PermanenteDocs Chat on GME and the physician pipeline

The health care industry faces an ongoing physician shortage, so there’s a need to ensure a regular pipeline of new doctors. During the summer, residency begins for a lot of medical school graduates and graduate medical education (GME) is a necessity for residents to gain the training they need to enter practice. Are there enough GME programs to sufficiently meet the needs of residents, and what are some innovative programs to advance resident training? On this PermanenteDocs Chat, co-presented with the American Medical Association, host Alex McDonald, MD, chatted with guest Sanjay Desai, MD, of the AMA to discuss physicians’ careerlong path to learning.

Guest

• Sanjay Desai, MD, chief academic officer and group vice president of medical education, American Medical Association.

Watch the full replay video or listen to the podcast above.

Podcast transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.

Alex McDonald, MD: Hello, everyone. Welcome to the PermanenteDocs Chat. Thank you so much for joining, wherever you may be listening, watching, or tuning in from. I’m your host, Alex McDonald. I practice family and sports medicine here as part of the Southern California Permanente Medical Group at Kaiser Permanente, and I am very excited to welcome you to a very special podcast today. This is our first PermanenteDocs Chat done in collaboration with the American Medical Association. This will be a monthly podcast co-presented by The Permanente Federation and the American Medical Association. I’m very excited to welcome our guest today. It’s July, and new residents all over the country are starting their residency, and people are moving from junior residents to senior residents or fellows, and today we’ll be speaking about GME with the American Medical Association’s chief academic officer and group vice president of medical education, Dr. Sanjay Desai. Dr. Desai, welcome to the podcast, and thank you for being here.

Sanjay Desai, MD: Thanks so much, Dr. McDonald. I really appreciate the opportunity to talk with you.

AM: Wonderful. For anyone out there listening live on the webinar, if you have questions, please drop them in the Q&A, and we’ll get to as many as we can. This is going to be a pretty quick 20-minute discussion, so get your questions in early, and we’re just going to jump right in. Dr. Desai, in your own words, tell us who you are and what you do.

SD: Thank you. Actually, GME is my home. This is a great topic to be part of. As you said, I am the chief academic officer at the AMA. I came here about a year and a half ago, but I spent the last 12 years as a program director for internal medicine at Johns Hopkins, where I was a professor of pulmonary critical care medicine. So, I still do clinical work there. And all of my professional activity really was in GME, and July 1st was the day of the year that was most important to me. So, it really is a celebratory month in many different ways. Here at the AMA, we do 4 main things in medical education. We look after some policy, so there’s a lot of policy that helps shape regulation and accreditation and training in GME. We are a co-sponsor of the LCME (Liaison Committee on Medical Education). There’s a whole alphabet soup that people are probably aware of, but LCME is an important one. That’s the organization that accredits MD-granting medical schools in the country. We also have a large effort in innovation. And I’d love to get into that a bit more. And then, in addition to that, we look after equity, diversity, and belonging and try to promote that as much as we can. So, there are multiple areas. The last one which is not GME is that we actually look after the CME credit system in the country. So those are all AMA professional activity credits that we provide physician reward activity credits that people can seek at CME.

AM: So really, it’s a whole continuum of education, from undergraduate medical education to graduate medical education to continuing medical education, and the AMA is doing such phenomenal work across that whole spectrum. Because we want to train good doctors, and we want to make sure those doctors stay up to date and continue to practice the evidence-based medicine that our country needs, quite frankly.

SD: I like what you said because too often we think about medical education in compartments, and those compartments still don’t talk to each other very well. And that leads to these really abrupt transitions. One, we’re going to focus on GME, but once you get into it, it’s abrupt, and getting out of it, as you know, is very abrupt as well. We’re trying our best to make it a seamless continuum of lifelong learning.

AM: Yeah, that makes perfect sense. One thing, as many of you listening know, I’m one of the faculty members for our Family Medicine Residency and our sports medicine fellowship [at Kaiser Permanente San Bernardino], and one of the things I always impress upon my residents is the fact that you’re always going to be at a point where if you ever feel like you don’t have to look things up or you feel like you know everything, then something has gone horribly wrong. And you should continue to be learning and continue to look things up and learn for the rest of your career. And that’s really what is probably the most challenging but also most rewarding about a career in medicine.

SD: I absolutely agree. I mean, I think that it’s hard to find a group of people more eager to learn than physicians, and I think one of the reasons they seek after the educational model is because they’re curious. And I think we’ve done a pretty good job, unfortunately, of making it hard to continue the joyful learning that we sought after when we went into this. So that’s really one of our aspirations, Dr. McDonald, to try to create and bring back that joy of learning and make it easier for us to do that. I think there’s no time like now, with the advent and dissemination of AI and generative models of AI, that I think remind us that we can’t possibly know all of this. We’re going to have to continue to learn. So, you can bring that energy to this.

AM: Exactly. Well, you mentioned innovation, so let’s start there. Graduate medical education has been growing and evolving. You know, there were duty hour restrictions about 10 years ago, which sort of threw everything on its head, but there have been multiple other changes. It may be a little bit more incremental since then. Tell me, what are some of the most innovative changes within GME in the last couple of years, and what might be coming in the future or in the near future?

SD: I think we’re finally making progress, and we need to make much more, guess what really matters in GME. If you take a step back, the entire purpose of a medical education system is to produce a physician workforce that can care for our patients, families, and communities. But the system that we have is a time-based model. We say that if you go through 4 years of medical school and you go through X number of years of residency, as defined by the accrediting bodies, then you are competent. And we know that that is not true. There are data from multiple specialties to demonstrate that that is not true. The simple way I explain it is, if you ask any patient what they would rather have, someone that’s gone through X number of years of schooling or someone that is competent and caring for you? And I think that’s an obvious answer. So, we need to move, Dr. McDonald, to a competency-based model. And there are many barriers to that. That’s where innovation is occurring. There’s innovation in the UME (undergraduate medical education) space, the medical school space. And there are multiple schools that have gone and started to implement competency-based medical education. In fact, some, like OHSU (Oregon Health and Science University), have been graduating the vast majority of their students before 4 years because they have a rigorous competency-based model. It gets much trickier when you get to GME.

Residency has this dual role of being a learner and continuing to train and being a physician caring for patients. So, there’s a workforce dependency in residency that is very difficult in our current system to extricate from the learning and training role of a resident. It makes it hard to implement CBME (competency-based medical education). But you asked about innovation. We are funding multiple grants in multiple areas. One of our priority areas is competency-based medical education. And we are doing that. We did it in UME, and now we have a pilot in GME, so at Mass General Brigham, there’s a group there that is implementing competency-based medical education in residency programs. And they’re starting with pathology. And the goal is to develop a competency model, assess against it, and then what they call promote in place, that circumvents this barrier workforce because you keep them employed even though they go forward. And so that’s still nascent, and it’s evolution. There’s another model at Stanford with emergency medicine using competency-based medical questions. So, innovation is occurring, but it is hard because of the inertia, because of admin. But I would say, Dr. McDonald, the biggest reason it’s hard is because of culture. We need to change the culture in which we immerse these trainees so that we can do this more effectively.

AM: I think that’s such an interesting point, applying the individual learner to a curriculum versus applying the curriculum to the individual learner. I always like to think about, here in family medicine, we do lots of different things. We do some procedure-based things. We do some minor procedures. We do more cognitive-based education and learning, and it’s just so interesting to see different residents progress at different rates. And some of them are very good with their technical skills, maybe not so good with some of the more cognitive functions, and everyone sort of has a different place along that spectrum of the multiple different aspects of which we expect people to have skills when they graduate. So, rather than forcing the curriculum to fit the end, excuse me, forcing the person to fit the curriculum, really fitting the curriculum to the individual learner feels like that would be a much more efficient way to train but also a much more enriching way that really meets with some of what we know in the science about education and adult learning, as opposed to saying, “Here’s what you have to know. Read this book.”

SD: And it’s exactly right. We’ve developed this model talking about barriers to lifelong learning, and you’ve just highlighted one, which is that you have this one-size-fits-all model and randomness. In medical school, 2 people, one who majored in biochemistry and one who majored in public policy, are sitting together in a chemistry class, and they are getting different things after that time in class. And then, similarly in residency, the schedules are random. They’re not based on what people have learned, at least for 99% of training programs in the country. They’re based on this random shuffle of priorities, of when people can be where, and so it leads to, you know, the goal is to bring back and fuel and feed that curiosity. So, you want people to learn continuously. But what happens because of randomness, and one-size-fits-all is that they have these decelerations in their development because you’re in an environment where you’re not meeting the need that you have. And that becomes frustrating, and it becomes less fun. And so how do we make that slope continuous? One way to do that, from an innovation perspective, is what we’re really heavily investing in now called precision education. It’s bringing the right education to the right person at the right time. And that was really hard to do before because we didn’t have the data and technology to do it well. Many kids are using Khan Academy now, right? That’s an opportunity for learner agency in their learning, it’s what they need at this time, and it develops competency. And you move forward. Bringing those types of models into medical education is one of our aspirations, and we’re working with a number of schools that are actually moving pretty fast in the space. So, it’s pretty fun.

AM: And I imagine one thing that we’re really thinking about right now, and I know the AMA is doing a ton of work here, and so is Permanente Medicine, is physician wellness, resident wellness. If you’re being forced to do menial tasks that don’t meet your need, where you don’t feed your curiosity and are … what’s the opposite of precision? Lack of precision education, I imagine that’s a recipe for burnout and for all the other mental health consequences therein, which really don’t help anyone. It just creates more burden and more work and more burnout in our students and our residents and our attendees also, quite frankly.

SD: I think you link 2 really important notions that we’re thinking about together here. One is burnout. I think many consider this an existential threat to our profession, and the story I often say is the number of colleagues of mine who are physicians who tell me that they hope their children do not pursue medicine is increasing. I feel that certainly when you think about that, what a tragic situation that we’re in that’s fueled by burnout, which is fueled by the admin and all the other work environment circumstances that we’re in. We really need to get to the root cause of why people feel the way that they feel, the moral injury, the dissatisfaction, the detachment, all of those things. We are doing work in this space. In fact, we started about 10 years ago developing a third pillar of medical education, health system science (HSS). There’s clinical sciences, there’s basic sciences, and there’s health. We just provided a grant to the Bernard Tyson School in Southern California who are implementing an HSS curriculum through medical school, and this links to burnout because one of the reasons that people feel some of what they feel is because they are not empowered to help think about how do I improve the system, all the forces on it. Thinking through health system science, we hope, is starting to address upstream one of the reasons that people feel the way they feel when they’re practicing medicine. We’re strong advocates for the Lorna Breen legislation that just came through Congress, trying to take all the stigmatization of mental health off of credentialing and off of licensing. That’s another important step that, again, is upstream and administrative. These are not necessarily GME things, but just thinking through what are the drivers of burnout, and how do we again study them and move upstream to try to mitigate them. I think this has to be a priority for everybody who’s around physicians right now, whether they’re medical school residents or in health systems or independent practices.

AM: That’s so true. I had the chance to actually meet Dr. Lorna Breen’s brother-in-law at a conference this spring. It was absolutely incredible. So, I completely agree with you that we have to reduce those barriers and those things where we have a lack of autonomy and self-control. And I think bringing it back to GME, who has less sort of autonomy over their own schedule than a resident sometimes, especially a brand-new resident who’s in this very chaotic, high-pressured world where, you know, let’s be honest, lives are at stake. And how can we help provide some sort of autonomy or at least a sense of locus of control, which we know is a recipe for burnout and challenges with our residents? Do you have any thoughts regarding that?

SD: That’s so on the minds of so many. And I think probably most people listening are aware of the increase in unionization that’s occurring across the country. I think that’s one of the outcomes of what you just described, this lack of power, this lack of agency. And so, I think we need to think through how is GME structured? We talked at the beginning, Dr. McDonald, about the workforce dependency of residency. And I think that’s where the conflict occurs. Conflict occurs because we want to train, and I think everybody fully intends and genuinely wants them to learn. And that’s why they’re here. But we have a certain number of physicians that need to take care of a certain number of patients, and we need to do that 24/7, 365 days a year. So how do we create more effective interprofessional models or how do we increase the number of GME spots? I know that’s one of the conversations that’s been happening for literally decades, and I think it will continue. It needs to continue.

So we need to change the structure, the numbers of people, and the way that we deliver care so that we can reduce the workforce dependencies and actually create the environment in which someone can be healthy and continue to learn and take ownership of their patients and feel like they’re developing and all of those things that we want them to do. And that’s a really complicated ask. And we’re a country where we’re self-governed. We are a country where the GME programs are dispersed geographically in structure. There’s community-based, there’s university-based. They’re funded by different mechanisms, most by Medicare, you know, but also by other mechanisms as well. So, it is a fragmented system that’s hard to have one solution for. If it was easy, obviously we would have figured this out sooner. But I would say, along with you, that the need to figure this out is urgent. I think that starts with exemplar programs, programs that are doing it well. And we look at how they’re doing it, and you see how the residents are experiencing their training. And what did they do to allow and enable that to occur? I think it’s going to be complicated. It’s going to be probably related to that particular environment. But there’s got to be lessons that you can take from there and then scale, replicate, reproduce, so that we can spread the wisdom of that and make it better, generally better for residents in the country.

AM: Yeah, so just like health care in general, it turns out that GME is complicated also.

Well, it’s funny. So many of you know, I actually did my intern year at a very large academic institution that really relied very, very heavily on their resident workforce. And then I came here to Kaiser Permanente in Fontana, where the residency is not the main driver of the workforce in the hospital. And it was a very different environment and a very different learning experience for me. And you know, I got things out of both systems. I’m not going to sugarcoat it, but one was maybe a little bit more gentle than the other. Let’s put it that way.

SD: Just on that point, I think that it’s, you use the word gentle, which is what I’m reacting to a little bit because I think that often people have in their minds certain attributes of gentle or healthy or less burnout, but I don’t think they’re always what we think that they are. So, for example, work hours come up often and so what we know is when you look at the UK or when you look at other countries that have far less work and much more strict work hour regulations, burnout is equal or higher than this environment. So certainly, hours play a role. But I think that we quickly jump to one attribute or another, and I think we need to step back and say, how do we, for me, and when I talk with residents often, it is that what they are usually seeking is the meaning and the purpose that drew them to the profession, and working the hours that they work and becoming fatigued takes that away. That corrodes that experience. So that’s one of the factors, for sure. But I think it’s hard to say we or I think it’s not possible to make a linear relationship from any one attribute and say, if we fix, if we change this one, this will break, because what we need to do is we need to bring back meaning, bring back the experience that I think you and I had when we were able to spend time with our patients and actually get to know them and learn about them. I pre-rounded every day in the hospital at the bedside, because that’s where the paper chart was. And I’m not advocating that we go back to paper charts. But in the world of EMR (electronic medical record), how do we bring that experience back? How do we bring back the time that we spent with patients so that we could get the joy of knowing them and feeling the reward of helping them? That’s not as simple as hours. It’s not as simple as what food is available. All of those things matter, absolutely. That’s the work environment. But what I think is core and what we need to figure out is how do we get them with their patients again? That’s what we need to figure out.

AM: Yeah, I completely agree with you. And perhaps gentle wasn’t the best word. But having more meaning. So, I completely agree with you that it’s about that connection and that meeting, and that’s why you went into the profession in the first place. So, this has been great. We’re almost out of time, I do want to ask a quick question here about, you mentioned this earlier. In our current GME system, are we adequately creating and preparing the physician workforce we need for our country, both now and in the future, as the big numbers are getting older and older?

SD: That’s such an important question. We again, we are a self-governed profession. We do not have a national blueprint for a physician workforce. So, because of that, we are not currently, nor do I think if you look at the pipeline, we are not any time in the near future going to have a physician workforce capable of caring for all of our patients and communities. It’s just the reality of having a self-governing workforce that has incentives that are as they are. And so, how do we manage that? So, I think we need to think through, we just go way upstream well before GME. You know, who are we recruiting into the profession? What incentives are in the system for what specialty they choose? And this gets into remuneration, it gets into geography. Obviously, it gets into debt. All of those things, I think, play a role. So again, very complicated. But I think we need to start to imagine or have conversations around this is the need for the country. How do we create the right incentives for people to pursue career choices that position us better to care for our population, particularly as it ages, because we’re going to have a different population in 20 years than we have today. So, this is equally urgent. It’s just that the effects won’t be seen for some time.

AM: There was a question here in the chat that I want to get to as well. What do we wish that undergraduate medical students knew before entering graduate medical education residency training programs? Is there anything like any pearls of wisdom or anything specific that you’ve heard through your work?

SD: I hope what we can let them know is that we are going to create a system that lets them care for patients and get and reap the aspirations that they have for pursuing this field. In terms of advice, I think that hopefully we’re moving away from a system where they have to get this mark and that mark and this checkbox and that checkbox. And they can actually take a step back and hopefully have the maturity to reflect upon themselves and think about what do I need to learn? How do I need to develop to better care for patients? For me, it would have been spending more time with communication. Or it may have been more time with underserved communities. Those skills that when you think about who do I want caring for me or my loved one and what is the distance between that archetype and me, that’s what I would tell undergrads. Try to develop yourself in this basis too. But it’s hard to say that because the system is set up in a way that drives them to this score and that score, because that’s the key, you’ve got to pass this gate. So, we need to work on the gates. Those of us that have some ownership around the gates need to work on the gates. But that’s the advice I would give them. And I hope we enable a process and an environment to let them pursue that.

AM: Yeah, that’s so well said, every system is perfectly designed for the result that it gets, right? And here we are. Well, last question here and then we’ll wrap up. Tell us what makes you most proud to be a physician and an AMA member.

SD: Oh, thank you so much. I think what makes me most proud to be a physician is just doing what we’re able to do. I think every day I care for patients, I am reminded of what a privilege it is to do this. And I know many people in many different professions, and I don’t know anyone who has this privilege. So, I feel very proud that we’re able to help people, people that need help. And I’m most proud of being an AMA member because they are also mission-driven to support physicians and help them care for patients, to try to make the work that we do, the goals that we have, easier to accomplish, to get rid of these barriers, to be… to eliminate anyone else in that exam room. You know, there’s so much encroachment, as we’ve seen so much this year, from legislation that’s passed or Supreme Court rulings that have come out. They are tireless in their mission and activity and advocacy to bring back that relationship between a physician and their patient. That makes me proud.