MedPAC Testimony Faults Residency Programs for Lagging Behind Patient Needs

Medical residency programs are not adequately training residents to meet the needs of the nation's changing patient population base, leaving new physicians without the knowledge and skills necessary to deliver high-quality care to specific patient populations. That was one of the messages delivered by Michael Whitcomb, M.D., former senior VP of medical education for the Association of American Medical Colleges, who spoke before the Medicare Payment Advisory Commission, or MedPAC, here on Oct. 2.

One of the biggest challenges facing American medicine is the ability to provide high-quality care to patients with chronic illnesses, said Whitcomb, who was one of three witnesses to testify before MedPAC. Roughly 130 million Americans now suffer from one or more chronic illnesses, but according to research conducted on this issue, these patients are not receiving high-quality care, he said.

The nation's medical residency programs are grounded in the past, said Whitcomb, focusing more on hospital-based or acute care than on preventive care and appropriate management of chronic diseases.

"What you really want to do is to provide care that will keep patients out of the hospital, or, if they have been hospitalized, make sure the care that they receive after they have been in the hospital is adequate," he told MedPAC. "That responsibility falls disproportionately on internal medicine and family medicine."

Whitcomb reminded the MedPAC commissioners that physicians learn how to practice medicine during their residency training, not during medical school, making residency training the key to improving physicians' ability to care for patients. He urged residency programs to move beyond the status quo and begin asking questions such as, "Are doctors currently providing high-quality care?" and "What do they need to provide high-quality care?" when designing or redesigning their residency programs.

"It is critically important to be sure that we know what it is doctors need to be able to do to provide high-quality care, and we then need to monitor them as they go through the program to make sure they are meeting the milestones that need to be acquired," Whitcomb said.

He cited various factors that are blocking changes in residency training, such as the pervasive linkage of medical education infrastructure to teaching hospitals, which results in a nearly exclusive focus on inpatient care.

"With very few exceptions, when we think about clinical care, it is hospital-based care," said Whitcomb.

Hospital-based clinical faculty have a vested interest in retaining resident duty responsibilities, he said, given that the financing of graduate medical education is linked to hospital-based experiences.

"It is the linkage to the hospital source of funding that maintains much of the way our system is currently organized," Whitcomb said.

He also decried the fragmentation of professional oversight and governance of residency programs by the numerous medical specialties, saying that fragmentation makes it difficult to reach a consensus on how to redesign the programs.

Medicare has a substantial stake in the medical education process, spending nearly $9 billion in support of graduate medical education and teaching hospitals in 2006 alone, said Craig Lisk, M.S., a senior MedPAC analyst. Thomas Nasca, M.D., CEO of the Accreditation Council for Graduate Medical Education, or ACGME, said he would give residency programs a grade of "C" when evaluating whether they are training physicians for health care delivery in the 21st century. That's better than the "D" grade assessed five years ago, but far short of the "B+" or "A-" that is the goal for 2012, he said.

Several years ago, residency programs were accredited based on minimal standards, a process known as the trailing-edge phenomenon, according to Nasca. But in the past 10 years, the accreditation process has moved toward an active fostering of change and innovation through implementation of specific standards, something known as the leading-edge phenomenon, he said. It's a trend he predicted would continue.

Residency programs now are designed around the immediate needs of the public, Nasca added, not the future needs of the public. Moreover, the curriculum is now dominated by knowledge accumulation, not necessarily skill sets, he said.

ACGME has developed six core physician competencies that will be used as the basis for resident training. These competencies include medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice.

"Over the last seven years, we have asked the field to begin to innovate (in) these areas, especially the last two, which are the main drivers of understanding how to meet the needs of patient populations," Nasca said.

The ultimate goal, he said, is to design a residency program that five years from now will incorporate the required outcomes in each domain of clinical competency and use standardized evaluation tools to measure the outcomes in a formative and summative way.

Thomas Dean, M.D., of Wessington Springs, S.D., the only family physician on MedPAC, said during the question-and-answer period that the country needs effective graduate medical training programs, but it also needs to recruit the people who are "most needed in the system."

"If we are going to be able to staff things like the patient-centered medical home, we just have to have more primary care physicians, and clearly we are not getting those people," Dean said. It can be difficult to recruit physicians to practice in rural areas unless they are from those areas, he added, and aspiring physicians from rural areas face certain obstacles that can hinder their attempts at becoming physicians.

"Unless we address those barriers ... we are not going to really get the workforce we need to serve these new models we are talking about," Dean said.