A newly released Institute of Medicine report highlights important gaps in training the physician workforce in the US. In this blog post, Don Goldmann, MD, Chief Medical and Scientific Officer at IHI, and Jesse McCall, Senior Project and Regional Operations Manager at IHI, comment on the report and note important considerations for the future of graduate medical education.
A just-released comprehensive report from the Institute of Medicine (IOM), Graduate Medical Education That Meets the Nation's Health Needs, puts a bold exclamation point on a chorus of reports and commentaries calling for transformative change in graduate medical education (GME) in the US. The IOM report is so well-researched, articulate, and thoughtful that it deserves to be read in its entirety by anyone who has been frustrated by the arcane and largely irrational funding system for GME and the glaring deficiencies in how GME currently is structured and delivered in many health care delivery organizations that receive federal funding.
The IOM report correctly notes that the current system produces a physician workforce that is not sufficiently diverse, is over-weighted towards specialty rather than primary care, and is mal-distributed, creating shortages in rural and underserved communities. Medical residents spend a disproportionate amount of time on hospital wards rather than in primary care clinics or the community. Despite recent progress in some programs, residents generally leave training with inadequate competencies in interprofessional teamwork, coordination of care, cultural sensitivity, health economics and "right use" of diagnostic tests and treatments, quality improvement, and (surprisingly) health information technology and mobile health (or mHealth). Although not highlighted as graphically in the IOM report, other areas that need greater emphasis include professionalism and ethical practice, understanding how to partner with community services and public health agencies, person- and family-centered care, geriatric and end-of-life care, and care in nursing homes and assisted living facilities.
These gaps in training have not gone unnoticed by the organizations responsible for ensuring the quality of medical school and graduate medical education. For example, the Association of American Medical Colleges (AAMC) has articulated core competencies that need to be introduced in medical school to prepare physicians to be well-rounded providers as they move on to residency and practice and has also developed programs to train faculty how to effectively teach quality improvement and patient safety to trainees. The Josiah Macy Jr. Foundation and the Institute for Healthcare Improvement partnered in the Retooling for Quality and Safety initiative, an effort to integrate quality and safety into medical and nursing school curricula and foster joint learning. The Accreditation Council for GME (ACGME) Next Accreditation System, Pathways to Excellence, and most importantly, Clinical Learning Environment Review (CLER) program are designed to address many of the specific problems raised in the IOM report. ACGME has been proactive in bringing together key stakeholder organizations, including IHI, in an effort to develop a collaborative approach for accelerating progress.
To help academic medical centers accelerate improvement of their CLER program, ACGME and IHI are partnering to offer a one-day workshop on October 24 called Graduate Medical Education: Focusing on Quality and Safety in a Clinical Learning Environment.
Research by IHI's Innovation Team and the early experience gathered from CLER site visits demonstrate just how far we have to go to foster a training environment that will produce a competent physician workforce — particularly a workforce that knows how to practice cost-effective, interprofessional, team-based care that respects the preferences and circumstances of patients and families. Among the priorities are the following:
Align GME with the organization’s overarching quality and safety goals. In general, the C-suite of academic medical centers (AMCs) and the AMC's designated institutional officer (DIO) and residency program director do not have a coordinated plan to harness the time, energy, and creativity of the resident workforce in accelerating progress towards making care better, safer, and more cost-effective. Often, neither the program directors nor the residents are even aware of the AMC's quality and safety goals, let alone encouraged and enabled to align their activities to these goals. GME quality improvement projects tend to be one-off efforts and seldom contribute to the organization's goals, involve other professionals on the care team, or catalyze sustainable improvements in the system of care. Too often the emphasis is simply on encouraging reporting of errors and adverse events; although this is an important gauge of the safety culture and an important source of information, it does not develop competency in understanding and addressing the systems problems that led to the errors. Moreover, work on safety needs to be balanced with projects that address quality and value, such as delivering the right care to the right patient every time.
Develop and support faculty who are capable of guiding experiential and interprofessional learning in quality and safety at the bedside. It no longer is acceptable to claim that AMCs do not have faculty who are competent in leading experiential learning without aggressively addressing the problem. Ultimately, criteria for recognition, payment, and advancement will need to be adjusted so that faculty incentives are aligned with expectations.
Support front-line quality and safety efforts with timely expertise and resources, including direct support and coaching from quality improvement experts and providing trainees and program leaders with real-time data to monitor progress towards meeting concrete goals.
The IOM report outlines a comprehensive and sensible set of recommendations to address these and other issues that will need to be solved if we expect to transform the GME system within the 10 years’ timeframe suggested by the report's authors. Several of the recommended actions will be particularly challenging:
Development of metrics that will drive performance-based payment and transparency. There are many lessons to learn from efforts to accomplish this goal in health care. Health care delivery organizations are already struggling to respond to a staggering number of quality and safety measures, so the GME measurement developers will need to balance measures that truly reflect the success of GME programs in training competent residents against the increased burden of measurement and reporting. Questions that measurement experts will need to address include:
Given that the current ACGME competencies are very broad, how granular do the sub-measures need to be, and how can they be accurately and efficiently obtained in the practice?
- If the aspirational goal is a Triple-Aim-ready physician workforce, do the current competencies get to the heart of what a physician should master to tackle the Triple Aim
- If a goal is to align resident learning with organizational quality and safety goals, how does one measure the contribution of residents as a whole and individually in meeting these goals? And how does one assess competency in interprofessional teamwork, which is required to advance organizational aims (hint: maybe ask the nurses and start thinking about teamwork as a cross-professional accreditation issue)?
Careful consideration of the evidence that pay-for-performance improves quality and safety.
The Institute of Medicine report, Rewarding Provider Performance: Aligning Incentives in Medicare
, outlined several strategies for phased implementation of pay-for-performance systems. Many of these strategies have been adopted by the accountable care organization movement; however, challenges still exist in accurate performance measurement, increased administration costs, and respect for physician autonomy and patient preferences.
Allocation of transformation funds in a way that actually drives innovation and leads to demonstration projects that produce scalable, context-sensitive change.
IHI and ACGME experience to date has not unearthed an abundance of innovations designed to address the current gaps in training. As noted briefly in the IOM report, innovating on innovation will be required.
- Innovations need to be viewed as part of a pathway from innovation, to prototype development and testing, to testing in diverse contexts and circumstances, to scale up. The US health care system is teeming with great ideas that have not spread, in part because this pathway has been short-circuited in the thirst to find and spread new ideas
- The experience of the Center for Medicare & Medicaid Innovation in funding and evaluating demonstration projects, including projects designed to evaluate new payment methods, should deeply inform expansion of this work in the GME environment. Real-time, context-sensitive, pragmatic, adaptive designs — as discussed by Shrank in a 2013 Health Affairs article, and Mackenzie, Goldmann, Perla, and Parry in a 2014 Journal for Healthcare Quality article — will be critical. Adequate funding should be designated for formative evaluation of prototypes as they are tested in broader contexts.
Collaboration with organizations that are dedicated to improving the pedagogy of resident training, such as AAMC, the Macy Foundation, and others outside of health care. How we teach is as important as what we teach. For example, advances in asynchronous virtual learning, simulation and case-based learning, and team learning will have an impact on how faculty are trained to support GME. Providing real-time interventions customized to the individual needs and learning styles of residents will be critical.
The IOM report largely illustrates the transformation process from the point of view of the government and AMCs. This perspective is necessary if we are to make the changes we need. However, as the authors of the report know well, the ultimate customers are the residents and the patients we will entrust to their care. Residents and patients should be fully involved in the processes outlined in the report. It may be useful to have the various committees constantly reflect on how a medical student would choose a training program if he or she controlled a portion of the federal spend on GME. What data would he or she want to see and how might this influence the measurement framework? Should not the data include information on work-life balance, availability of confidential counseling, the institution's track record on bullying behavior — in other words, a balanced scorecard reflecting that the resident can expect "exactly the training I want and need, precisely when, where, and in the form I want and need it” (to paraphrase Moore and Wasson in their 2006 article). What measures would a patient want to see? This is a largely unexplored area that urgently needs development.
Our hope at the Institute for Healthcare Improvement is that this superb IOM report catalyzes system-wide improvement efforts as deeply profound as To Err Is Human and Crossing the Quality Chasm. IHI is honored to be among the many organizations that are working collaboratively and proactively to address the gaps identified by the IOM.