Why Residencies Are Worth Building (Part 1 of 2)

Medical education has always been a subject close to my heart. I got my first taste of teaching as a chief resident in emergency medicine (EM) while in NYC, and continued that journey as a toxicology fellow and clinical faculty at Emory University. I later served on the faculty of the EM residency at the Medical College of Virginia, and then later when I returned to California, at Kern Medical Center in Bakersfield. And I'm currently medical director, clinical chair, and academic chair for emergency medicine at Kaweah Delta Medical Center in Visalia, Calif.
Over the past few years, I've been excited to watch CEP America's growing foothold and interest in academic medicine. We now administrate three EM residencies (at Kaweah Delta, Arrowhead Regional and Desert Regional medical centers) and Kaweah Delta's family medicine residency and transitional year residency. In order to attract top-notch faculty, we've made key changes to our site policies and are currently working on updating our Partnership pathway and strategic initiatives.

I sincerely believe that graduate medical education (GME) presents an excellent opportunity for our practice, our hospital partners and the communities we serve. In today's post, I'll share a little bit about what's involved in developing a residency program. In a future post, we'll look at the example of Kaweah Delta's EM residency program, the first ACGME-accredited residency program CEP America helped build from the ground up.


Why Invest in GME?

Starting a medical residency or fellowship program is a huge undertaking, but it also brings many rewards for hospitals, physician groups and the community.
Funding. The federal government reimburses academic medical centers for both resident training and the higher patient care costs they incur (though not dollar for dollar). This cost structure is currently calculated based on the number of Medicare beneficiary inpatient discharges per year. There is currently work under way in congress to perhaps change this in the future.
Access. A quality academic program can attract both faculty and residents to underserved areas where recruiting is otherwise difficult. Faculty positions are attractive to many high-achieving physicians. And the majority of doctors work within 50 to 75 miles of where they completed their terminal residency or fellowship training.
Staffing. Residency can dramatically decrease recruitment costs for hospitals and physician groups. Hiring a former resident can save tens of thousands of dollars in advertising, travel and recruiter fees.
What's more, these candidates have already spent three to four years immersed in the workplace culture. They're in an excellent position to judge whether we're a good fit, which can foster longevity with our organization.
Professional development. Teaching hospitals support a high level of academic involvement. Both faculty and students engage in scholarly projects like research, academic writing, presentations, curriculum development and advocacy. In addition, medical education tends to drive evidence-based practice and academic rigor across the institution. (We'll look at one example in my next post.)
Community benefit. Residents augment the workforces of inpatient services, community clinics, urgent care centers and emergency departments. This helps to increase access and shorten wait times. Also, when residents moonlight at area hospitals, they help to spread the latest medical advances and best practices to non-academic settings.
Leadership and reputation. As residency alumni disperse across the country into jobs and fellowships, they take with them the unique ideas and skills they have gained. In this way, they serve as a living testament to the quality and innovation of their residency institution.

Oversight of Academic Hospitals

In addition to meeting the quality requirements of Centers for Medicare and Medicaid Services (CMS) and the Joint Commission, academic medical centers are governed by additional regulations.
The Accreditation Council for Graduate Medical Education (ACGME) is the accrediting body for institutions, residencies and fellowships. It operates on several levels.
First, ACGME sets requirements for the institution as a whole. For example, all academic hospitals must have a designated institutional official and a graduate medical education committee who coordinates activities across all residency programs.
ACGME also makes rules common to all residencies and institutions. For example core faculty must be board-certified, have academic appointments at accredited medical schools while the institution as a whole must adhere to patient safety and clinical environment of care and learning goals.
Finally, Residency Review Committees (RRCs) formulate unique rules for each specialty. Here are a few that apply to EM residencies. (These examples by no means represent an exhaustive list.)
  • A core faculty member may supervise a maximum of three residents.
  • Core faculty may not work more than 20 -28 (depending on positions title) clinical hours per week.
  • Core faculty must publish peer-reviewed research (or equivalent scholarly activity) every five years at minimum.
  • Residents must demonstrate competency in a list of EM procedures (e.g., intubation, lumbar puncture).
  • Residents may not work more than 80 hours per week.
As you might imagine, all of this regulation can be complex to navigate. Fortunately, ACGME is seeking to better align itself with CMS and the Joint Commission. For example, all three accreditors now have requirements around transitions of care. (Of course, they all come at this idea from different directions, so satisfying all three accreditors takes experience and know-how.)

GME Building Blocks

Building a GME infrastructure is a marathon, not a sprint. Most hospitals take several years to prepare for accreditation. A few key elements that need to be in place:
Administration. Accreditation requires the establishment of certain offices, positions and committees to coordinate GME across departments. As noted above, the regulations can be quite Byzantine, especially in hospitals with multiple residencies. For this reason, it's important to recruit leaders who understand the various institutional and specialty-specific requirements.
Faculty recruitment. A strong core faculty is essential to the success of any GME program. Because faculty must be board-certified and interested in scholarly work, the candidate pool is relatively small. However, this is usually offset by the fact that certain physicians are highly motivated to seek out teaching opportunities.
Staffing. Each RRC specifies a minimum supervision ratio, usually three to four residents per faculty member.  The larger your residency class, the more faculty you will need to add (and in many cases, nurses and support staff as well).
Customer service. Patients at academic hospitals encounter multiple caregivers. This can be confusing — especially if it's a change from the hospital's past practice. Scripting, signage and introductions can help acclimate patients to having residents and students involved in their care.
On a positive note, one small study found that patients' appreciated the extra "face time" they got with residents. Another more recent study showed that the involvement of medical students in patient care did not negatively affect patient satisfaction scores. Kaweah Delta is currently studying patients’ perception of academic medicine (more on that in Part 2).

Support From the Partnership

In the past few years, CEP America has taken major steps to support the practice of academic medicine among its partners.
The partnership will hold its first academic medicine interest meeting in April 2016. National experts will discuss the basics of establishing an ACGME training program. Partners will also have opportunities to network with academic colleagues from across the country.

GME in Action

Getting a GME program off the ground is quite a challenge. However, once the machinery is up and running, and academics and patient care are integrated, it becomes a self-fulfilling prophecy.
In my next post, we'll look at how CEP America helped Kaweah Delta Health Care District build a residency program from the ground up.

[Image credit: "Stethoscope" by Dr.Farouk licensed under CC BY 2.0