We gratefully acknowledge the sponsorship of the Charles Q. North, MD of the University of New Mexico Department of Family and Community Medicine for his support of the transcription and editing of this section of the Proceedings of the Twenty-Sixth National Conference:
The following transcription is of the first plenary session of the 26th National Conference on Primary Health Care Access, held April 13, 2015 at the Hyatt Regency Orange County. This section follows: “Time Will Tell”: the Proceedings of the 26th National Conference – “Issues in the Training of Primary Care Physicians (Part One, Henderson)”, Monday April 13, 2015.
Thomas Hansen, MD, Advocate Healthcare, Chicago [Dr Hansen is a Fellow of the National Conferences]:
I’m going to just talk a little bit about my role at Advocate Healthcare and some of the concerns that I have.
For those who are not familiar with Advocate Healthcare, we have 12 hospitals in the system. After a merger we will be bringing on four more.
Four of our hospitals are teaching hospitals, all of which became teaching hospitals prior to becoming part of the system. So you know they had their independent culture and identity.
Three of the hospitals are accredited by the Accreditation Council on Graduate Medical Education [ACGME]. Three programs are dually accredited by the American Osteopathic Association [AOA] and ACGME. One hospital has three programs accredited only by the AOA, all part of A. T. Still School of Osteopathic Medicine’s “Opti”. Those AOA programs are in family medicine, neurosurgery and neurology.
I have responsibility in total for 31 programs, 631 residents, fellows and over 2,000 medical students who are coming through our system on an annual basis.
We are a health system, but we don’t operate our own medical school. For the third-year medical school clerkship years, we have three primary medical school affiliates with students coming in from the University of Illinois, Chicago; the Chicago College of Osteopathic Medicine; and the University of Chicago Medical School.
For our fourth-year medical student experiences, we open up to any student who wants to come to our system. I mentioned a possible merger with North Shore University Health System, which, itself, has a primary affiliation with the University of Chicago.
It’s a complex system. My job as the chief academic officer, which I was hired for two years ago is to oversee, encompasses undergrad medical education, GME, CME, the library services, and research.
As far as GME is concerned, the executive suite had imagined we could consolidate four family medicine programs, three internal medicine and two OB programs into one program with 210 residents. The thought was that by consolidating we would achieve economy of scale. It quickly became clear that a combined residency was not an ideal situation, especially since the distance between our two furthest hospitals is about 160 miles. We talk about patient safety, but requiring residents to drive between sites through Northern Illinois is in itself an unsafe practice for our residents.
Another executive suite directive was that we move towards a single sponsorship. Although the GME leadership had been very resistant to trying to standardize across the Advocate Healthcare system, the single sponsorship idea does make sense.
In response, I created the Advocate Graduate Medical Education Committees [GMECs]. Each hospital still has its own GMECs at each site, but I created an Advocate GMEC comprised of all the program directors, who come together once a month. This was the first time that our program directors were talking to each other – not only across the system, but within the individual hospital sites. It really was an amazing outcome!
The internal medicine program directors were discussing which metrics we need in order to meet their requirement for clear criteria. They became a force to leverage IT to start working with the residency programs. We had to figure out how do we have a model where we can capture the data for the patients that are residents are seeing.
Soon afterward, the family medicine residency programs came together to start talking about the metrics that they needed. There really was a lot of synergy that was the outcome of the programs talking with each other.
For those who have ever gone towards developing a single sponsorship, you know that it raises the issue of how to develop institutional policies across a system, in which each of the hospitals have their own institutional policies.
The program directors didn’t even know we had institutional policies. Now they’re participating in writing those institutional policies in a way that makes sense for us as a system. How do we address the clear requirements in a way that, that is providing better quality of care? How do we you improve patient safety, etc.?
One nice thing about having an Advocate Hospital GMEC, is that we now at our meetings. we have the head of quality improvement, the head of patient safety, the heads of research, of library, of IT, and other relevant departments participating in our annual and our monthly meetings.
We are able to offer faculty development that makes sense across the system; especially with regard to the Next Accreditation System [NAS] and Milestones. [see Proceedings of the 25th National Conference: April 14, 2014 – Second Plenary Session, Part 1 (Allen)].
We have been looking at the organization chart and the fact that different people at our sites have similar jobs, but they all have different titles and different pay scales. How do we level the playing field for staff, and then address resident salaries?
I believe that there are issues, not only for Advocate Healthcare, that I think will become national issues in the coming years. At Advocate Healthcare our faculty are primarily for residency programs. They are physicians whose productivity is based an RVU model of how many patients they see.
When I was at Creighton, part of my faculty contract was research, clinical productivity and teaching. My physicians – the faculty for the residency programs – don’t have those provisions in their contracts. These same physicians are also faculty for the medical schools with which we’re affiliated. They have these dual functions because of the LCME requirement that you have to be a faculty member in order to teach at the third-year medical student [M3] level.
The physician faculty are starting to say say: “I’m trying to get these milestones finished. I have to be on the CCC. I have to do all these other things. I have only so many hours in the day. Our primary focus has been on GME, but the requirements for ACGME-accreditation have increased significantly.” Our physicians are starting to opt out of being teaching faculty.
The first consequence is that I just can’t take more medical students. Chicago’s a saturated market. We cannot take any more students. Now we’re starting to decrease the number of students that we’re able to educate within our system.
There are also issues around funding and the “cap allotment”. In my system. We have a direct medical education [DME] cap of 598 DME. Last year, for the 2013 cost report I had to claim 620 – that is, 22 FTEs over cap.
My executive team has said we have to be at cap, because we don’t know what’s going to happen over the next couple of years as a result of the IOM report; and because President Obama’s 2016 budget is proposing reducing the IME reimbursement by 10% for 10 years.
In Illinois, we have a new governor who’s trying to reduce our budget. That will affect Medicare and Medicaid reimbursement to our hospitals.
Advocate Healthcare’s primary CFOs are saying that we have got to be very cautious in this time. They are absolutely right. I absolutely support them. We’re looking at decreasing the number of residents in our system. We’re looking at decreasing the number of faculty who are willing to teach in our system, but if we don’t have faculty and residents teaching, we have to decrease the number of students even further in our system.
In the meantime, our service lines are trying to grow, because they know their bottom line is going down. They believe that if they bring on these other service lines, it will enhance their income. The best way to do this is to hire residents, because they’re considered “cheap labor”. There is this duel going on right now between residents being seen as revenue-enhancing cheap labor and the drive to lower our cap. How do we grow the service lines?
Behind all this, of course, is the whole transition within our AOA programs to ACGME. There is some ambiguity about whether the AOA requirements are going to change. I’m saying we’ve got to make sure we’re planning now, cause we’re admitting residents where I have no data that they’re going to be able to graduate in our AOA programs. We see some, I’ve had a couple of conversations where we now have some systems trying to offload AOA programs cause they know that they don’t have the clinical material to be able to continue the programs. They are trying to figure out how to do that.
And so the potential issues moving forward: teaching hospitals are being bought out by healthcare systems, so these kinds of decisions are no longer being made locally. Fewer faculty exist for resident and student education, fewer residents are present to teach medical students. Some consider residents as cheap labor while other are trying to identify the financial risk to the system of their being.
ACGME education requirements are becoming a disincentive for physicians to teach. Faculty are saying that they can’t do all these things. The AOA transition to ACGME adds further uncertainty.
So, the question that I’m asking myself, is the U.S. creating a medical education system, in which we have impending shortage of attending physicians to teach, a reduced number of residents in training to do for the funding, and then reduced number of medical schools and medical students, due to no teachers and not enough residency spots?