational equivalency among training sites; and development of an educational continuum with recruitment and/or training at multiple levels, including K--12, undergraduate, graduate training, residency, and practice. The program's positive influences on the UWSOM have included historically early attention to primary care and community-based clinical training and development of an ethic of closely monitored innovation. The use of new information technologies promises to further expand the ability to organize and offer medical education in the WWAMI region.     

Effects of an expanded medical curriculum on the number of graduates practicing in a rural state

In 1973 the University of North Dakota School of Medicine (UNDSM), following the national trend toward four-year medical programs, expanded its previous two-year medical school curriculum to include all four years of medical education. It was hoped that this change, along with a renewed emphasis on primary care-oriented residency training within the state, would encourage medical students to establish practices within the state. In 1985 the UNDSM's Center for Rural Health mailed questionnaires to the 2,230 living graduates of the UNDSM to document a variety of their personal and practice characteristics. Based on the responses to the 924 completed questionnaires, the authors found that (1) the students from rural North Dakota were more likely than were urban students to practice in rural areas of the state, as were the students with primary care specialty training; and (2) the alumni completing residencies in North Dakota following the curriculum expansion (1976-1985) were more than twice as likely to establish practices in North Dakota. It was concluded that recruiting medical students (preferably in-state "natives") from rural areas, training them in primary care specialty areas, and enabling them to remain in North Dakota for the duration of their medical training (including residency training) combined to exert a considerable "retaining" effect on the UNDSM alumni.     

Primary care by desire or default? Specialty choices of minority graduates of US medical schools in 1983.

This study was undertaken to determine if US medical school students of different racial/ethnic backgrounds demonstrate similar patterns of evolution of specialty choice between their senior year of medical school and their third postgraduate year. The study identified the specialty choices of US medical school seniors in 1983 through their responses to the Association of American Medical Colleges Graduating Medical Student Questionnaire (GQ). The cohort was classified into three groups: underrepresented minorities, non-underrepresented minorities, and whites. Using these AAMC data as baseline, each racial/ethnic background group was tracked through their third residency year. Comparisons were made between anticipated specialty choices as senior medical students and actual specialties as revealed through residency tracking. The study found that more than 95% of the cohort began residencies in specialties compatible with their GQ choices. Unexpectedly, almost 20% of blacks, Commonwealth Puerto Ricans, and other Hispanics were not in graduate medical education in their third postgraduate year. This group needs to be studied further in order to learn the proportion of these physicians who subsequently completed residency training and the reason(s) for attrition in physicians who did not fulfill minimum training requirements for board certification.     

Financing medical education

The cost of a medical education may dissuade qualified young people from entering the medical profession or may so load them with debt that they cannot pursue relatively low-paid careers in primary care or clinical investigation. Three aspects of this problem are examined: (1) the cost of medical school, (2) the magnitude of student indebtedness, and (3) the effects of this indebtedness on career choices. High tuition and fees require many students to assume sizable educational debts, some of which are so large that the trainees will be unable to repay them unless they enter highly remunerative specialties. Also, high levels of indebtedness may increase default levels once graduates feel the full impact of scheduled repayments. Several steps would help to alleviate this problem, but are unlikely to solve it. First, medical schools should lower tuition or at least declare a moratorium on increases. Second, limits should be imposed on the amount of total education debt a student is allowed to assume. Third, hospitals with extensive residency programs should assume some responsibility for helping trainees manage their finances. Fourth, the government should institute a loan forgiveness program that addresses the need for physician-investigators, primary care physicians, those willing to practice in underserved areas, and those from underrepresented minorities. And fifth, all institutions involved in medical training and its finance should work together to advise students on managing their debts.     

Why we should reduce family practice training to two years.

Family practice (FP) should consider decreasing its residency training from three years to two years. These are troubling times for FP. The number of U.S. medical students choosing FP has declined, FP physicians have difficulty maintaining the broad range of skills they learned in residency, and salaries have flattened. FP provides the best training for physicians who care for undifferentiated or continuity patients of all ages in an ambulatory setting. The author proposes that FP should focus its training on this large health care niche and develop a two-year curriculum that reduces inpatient and specialty rotations while increasing time in the family health center. At the same time, he recommends a third or even a fourth year of training be used to develop skills in any number of specialty areas. FP salaries are unlikely to be affected by these changes, residents would rack up less debt, and savings in society's contribution to graduate medical education would be realized. Reducing the length of FP training to two years will make FP more nimble, adaptable, and cost-effective.     

Evaluation of a one-year Masters of Public Health program for medical students between their third and fourth years.

For physicians to better treat and advise their patients on the roles of behavioral and social factors in health and disease, greater levels of competency in social and behavioral sciences are needed. Physicians should also understand the structure, financing, and administration of the health care delivery system, so that they will be able to practice medicine effectively and participate in planning and managing the delivery of care. And, improving overall public health requires that physicians understand the basic tenets of population-based medicine. One way to achieve these goals is to develop education and training programs for integrating formal public health training with formal medical training.There are many models by which a medical student or practitioner can obtain a master of public health (MPH) degree. In this article, the authors describe an accelerated one-year MPH program for competitively selected New York City medical students who have completed their third year of training and enroll at the Mailman School of Public Health, Columbia University. The Macy Scholars Program, offered between 1999 and 2007 to 12 students per year, is completed between the third and fourth years of medical school. Under full-tuition scholarships, students complete a practicum experience, attend seminars, and write a master-level paper or thesis, among other requirements. Data from an evaluation of this program demonstrate participant satisfaction and support of the program, outstanding academic performance, and the effect of public health training on their residency and career choices.     

The general practitioner: How much psychiatric education?

One hundred nine general physicians practicing in small rural communities completed questionnaires regarding the number of patients they saw with psychiatric problems. Respondents were also asked to give details of their psychiatric and medical training, to indicate where they obtained new information about psychiatric topics, and to rate the importance of 36 items in daily medical practice. Over one half felt their medical school training in psychiatry was not on par with that received in internal medicine, OB-GYN, surgery, and pediatrics. We suggest the 36 items they ranked be used as a guide in developing a core curriculum for family practice residency training programs as well as for the design of continuing medical education for general physicians.     

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.     

Competency-based residency training: the next advance in graduate medical education.

The goal of all graduate medical education is to ensure that the graduating physician is competent to practice in his or her chosen field of medicine. The evaluation of a resident's competency to practice, however, has never been clearly defined, nor has the fixed period of time given for residency training in each specialty been shown to be the right amount of time for each individual resident to achieve competency. To better ensure that new physicians have the competencies they need, the author proposes the replacement of the current approach to residents' education, which specifies a fixed number of years in training, with competency-based training, in which each resident remains in training until he or she has been shown to have the required knowledge and skills and can apply them independently. Such programs, in addition to tailoring the training time to each individual, would make it possible to devise and test schemes to evaluate competency more surely than is now possible. The author reviews the basis of traditional residency training and the problems with the current training approach, both its fixed amount of time for training and the uncertainty of the methods of evaluation used. He then explains competency-based residency education, notes that it is possible, indeed probable, that some trainees will become competent considerably sooner than they would in the current required years of training, quotes a study in which this was the case, and explains the implications. He describes the encouraging experience of his neurosurgery department, which has used competency-based training for its residents since 1994. He then discusses issues of demonstrating competency in procedural and nonprocedural fields, as well as the evaluation of competency in traditional and competency-based training, emphasizing that the latter approach offers hope for better ways of assessing competency.     

Physicians at the medicine/psychiatric interface: what do internist/psychiatrists do?

Studies have convincingly demonstrated that some 50% of patients in primary care settings have both medical and psychiatric diagnoses requiring dual treatment. The concept of primary care psychiatry has emerged in recent years as one way to address this problem. In 1979 the first combined medicine-psychiatry residency was formed. There are now over 20 such programs, but there is little information on how these doubly trained physicians actually practice. In 1997, the authors surveyed the 268 physicians with board certification in both internal medicine and psychiatry that were listed with the American Board of Medical Specialties. Only 15% practiced any type of medicine at all; the rest were involved only in the practice of psychiatry. Although 75% identified themselves only as psychiatrists and worked predominantly in psychiatry, 95% reported using both their medical and psychiatric training in their professional work. They reported that the dual training made them better physicians, improved their professional credibility, and enhanced their diagnostic skills. Several significant barriers were discovered that directly affect the ability of physicians to practice in two fields. Findings, study limitations, and potential implications for the field and its patients are discussed.     

Psychiatric education in an era of rapidly occurring scientific advances.

Scientific advances in the fields of molecular biology, neurobiology, pharmacology, epidemiology, genetics, neuroimaging, and cognitive neuroscience are influencing psychiatric diagnosis and treatment, and this influence will grow substantially in the future. The current shortage of psychiatrists will increase over the next several decades, resulting in the need to train primary care physicians in basic psychiatric care and the use of non-physician mental health professionals to administer time-intensive, formal psychotherapies. The juxtaposition of these two trends-an increasing scientific influence on the clinical practice of psychiatry and fewer psychiatrists to deliver that treatment-is cause for changes in the approach to psychiatric education. In addressing these issues, the authors suggest that (1) psychiatry should be more integrated into undergraduate medical education in both basic science and clinical curricula, (2) residents in primary care disciplines should have more direct exposure to psychiatric training, (3) joint instructional experiences involving psychiatry and primary care residents should be encouraged, (4) psychiatry residency programs should maintain flexibility in order to incorporate rapid advances in diagnostic procedures and treatments into residency training, (5) research experience should be integrated into psychiatry residency programs, and (6) departments of psychiatry must develop the leadership and expertise necessary to implement the incorporation of rapidly advancing scientific discoveries into the psychiatric curriculum.     

The programs and context of medical education in Argentina.

There are 29 medical schools in Argentina (this number has increased rapidly in the last decade) offering a 6-year curriculum that usually consists of 3 years of basic science, 2 years of clinical sciences, and one internship year. Annually, 5,000 physicians graduate from these programs. Admission requirements vary depending on each university's policy. Some do not have entry requirements; others require a course, usually on the basics of mathematics, biology, chemistry or physics, and some introduction to social and humanistic studies. Each year, there are approximately 12,000 first-year medical students attending the 29 schools, which suffer a high dropout rate during the first years because of vocational problems or inability to adapt to university life. Some schools have massive classes (over 2,000 students), which makes it difficult for the schools to perfect their teaching. The number of full-time faculty members is low, and some of them have appointments at more than one medical school. Residency programs offer an insufficient number of places, and fewer than 50% of the graduates can obtain a residency position because of strict admission requirements. Coordination between the Ministry of Health, representing the health care system, and the Ministry of Education, representing the medical education system, needs to be improved. Despite the problems of medical education in Argentina, the movement to improve the education of health care workers is growing. The author offers two recommendations to help accomplish this goal.     

Teaching medical ethics during residency

Because practicing physicians are poorly prepared to resolve many ethical issues that arise in patient care, this article proposes that residencies include practical training in medical ethics. Training in medical ethics helps physicians recognize ethical issues in patient care and resolve those issues wisely. Furthermore, such training has its maximum impact during the professionally formative years of residency. The article specifies key ethical concepts residents should know, including knowing how to obtain informed consent, knowing what to do about incompetent patients, knowing when to withhold or disclose clinical information, and knowing how to use resources properly. The article also points out that the success of residency training in ethics depends on strong commitments from the department: endorsement by the chairman and the residency program director; recruitment of several dedicated faculty; support for adequate ethics training for these faculty; dedication of conferences, rounds, and consultations to teaching ethics; and allocation of sufficient funds.     

Are we serious about teaching professionalism in medicine?

Medical professionalism is an increasingly common topic of discussion in the medical education literature. Much of the recent literature on this subject addresses areas of weakness in the educational curricula of medical schools and residency programs. But students are living a world in which professional behavior is being redefined, often in ways that run contrary to the medical education curriculum. This article outlines three fundamental challenges that powerfully affect the ability to promote professionalism in students and young physicians. To overcome these challenges, the author suggests four steps that can be taken in the medical education community. First, medical schools should address cost and access to care as first-order intellectual problems and should encourage research programs in these areas. Second, schools should develop programs to humanize science and restore scientific integrity beyond the requirements of compliance programs. Next, medical school leaders should celebrate those who best embody moral leadership in the profession. Finally, the medical education community should acknowledge that the availability of affordable health care to the public depends on the practice choices of medical school graduates and should accept greater responsibility for this outcome.     

Recognition of clinical immunology as a distinct medical subspecialty: importance for the practice of allergy

BACKGROUND: Although residents trained in accredited teaching programs in allergy and immunology are exposed to many areas of clinical immunology, the vast majority of these residents' subsequent practices are composed of caring for patients with allergic and asthmatic conditions. Except for rheumatologists, almost all other clinical immunologists appear to lack organized training programs, defined certification pathways, and clear career opportunities. OBJECTIVE: Recognition of clinical immunology as a distinct medical subspecialty with many areas of expertise will enhance the image of allergists and clinical immunologists, ensure subspecialty certification, and provide better career opportunities. METHODS: Documents, publications, and private opinions of individuals within professional allergy and clinical immunology organizations were evaluated for possible contribution to the subject content of this article. RESULTS: There is a need for defined residency programs, medical board certification, and professional organizations that speak for and provide postgraduate education for all clinical immunologists. Molecular and genetic discoveries are delineating the central role of fundamental immunology in all immune-mediated diseases and future therapy of allergic and immunologic diseases. CONCLUSIONS:Allergists of the 21st century should participate in the growing recognition of clinical immunology as an important medical subspecialty that can provide science-based therapies for allergic and immunologic disorders. The future practice of allergy depends largely on the molecular and genetic discoveries that serve to unite all practitioners of clinical immunology. Forging common alliances of education, certification, and career pathways with other clinical immunologists is the correct investment for a bright future for allergy.