Whitney Palmer

GME Gets Outpatient Treatment

Published in the November 2010 Association of American Medical Colleges Reporter

—By Whitney L.J. Howell, special to the Reporter

When Ben Wilde told the aging bus driver he could not continue driving due to his poor eyesight and neurological issues, Wilde saw despair in his patient’s eyes. He knew the man had no financial alternatives and would likely be trapped in a devastating situation.

“I realized how important it was that I was there to help him,” said Wilde, a family medicine resident at Southern Illinois School of Medicine.

The experience underscores a reemerging viewpoint among many medical educators: that a larger share of residency training should occur in the community outside the hospital. It is valuable, proponents say, because most of the nation’s health care takes place in the outpatient setting. Working in these environments can familiarize physicians with managing chronic disease and providing continuity of care. Although the Accreditation Council for Graduate Medical Education (ACGME) for decades has required that family medicine residents train partly in community settings, this approach is spreading to other specialties, including pediatrics, obstetrics and gynecology, and psychiatry.

More and more, a resident’s time is divided more equitably between inpatient and outpatient facilities.

Pediatrician Tracy P. Milbrandt, M.D. (left) and resident Kristopher Cunningham, M.D. explain information to Noah Miers during a visit to the Pediatrics Clinic at Southern Illinois University School of Medicine.

Although this is not feasible for some specialties, such as surgery or radiology, it can have major benefits for others.

“It’s important we train our residents to work in all environments where we see health care going on,” said Joe Gravel, M.D., president of the Association of Family Medicine Residency Directors. “They will learn more accountability in treating patients, and we have a greater chance to teach them preventive rather than reactive medicine.”

No data exist on how many medical schools or teaching hospitals are placing residents in community-based training settings. However, the health care reform law tasked the Centers for Medicare and Medicaid Services with gathering details about how many residents spend time in outpatient settings, and how many hours they invest in this training.

According to Sunny Yoder, AAMC director of resident affairs, public policy experts are interested in outpatient graduate medical education (GME) because it balances the residency experience and provides an opportunity to learn about topics not typically encountered in the hospital.

“There is great interest in having residents practice in settings where people go most often to see a doctor,” Yoder said. “While keeping residents in the hospital may be advantageous in some cases, some policymakers believe there will be improved patient care down the line if they train in clinics.”

Financial support for resident work outside inpatient settings is a traditional sticking point. A January Annals of Internal Medicine article found that about 42 percent of community health centers are already primary care training sites, yet receive no funding to cover associated costs. Teaching hospitals have historically not received Medicare reimbursements for training that took place outside their walls.

But thanks to the health care reform law, changes are coming. The law authorized $25 million for the current fiscal year and $50 million for 2011 and 2012 to fund teaching health centers (THCs), defined as community-based, ambulatory patient-care facilities that operate a primary care residency program. Each THC can apply for $500,000 a year for up to three years. In its June report to Congress, the Medicare Payment Advisory Commission recommended that THCs receive funding for direct and indirect education costs, but that the funding be authorized through the Health Services Resource Administration rather than Medicare, as is the case with GME programs in children’s hospitals. The new law also gives hospitals the green light to seek Medicare reimbursement for residents’ offsite work, provided hospitals pay for most or all of the residents’ salary and benefits.

In addition, the 2009 American Recovery and Reinvestment Act allocated $500 million to the National Health Service Corps to train providers who will work in clinics and similar facilities. Moreover, in 2009 the Council on Graduate Medical Education recommended that the federal government remove barriers to, and implement incentives for, establishing non-hospital primary care training programs. The federal government’s fiscal 2010 budget allocated $254 million for health professions education under Title VII and $244 million for Title VIII nursing programs—two programs that typically support training for more outpatient-focused specialties.

In the fiscal 2011 budget proposals, President Obama requested $260 million for Title VII programs but no increases for Title VIII. Congress is expected to consider the appropriations bill after November’s midterm elections. Removing residents from the hospital, however, can create challenges both for medical education and patient care, said Jeffrey A. Stearns, M.D., medical education director and associate dean for medical education at the University of Wisconsin School of Medicine and Public Health. Shifting residents from one setting to another increases the workload for physicians remaining in the hospital and reduces the time residents learn as a team with other residents and attending physicians. Another roadblock, Stearns said, is the mindset some community practices hold toward education.

“We must retrain doctors who will be faculty for residents,” he said. “They must understand their teaching role and be comfortable with speeding up their days—they can’t see only one to two people an hour. They’ll need to see more.”

The reform law will make it much easier for academic medical centers to provide outpatient training overall, said Rosemarie Fisher, M.D., associate dean of GME at Yale University School of Medicine and chair of the internal medicine review committee for the ACGME.

“Getting more residents into ambulatory training is a necessity. This is a major part of medicine right now,” she said. “Whether it’s a federally funded health center, a private practice, or even a clinic on hospital grounds doesn’t matter as long as the experience happens.”

Having residents in outpatient settings can be a win-win situation, Gravel said. Over time, residents become familiar with patients’ medical histories, while patients enjoy increased access to quality health care. Several teaching hospitals and health systems already have residency training sites outside the hospital. For example, Yale’s residents spend four weeks in an outpatient block rotation where they train in many health care settings. Internal medicine residents accompany nurse practitioners on home visits to treat older adults. Ophthalmology and otolaryngology residents see patients in Hill Health Center, Connecticut’s largest community health center. Pediatric residents serve students through school-based clinics. Private practice training experiences are also available.

According to Fisher, community training does not compromise the residents’ ability to practice and learn new skills.

“Our residents do everything under a licensed physician’s direction, and they can do the same things they do in hospital-based clinics,” she said. “They practice rather independently, they do histories, physical exams, they talk with patients and discuss cases with attending physicians, and they do small procedures.”

Residents in the community learn by seeing the same patients (and their conditions) over time, said Karen Broquet, M.D., professor of clinical medicine and associate dean for GME at Southern Illinois University School of Medicine. The school offers private practice training in small towns statewide. First- and second-year residents attend continuity clinics one half-day a week, and third-year residents attend two half-days a week.

According to resident Wilde, days in the community affect the emotional side of medicine, as well.

“It teaches us to be more compassionate, to understand that patient needs must be met,” he said. “It doesn’t come down to whether the bills get paid or who even pays the bills.”

To read the full article online: https://www.aamc.org/newsroom/reporter/nov10/161758/gme_gets_outpatient_treatment.html

November 17, 2010 - Posted by wjpalmer | Healthcare | 2009 American Recovery and Reinvestment Act, Accreditation Council for Graduate Medical Education, Association of Family Medicine Residency Directors, community rotations for residents, graduate medical education, graduate medical education at Southern Illinois University School of Medicine, graduate medical education at University of Wisconsin School of Medicine and Public Health, graduate medical education at Yale University School of Medicine, Jeffrey Stearns, Joe Gravel, Karen Broquet, medical students working in community, National Health Service Corps, residents working in the community, Rosemarie Fisher, Southern Illinois University School of Medicine, teaching health centers, Title VII funding, Title VIII funding, University of Wisconsin School of Medicine and Public Health, Yale University School of Medicine