The GME Bottleneck Is Here! - Feinberg School of Medicine

Report
From the New MCAT to the GME
Bottleneck to Faculty Burnout:
Unprecedented Challenges and
Change for Academic Medicine
Feinberg School of Medicine
Northwestern University
Chicago, IL
Darrell G. Kirch, M.D.
President and CEO
November 11, 2014
A Growing Sense of Uncertainty in
Academic Medicine
We talk about
interprofessional teams,
but how do we put them
together?
Whenour
willnew
residency
Given
partnerships, is
slots
increase?
our
core
academic mission
Are we going to lose a whole changing?
generation
Is our business
modelof
ofscientists?
“cross-subsidies”
sustainable?
Is our commitment to diversity
fading?
What does it mean to be a
faculty member in the future?
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What will be the “new normal”
(and when will we get there)?
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1965 – The Coggeshall Report
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Increasingly, it appears
that the new normal may
very well be a state of
persistent uncertainty!
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Fears Grow in United States Over
Ebola’s Spread Outside West Africa
—Reuters, Oct 10, 2014
Islamic State Crisis: Heavy Fighting
on Iraq-Syria Border
—BBC News, September 30, 2014
Global Growth Woes Threaten
to Beset US Economy
—Wall Street Journal, October 21, 2014
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A Deeply Divided Government…
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…Reflecting an Ideologically Dividing Public…
1994
Consistently
liberal
2004
Mixed
Consistently
conservative
Consistently
liberal
Mixed
2014
Consistently
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liberal
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Mixed
Consistently
conservative
Consistently
conservative
…With Health Care Caught in the Middle!
4.9 Million Americans Left Uninsured In States Not Expanding Medicaid
24,000
182,000
40,000
25,000
55,000
120,000
17,000
33,000
58,000
78,000
191,000
193,000
319,000
162,000
194,000
144,000
17,000
409,000
191,000
1,046,000
242,000
138,000
Implementing Expansion in 2014
Not moving forward at this time
Open debate
#
Number of residents who will remain uninsured
Source: Kaiser Family Foundation (coverage gap # December 2013) (expansion decisions as of August 28, 2014)
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764,000
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Despite All This Spending,
Our Health Outcomes Lag Globally
U.S. Comparison to OECD Nations
2012
2012
2012
Life Expectancy
Infant Mortality
Adult Obesity
Bottom Quarter
4th Highest
Highest
78.7 yrs compared to
Japan at 83.2 yrs
6.1 deaths/1,000 births
compared to average 4.0
deaths per 1,000 births
35.3% obese compared
to average 22.7%
Source: OECD Health Data 2014
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More Doctors Will Be Needed To Even Begin
To Close the Gap
Projected Supply and Demand of Physicians, 2008-2025
www.moredoctorsnow.org
Source: AAMC Center for Workforce Studies
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The GME Bottleneck Is Here!
Results from the National Resident Matching Program 2002 – 2014
Before Scramble/SOAP
2500
2,155
2000
Unfilled PGY-1 Positions
1500
991
1000
975
883
U.S. Seniors Unmatched to PGY-1 Positions
500
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Source: Results and Data 2014 Main Residency Match
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Is All This Uncertainty Taking Its Toll?
Emergency medicine
General Internal medicine
Neurology
Family medicine
Otolaryngology
Orthopedic surgery
Anethesiology
Obsterics and gynecology
Radiology
Physical medicine and rehabilitation
Mean burnout among all phsycians participating
General surgery
Internal medicine subspeciality
Opthamology
General surgery subspecialty
Urology
Psychiatry
Neurosurgery
Pediatric subspeciality
Other
Radiation oncology
Pathology
General Pediatrics
Dermatology
Preventive medicine, occupational medicine, or environmental medicine
0
10
20
30
40
50
Source: Shanafelt T, Boone S, et al. Burnout and satisfaction with work-life balance among U.S. physicians relative to the general U.S.
population. Arch Intern Med. 2012;172(18):1377-1385.
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60
70
In academic medicine,
we face uncertainty on
all mission fronts!
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The Medical School “Cauldron”…
Grants and
Contracts
Physician
and Hospital
Revenues
Tuition and
Appropriations
Discretionary
Fund
Clinical Care
Education
Research
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…But Not All Funding Sources Are
Created Equal!
Fully Accredited Medical School Revenue by Source, FY2013
Total Revenue: $101B
Median Revenue: $521M
Faculty Practice Plans
39%
Government &
Parent Support
5%
Other Grants &
Contracts
9%
Federal Grants &
Contracts
17%
Source: LCME Part I-A Annual Financial Questionnaire, FY2013
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Hospitals & Medical
School Programs
17%
Research Funding Isn’t Likely to Grow
NIH Funding in Billions – FY 2000-2015
$32
$30.10
$30
$28
$26
Billions
$24
$22
$19.0
$20
$18 $17.8
$16
$14
$12
$10
$8
$6
$4
$2
$0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Current
Constant (BRDPI)
Sources: NIH Budget Office; House and Senate Appropriations Committees
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Student Tuition and Debt Are at the Limit
Mean 4-Year Cost of Attendance and Medical Education Debt of
Indebted U.S. Medical School Graduates in 2014 Dollars
$300,000
$288,098
$250,000
$219,196
$200,000
$172,074
$150,000
$149,999
Private 4-year COA (In-State)
$100,000
Mean medical school debt of indebted private school graduates
Public 4-year COA (In-State)
Mean medical school debt of indebted public school graduates
$50,000
2002
2004
2006
2008
2010
Sources: AAMC Tuition and Fees Questionnaire, LCME Part I-B Student Financial Aid Questionnaire
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2012
2014
Teaching Hospitals Will See Significant Cuts
AAMC Projected Medicare Losses for All Major Teaching Hospitals
12%
$4,000
Estimated Losses (Millions)
10%
$3,500
$3,000
8%
$2,500
6%
$2,000
$1,500
4%
$1,000
2%
$500
$0
0%
2014
Sequestration
2015
2016
DSH/UCP Cut
2017
2018
2019
Fiscal Year
Readmission
VBP
ACA
Source: AAMC Analysis of IPPS Impact File, FY2014 Final Rule Data (August 1, 2013 Release)
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2020
Multi-Factor
Productivity
2021
2022
% of Total Payments
Estimated Losses as % of Total Estimated
Revenues
$4,500
Despite all this, it falls to
academic medicine to lead
health care transformation!
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Our Imperative to Survive and Thrive in a
New Normal of Uncertainty
Source: AAMC Analysis of AHA 2011 annual survey data
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What will be the critical success
factors necessary for us to
accomplish this transformation?
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1
We need to create a new culture!
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Our Culture Will Be—and Is—Transforming!
Hierarchical
Collaborative
Autonomous
Team-based
Competitive
Service-based
Individualistic
Mutually Accountable
Expert-centered
Patient-centered
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2
Building a new culture will
require a future-oriented
model of leadership!
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The New Leader Arrives!
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Leaders of Health Care as “Multipliers”
Source: Wiseman L, Bradwejn J, and Westbroek E. A New Leadership Curriculum:
The Multiplication of Intelligence. Academic Medicine 89(3). March 2014.
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3
We must rapidly adopt new
reimbursement and care models!
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Seismic Shifts in Health Care Financing
and Delivery
Yesterday
Tomorrow
Fee For Service
Value-Based Payments
Paper Records
Electronic Health Records
Independent Hospitals
and Physician Offices
Large Health Systems
with
Employed Physicians
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The Health Care System of the Future Is
Integrated and Transitions Are Seamless…
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…and Academic Health Systems Can
Be the Key Drivers of Innovation!
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4
We must expand our definition
of health and biomedical
research– and our partnerships!
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Only Through the Full Spectrum of Research
Will We Improve the Health of All
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An Imperative for Institutions to Strengthen
Their Research Strategy
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5
We must shift the core paradigm
driving the continuum of
medical education!
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Our Goal: A True Continuum of Education
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What Should Drive Learning and
Assessment in Medical Education?
“Time In Seat”—
Accumulating Facts?
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The Complexity of Medical Decision-Making
Accelerates
Source: William Stead, IOM Meeting, 2007
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What Should Drive Learning and
Assessment in Medical Education?
Competencies!
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A New MCAT 2015 for New Doctors
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Holistic Review
Diversity
Holistic
Review
Pre-professional
Readiness
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Academic
Readiness
Competency Domains
Patient Care
Interpersonal
and
Communication
Skills
Professionalism
Knowledge for
Practice
The
Physician
Practice-based
Learning and
Improvement
Interprofessional
Collaboration
Personal and
Professional
Development
Systems-based
Practices
Source: Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, Aschenbrener CA. 2013. “Toward a Common Taxonomy of Competency
Domains for the Health Professions and Competencies for Physicians.” Acad Med 88(8): 1088-1094.
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Core Entrustable Professional Activities
a set of activities that entering residents should
be expected (entrusted) to perform on day one
of residency without direct supervision.
1)
Gather a history and perform a
physical examination
8)
Give or receive a patient handover to
transition care responsibility
2)
Prioritize a differential diagnosis
following a clinical encounter
9)
Collaborate as a member of an
interprofessional team
3)
Recommend and interpret common
diagnostic and screening tests
10)
4)
Enter and discuss orders/prescriptions
Recognize a patient requiring urgent or
emergent care, and initiate evaluation
and management
5)
Document a clinical counter in the
patient record
11)
Obtain informed consent for tests
and/or procedures
6)
Provide an oral presentation of a
clinical encounter
12)
Perform general procedures of a
physician
7)
Form clinical questions and retrieve
evidence to advance patient care
13)
Identify system failures and contribute
to a culture of safety and improvement
www.aamc.org/cepaer
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6
We must draw on
our resilience!
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[Resilience is] the glue that holds
groups together, provides a purpose
larger than the solitary self, and allows
entire groups to rise in challenges.
Martin Seligman, Ph.D.
Flourish
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If we do these things,
what can we create?
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Achieving The “Triple Aim”
Source: Berwick, DM, Nolan, TW, Whittington, J. Health Aff May 2008 vol. 27(3), 759-769.
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