Graduate Medical Education: Reflection of Past and Present Trends

Presentation by: Danielle Maholtz, COSGP National Medical Education Representative, Gabrilelle Rozenberg, COSGP National Legislative Affairs Representative, and Fritz Stine,  OMS-II UP-KYCOM
Written by: Daniel Krajcik, OU-HCOM

Brief History         

Federal funding of GME first started when the GI Bill was enacted in 1944, but was officially transitioned into a payment through Medicare in 1965, where a retrospective cost-based reimbursement for inpatient stays was enacted. This funding of GME was never intended to last long term, and was initially intended to only cover costs associated with Medicare patients. In this initial model, only Direct GME costs (DGME) were covered by Medicare – this includes resident salaries and is now calculated based on a per-resident amount (PRA). This model was modified in the 1980’s when the Indirect Medical Education (IME) funding stream was developed. The theory behind the development of IME costs is that teaching hospitals incur additional costs just by being a teaching hospital and having residents. IME was intended to help offset some of these additional costs to the hospitals. Both of these Medicare funding streams are tied to the institution’s Medicare patient volume.  These streams were developed at a time when hospitals served as the main site for physician training and GME monies are still primarily distributed to teaching hospitals, meaning most residents are trained in hospitals despite the fact that many go on to work in outpatient facilities. Also at this time, the switch to large health system focused training led to the development of OPTIs, where Osteopathic Medical Education was, and still is, run in consortiums with Osteopathic Medical Colleges, hospitals, and community based healthcare facilities.

The Balanced Budget Act (BBC) of 1997 was a major milestone in GME, where allopathic and osteopathic residency slots were capped at 1996 levels, meaning no more additional slots would be paid for by Medicare beyond what they had at the time (Note slots are still limited by this law today). Hospitals could, however, form entirely new residency programs where their cap would be limited by the maximum amount of residents within a five-year period at the end of their first five years in existence. It is also important to know that payment through Medicare severely limited the amount of funding to children’s hospitals, but this was partially fixed through the Children’s Hospital GME (CHGME) Program in 1999 and later the State Children’s Health Insurance Program (sCHIP).

Today

In 2014, the Affordable Care Act (ACA) created a $230 million Teaching Health Center GME program in an effort to expand primary care training. In total, the annual federal spending exceeds $15 billion with Medicare and Medicaid as the largest contributors ($9.7 and $3.9 billion dollars, respectively) followed by the Veterans Health Administration and HRSA.  Despite the cap imposed in 1997, many hospitals have expanded their teaching programs and added nearly 17,000 slots since then, through private donations and grants found outside the usual government beneficiaries.

In 2012 the Institute of Medicine (IOM) Committee on Governance and Financing of GME was chartered to address several current issues: including, but not limited to, mismatch between the health needs of the community and the specialty make-up of the physician workforce, the geographic maldistribution of physicians, and the growing gap between new physician’s knowledge and the competencies required for modern medical practice. Recommendations were made to continue using Medicare as a primary source of funding, but to also modernize the GME system to answer these growing issues we face today.

Moving forward from here, despite the cap, we still see first year residency spots growing steadily. Importantly, there are roughly 7000 more residency spots than applicants each year, but this still doesn’t address resident’s choice to practice in primary care or underserved areas. Medicare is still directly funding teaching hospitals, where only about 50% of primary care residents train. The Health Resources and Service Administration (HRSA), further backed by the ACA, is currently assessing workforce needs on a long-term basis to make recommendations both to congress and the senate.

There may be LOTS of changes that we see over the next few years coming from medical schools, GME programs, and the government. Government mandates in the near future will strongly influence where and what type of residency programs are formed, while 12 medical schools (one of which is Osteopathic, 11 are AMA Transformative Medical Schools) are starting to look into new ways to transform Undergraduate Medical Education (Competency-based systems) to meet the needs of the American population today and the future.

 

Reps for Vets: Wounded Warrior Project Fundraiser

By Krishna Patel, OMS-III Second Vice Chair

The American Association of Colleges of Osteopathic Medicine, Council of Osteopathic Student Government Presidents, and Campbell University School of Osteopathic Medicine joined forces with the local CrossFit007 in Lillington, North Carolina to benefit the Wounded Warrior Project. The event took place at CrossFit007 on January 18, 2015. Months of planning and organizational efforts were contributed by many groups nation wide. The goal of the event was to raise awareness of Wounded Warrior veterans, promote a healthy lifestyle, and spread awareness of osteopathic medicine. Each year, Council of the Osteopathic Student Government Presidents organizes a DO4U event, which comprises of osteopathic awareness and outreach to pre-medical students. This year, the collaborative team took a unique twist by educating future doctors on the sacrifices of our wounded veteran population.

Registration of the event was open to the public with proceeds going to the Wounded Warrior Project. Over 150 medical students participated in addition to students from Campbell University and community members. The event consisted of a guest speaker, followed by a team workout. Guest speaker, Captain Ivan Castro is well known for his completion of over 50 marathons and other athletic events. He is blinded Special Forces active solider who served in Iraq and is also an alum of Campbell University. His story and example moved the audience. Speaking to a room full of rising physicians, he stated, “You get all kinds of injuries…there is nothing like military medicine…You aren’t going to see just a stab wound or one gunshot wound. You will see all kinds of things…it’s not like anything you will see anywhere else.” He continued speaking to a filled room by sharing his insight on physicians – “This is why [my doctors] were great doctors; it is because they are first a great human being…Your bedside manner has to be impeccable. You have to be able to talk to a patient in a way they can relate to and listen.”

The workout portion of the event incorporated aerobic and weight lifting exercises in paired teams. The exercise was demanding, but numerous bright smiles could be spotted throughout the crowd, as people were constantly cheered on and reminded of the great cause they were contributing to. The fundraising goal was set to a bar of $2000. Through registration and private donations collected, Reps For Vets was able to raise almost $2300.

A very special thank you to all of those involved in Reps For Vets: Wounded Warrior Project, CrossFit007, American Association of Colleges of Osteopathic Medicine, Campbell University School of Osteopathic Medicine, Council of the Osteopathic Student Government Presidents’ Student Services and PR/Web Committees, Kristen Balkam OMS-III (LECOM-Bradenton), Robert Wills OMS-III (Touro-Nevada), Renee Sarno OMS-III (LECOM-Bradenton), Krishna Patel OMS-III (CCOM), Mona Bazargan OMS-III (MSUCOM), Erin Fitzpatrick OMS-II (CUSOM), Kate Taylor OMS-II (CUSOM), in addition to all of the participants and volunteers throughout the event!

See local news releases on the event:

WRAL    WNCN

Pictures can be found on our page: Facebook.com/cosgp

 

COMLEX Level 2 Survey

NOTE – Please complete ONLY if you have taken COMLEX Level 2 CE since January 1, 2014.

Hello Osteopathic Medical Student,

The College of Osteopathic Student Government Presidents (COSGP) is the student group of AACOM, comprised of the two of the elected student government leaders from each osteopathic medical school. The COSGP Medical Education committee is comprised of some of the student representatives from COSGP and we would like your help! We are conducting a quick survey on your experience with COMLEX Level 2. Your participation will provide information that can assist with other medical student who will take the exam in the future. The survey is anonymous, but we ask that your response is as accurate as possible. This survey is optional and no students are required to participate. Here is the link to the survey: https://docs.google.com/…/17b8nQ2X_OOl2y3h4Y2TUtZw…/viewform

Please complete the survey by March 22, 2015.

Thank you so much for you help. Please visit our website COSGP.org for resources and other information about your representation at the national level. If you have any questions please e-mail me at: COSGPMedEdRep@aacom.org

Thank you!

COMLEX Level 1 Survey

Note – Please complete ONLY if you have taken COMLEX Level 1 since January 1, 2014!

Hello Osteopathic Medical Student,

The College of Osteopathic Student Government Presidents (COSGP) is the student group of AACOM, comprised of the two of the elected student government leaders from each osteopathic medical school. The COSGP Medical Education committee is comprised of some of the student representatives from COSGP and we would like your help! We are conducting a quick survey on your experience with COMLEX Level 1. Your participation will provide information that can assist with other medical student who will take the exam in the future. The survey is anonymous, but we ask that your response is as accurate as possible. This survey is optional and no students are required to participate. Please note, any surveys less than 50% complete will not be able to be used in our research so please fill out as much as you can! Here is the link to the survey: https://docs.google.com/forms/d/1PwNdUQU6DowKLxb-Nf-xeebci9xZfgsXeKr094XlaHI/viewform. Please complete the survey by March 22, 2015.

Thank you so much for you help. Please visit our website COSGP.org for resources and other information about your representation at the national level. If you have any questions please e-mail me at: COSGPMedEdRep@aacom.org

Thank you!

Know Your Research

Written by: Eric Goldwaser, COSGP National Research Representative

Research is something that looms in the back of every pre-medical students mind when applying to medical school – “Do I need to do it?   Is a poster the same as a publication?  What are the interviewers going to ask me about it on my interview?”  Unfortunately, the conversation does not change much when it comes to medical students applying for residencies.  To most, research is an arduously enduring, intensely unsatisfying, and overly squandering chore that generally does not extend much further than an 8-week summer research stint in a lab.  It is honestly circumstantial whether or not the experience culminates in a poster presentation at a conference, or a retrospective chart analysis that makes it to publication years later.  The true feat that comes from doing research is being able to grasp what the project is all about in a broader scheme, which requires a depth of understanding beyond simply the experiments that were performed.

It is widely accepted that most medical students and physicians will not continue their research into residency and then clinical practice.  And that is totally fine.  Not everyone is cut out for months of meticulous pipetting, tedious protocol reviews that undoubtedly require ‘experimental adaptations’, and laborious data analysis that most often amounts to having to re-do the experiment.  But, as a medical student, the value is not in the publication that comes to fruition, nor the results that your PI gets excited about, but rather the experience that you can talk about to others (namely interviewers).

It is obvious that motives are often confounded by the current status of ‘importance of resumes’ – and again, that is totally fine.  You do not have to be vested in doing research out of love for the lab – we all have different reasons to do it.  Where the conversation turns sour though, is where the interviewer asks you to talk about your research and you are left reciting the memorized abstract and conclusion statements in bulleted form from the poster you presented three years ago.  It becomes painfully obvious the student who not only didn’t care to do the research, but also those who didn’t care to know what it is they were doing – i.e. the ‘why’.   The onus falls upon the medical student to KNOW their research, infinitely times more important than merely having done it.

I always ask students I interview about the research they put on the resume (if it is within the last 5 years, it is fair game, FYI).   If for nothing else, then to solely establish the legitimacy of the rest of the application.  After all, if a student adds research to their resume and is unable to speak about it, it begs the question about what else has been embellished or unsubstantiated based on those same premises.  At the end of the day, if you put your name on something, you should know what it is you are taking credit for enough to have an in-depth conversation about it.

I urge you the next time you are at a conference to peruse the poster presenters.  Ask the presenter about their research and see the response – do they turn around and recite their poster to you verbatim?  Do they engage you and present information outside of their poster?  I think you will find it a very helpful exercise in how you want to come across at your own interview when talking about research.  The bottom line: do your due diligence to know what it is your name is receiving credit for, because it is dreadfully apparent when you don’t.

Lead Intentionally

Presented by: Tim Lemaire, National First Vice Chair, OMS-III

Written by: Andrew Cudmore, ATSU-SOMA

Tim took the COSGP through a series of images that gave perspective on how leaders can be more effective when acting intentionally. References ranging from personal friends to popularized characters in literature and film were used throughout the talk to illuminate key aspects of leadership.

First, we were given a description of an artist that sees potential in everything and makes masterpieces from unexpected sources such as junkyards. His ability translated into opportunities for the young artist as he honed skills in patience with coworkers who did not yet see the same potential. This emphasis on patience also helped our presenter manage stores that were in disastrous condition. The potential for positive change was much greater for both leaders when they were able to patiently lead teams toward a certain goal.
The next several anecdotes included interpretations of fictional characters such as Albus Dumbledore from Harry Potter and The Jedi from Star Wars. Focusing on team members’ strengths was underscored as a key for guiding leadership meaningfully. Powerful concepts such as hope and strategy must be given careful attention in order to effectively empower others.

A valuable resource for helping focus on leading intentionally can be found at www.gallupstrengthcenter.com. Here, users can read through personal strengths in addition to laying out plans of action.
However students and physicians choose to lead, our speaker closed by sharing the advice of finding a group that you feel does important work. After this discovery, help the group through contribution of your strategic thinking. You can be a leader with your ideas.

Getting Your Message Across

Speaker: Louisa Sethi, NYITCOM

Written by: Andrew Cudmore, ATSU-SOMA

Louisa gave us an overview of how to more effectively convey messages. She advised that communication could be better utilized through a simple and clear list of objectives.
The first requirement was to know the audience. This calls for understanding the desires of the people that one tries to reach. Reflect on questions such as why they are listening, what is the best way to help them learn, and what obstacles they will present. The time spent preparing on these thoughts can pay off greatly through offering perspective.

The next goal was to have a clear message. Explicitly stating what one wants from their audience can clarify ideas and minimize confusion between people. This may require a pruning process that cuts some material out so that the core concepts can be properly transmitted. Making a message simple may also be more palatable if quotable sound bites can be included.

Preparedness was another crucial part of expression. Research of the opposite viewpoint may help a speaker be ready for questions that may arise during discussion and help bolster reasoning for a certain viewpoint. Confidence can be a very powerful byproduct of allowing ample amounts of time for research, practice, and structure for a lecture.

Engagement of the audience is another step that was essential to effective transmission of any message. Involvement of others in a discussion can make them care about a given cause much more than a one-sided lecture. This involvement calls for a balance between analytical and emotional reasoning to be made.

Lastly, a powerful ending can help to resolve a solution to conflict that has been built on a subject and subsequently solidify the idea presented. Use of these objectives can vary greatly across different settings. It is up to the speaker to extrapolate on these ideals and develop a talk that will best fit a given setting. She ended on an engaging open forum that helped the presentation stick for all those in attendance. What do you think? Are there some that she missed?

Match Day Development

Speaker: Sarah Wolff, COSGP National AOF Student Representative

Written by: Andrew Cudmore, ATSU-SOMA

 

Match week is an exciting time that differs greatly among medical schools. The AOA announces matches for its residency programs on the second Friday in February whereas the NRMP announces their matches for residency programs on the third Friday of March annually. The constant variable is an “unmatched report” is sent to medical schools for each student at 11:30 A.M. on the Monday to start the match week. Students are then notified if they matched and open spots are shared at noon just thirty minutes later. Four days later, students are notified of where they matched at 1 P.M. on Friday in a variety of ways.

There are benefits for having the delay in notification that keeps the nail-biting schedule intact from year to year. The students are part of a great celebration when the stress of unknowing is finally relieved. The schools get an opportunity to disseminate information for Graduation as well as increase alumni participation through fostering a sense of community and school pride during fourth year. Many questions remain after scheduling, however, and schools handle the process very differently from one another.

The issue of which match to celebrate, whether it should be military, SF match, the AOA, or NRMP or some sort of combination is something schools need to address. From there, the question of who should attend remains. Students receiving time off rotations can be a fickle process, and getting some away for a match celebration that they are not involved in can be a daunting task. Inviting other classes, family members, and friends also raises questions as to how to broadcast the event and properly plan.

Formality of the announcements can range from costumed parties with raffles and games to business attire with four course meals and speakers. Either way, the method of releasing results is one of the biggest differentiating factors of the ceremonies. If a student is not content with their results, it can possibly lead to a shameful event with unwanted attention. Our speaker suggested having a line of students come up to have someone read their match aloud after privately opening. This way, those who did not want to be announced could simply bow out and the focus would be diverted to those who wished to participate.

Once an idea for a match week ceremony has been established, great attention to planning must go into the process every year. Students with busy rotation schedules must be given notifications to save the date far in advance. What type of hotel accommodations, flight discounts, drinks, food, entertainment, and afterhours events should also be laid out for the festivities beforehand.

The event sets the stage for a terrific photo opportunity for the alumni involved. Gifts and award presentations can also be included to contribute to the celebratory atmosphere.

The major points to remember about match day is that it takes time to organize and that the passing down of documents is vital to get support for all four years of medical school. The exciting step that students take when entering residency deserves proper attention so that the lasting memory of their school’s care can be appreciated.

Leadership Series

Presented by: Frank Cusimano, AZCOM, Louisa Sethi, NYITCOM and Tim Lemaire, COSGP National First Vice Chair

Written by: Jordan F. Geroski, OU-HCOM

Congratulations, you are on your way to becoming an Osteopathic physician!  In that role you will have the unique ability to save lives and work with others to improve their own on the path to finding health.  Along with this great privilege and responsibility comes the inevitability that others will look to you as a leader.  We all have attributes of leadership within us, whether we choose to exercise them routinely or not.  To help unlock this full potential, members of the Leadership Committee put together a series of presentations on effective leadership and communication.  The first part of the series focused on knowing oneself, communication, and finding opportunities to lead and grow in the most unlikely of places.

Be Engaged

  • You can always learn something new!
  • Teaching other is the best way to learn
  • Being a leader sometimes requires you to step outside of your comfort zone, especially when facing new challenges.
  • We all have four sides of our personality and how we see ourselves
    • Known self – the self we know and actively share with others
    • Hidden self – the self which we keep hidden from others
    • Blind self – the self which other people see. This self is not always evident to us but is rather the way in which we come across to others.
    • Unknown self – this self is yet to be seen. It encompasses the self we are currently shaping and will become.
  • “What got you where you are today, won’t get you where you want to be tomorrow.” Remember to take time to check-in with yourself and be present in what you are doing.

Persuasive Communication & Getting Your Message Across

  • Winning over difficult crowds
    • Know your audience and understand their goals and desires
    • What is your intended message? Explain why you message matters to that particular audience
    • Find common ground
    • Set expectations
    • Expect resistance
      • Acknowledge opposing points of view
      • Anticipate and prepare for questions
    • Making your message powerful
      • Have a clear message
      • Be prepared and know your topic inside and out
      • Be truthful
      • Be passionate about your message and believe in it
      • Have confidence
      • Practice and prepare ahead of time
      • Keep it simple and lose the jargon
      • Engage your audience
        • Ask for input
        • Make your audience care about your message and what you have to say
        • End powerfully

Leadership Lessons in Unlikely Places

  • Lead intentionally! Have a goal, a strategy to get there, and the tools you will need in order to be successful.
  • Have the ability to see the possibility in things that others may see as trash
  • “We” will always be greater than “I”
  • As a leader, you need to recognize people that have the spark of hope in them. Encourage them and help them reach their potential as well.

The COCA Handbook Highlights

Speakers: The Medical Education Committee, COSGP

Written by: Jordan F. Geroski, OU-HCOM

The Commission on Osteopathic College Accreditation (The COCA) is made up of 17 members that meet three times a year to discuss the accreditation processes for Colleges and Schools of Osteopathic Medicine.  Currently, no student voting members sit on The COCA.  As a branch of the United Stated Department of Education (USDE), The COCA is not directly tied to the American Osteopathic Association (AOA) but must report any happenings, changes, updates to the AOA.  The COCA has a COM Accreditation Standards and Procedures handbook consisting of 9 chapters outlining the standards and procedures of The COCA.  Below are a small number of highlights of each standard.

  • Standard 1 – Mission, Goals, and Objectives
    • Encourages schools to continually evaluate and update their mission statement
    • Schools must release statistics on each class’s COMLEX performance to their students
  • Standard 2 – Governance, Administration, and Finance — If a school is part of a larger university then that school must be USDE accredited
  • Standard 3 – Facilities, Equipment, and Resources
  • Standard 4 – Faculty — schools must have faculty development program for continued development
  • Standard 5 – Students — schools must provide information about behavioral health programs to their students (availability of counselors, etc)
  • Standard 6 – Curriculum
    • Inter-professionalism must be a part of the education
    • Basic knowledge of components of research must be a part of the curriculum
  • Standard 7 – Research and Scholarly Activities — the school must do some form of research
  • Standard 8 – GME outcomes — the school must annually publically report acceptance and first time pass rate on the Level 3 examinations
  • Standard 9 – Prerequisites for Accreditation — this additional chapter pertains new colleges and schools. It contains information regarding starting a new COM/SOM.

Summary of the Applicant and Accreditation procedures:

  • Status progression
    • Applicant status – “I want to open a COM/SOM”
    • Pre-accreditation status (must be within 5 years of applicant status) – the Dean must be among the first hires
    • Provisional accreditation status – must be achieved by March in the year which the first class graduates and can be kept for up to 5 years
    • Accreditation status – this must be renewed every 7 years
      • “Accreditation with warning” remains private between The COCA and the school
      • “Accreditation with probation” becomes public knowledge
    • Self-study process
      • completed by a COM in preparation for their actual The COCA visit
      • Self-study must be sent to The COCA 60 days prior to the actual The COCA visit
    • On-site visit procedures – meetings are held between The COCA members and faculty, students, and administration

Information on The COCA can be accessed at www.aoacoca.org.

The full Accreditation of Colleges of Osteopathic Medicine: COM Accreditation Standards and Procedures can be found at http://www.osteopathic.org/inside-aoa/accreditation/predoctoral%20accreditation/Documents/COM-accreditation-standards-current.pdf.