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June 2017Volume 15 Issue No. 6
Residency Program Alert
12 tips for a smooth resident graduationResident orientation tips
New residents will be arriving to your program shortly. Crys S. Draconi, C-TAGME shares her 15 steps for planning and running a successful orientation. Review them to confirm you’re on the right track and to get a head start on next year’s planning.
Rethinking the USMLE
With the intent to improve the processes for selecting and licensing future specialists in medicine, Deepak Gupta, MD, and Sarwan Kumar, MD, have suggestions for changes to the United States Medical Licensing Examination.
What’s new in GME?
Keep up with what’s happening in GME by reviewing some recent residency headlines.
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P10
P12
INSIDE THIS ISSUE
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Graduation from residency is the culmination of a resident’s transfor-mation from medical school graduate to independent physician during an intensive, career-building education process.
Planning the event is a stressful undertaking. The final sendoff should be memorable to recognize all that residents have achieved. If done hastily or with little effort, graduation activities can fall flat or leave residents feeling like they played an underappreciated part in the program. Commit to an organized and well-thought-out plan in the months leading up to graduation in order to properly celebrate and send residents off into the workforce.
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2 |Residency Program Alert June 2017
Residency Program Alert (ISSN: 1545-0791 [print]; 1555-7669 [online]) is published monthly by HCPro, an H3.Group division of Simplify Compliance LLC. • Copyright © 2017 All rights reserved. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clear-ance Center at 978-750-8400. Residency Program Alert, 35 Village Road, Suite 200, Middleton, MA 01949; customer service: 800-650-6787; email: [email protected]; rates: USA: 1 year. $375; 2 yearrs. $675. Bulk prices available upon request. Credit cards accepted: VISA, MasterCard, American Express, Discover. • Residency Program Alert is independent
and not affiliated with the ACGME or any other organization, specialty board or society, vendor, or company. Information provided in a national periodical such as this must be general and may not apply to a particular situation, as facts and circumstances may differ. Thus, neither the publisher, editors, writers, advisors, consultants, or interviewees warrant or guarantee that the policies, regulations, legal, and other information herein are applicable or correct for any particular use. Consult a qualified professional for information tailored to your specific circumstances.
RPA STAFF MEMBERS EDITORIAL ADVISORY BOARDAlpesh Amin, MD, MBA, MACP, SFHMProfessor and Chair Department of MedicineUniversity of California, Irvine
Linda Archer, PhDVice Dean for GME DIOEastern Virginia Medical School
Bruce Armon, Esq.Saul Ewing, LLP Philadelphia, Pennsylvania
Patricia Braund, C-TAGMEProgram Coordinator Pathology University of Colorado School of Medicine
Sanjay Desai, MDProgram Director Vice Chair for Education Johns Hopkins University Crys Draconi, C-TAGME
Residency Coordinator Internal Medicine Boston University School of Medicine/Boston Medical Center Director of Operations, AROPC
Jacqueline Williams Gaines Program Coordinator Diagnostic Radiology
University of Arkansas for Medical Sciences
Sheilah Jiménez, BS, C-TAGMEProgram Coordinator Pediatric Residency University of Colorado School of Medicine
Nicole W. Karjane, MDAssociate Professor, Residency Program Director Obstetrics and Gynecology Virginia Commonwealth Uni-versity Health System
Ruth H. Nawotniak, MS, C-TAGMEGME ConsultantTAGME—Cofounder and VisionaryTAGME—Chair, Media Com-mitteeCoordinator Liaison, GMEC, UB-SUNY
Leisa Oglesby, BSRN, MBA, CPHQProgram Coordinator Pediatric Residency LSU Health Sciences Center-Shreveport
Jennifer Reemtsma, M.Ed Director, GME The Christ Hospital Health Network
This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission.
periods of time, such as graduation preparation.
“I tried to get as many graduation-related tasks completed before Match Day. There’s a bit of a lull between turning in the rank order list and Match Day, and I found it perfect for planning both graduation and orientation,” she says.
2. Create a resident graduation form
Second to diplomas, the most important piece of paper for Denise Lesniak, C-TAGME, medical education coordinator for emergency medicine at MetroHealth in Cleveland, is the resident graduation form.
By the middle of March, Lesniak creates a graduation form for each resident. She uses the form to personal-ize congratulations for residents during the graduation dinner and complete a post-residency survey. The form includes information such as the following:
• Resident’s name, address, phone number, and email
• Name of hospital/business
• Contact information for new hospital/business
Residency Program Alert has 12 tips from program coordinators that will help graduation festivities at your program run smoothly.
1. Have an advanced plan of attack
Preparing for graduation naturally aligns with prepar-ing for orientation, says Shareen Mann, a former residency administrator with more than 10 years of experience. Planning these two big events on top of daily activities can be overwhelming if coordinators leave it all until the last minute. Avoid stress by constructing a long-term plan to chip away at the various duties.
“In general, I found that the farther in advance I had things planned, the more smoothly they ran and the less stress I had,” says Mann. “Advanced organization left me time and energy to handle the crises that inevitably came up and to enjoy the events.”
Keep a checklist of tasks handy. The checklist should include a time frame of annual duties and when each should be completed, says Mann. Whenever there’s a lull in activities, use it to plan for more stressful
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Residency Program Alert | 3June 2017
• Name/contact information of new supervisor
• Permission to use resident information in alumni listing
• Special awards/acknowledgments during residency
At the graduation dinner, have the emcee read the name of each resident, his or her new place of employ-ment or fellowship as listed on the form, and the resident’s special awards or acknowledgments. This helps celebrate the successes of your residents and the program that helped develop them.
Following graduation, coordinators can use the form for many purposes, such as:
• Filling out mandatory post-residency surveys about the program. Lesniak sends a survey to all employers of the graduating class that asks one question: “Was [resident’s name] prepared to work for you?”
• Mailing the official residency diplomas. Coordi-nators withhold diplomas on the day of gradua-tion in case the resident does not sign all of the final paperwork the ACGME requires. Hav-ing the graduation form with the residents’ new addresses eliminates the headache of trying to find correct addresses after residents have left the program. Consider mailing the diplomas out around Independence Day to allow time for all incomplete paperwork from residents to arrive and get verified.
• Creating an alumni contact list. If your program plans reunion gatherings, refer to the list to send out invitations and all other appropriate material.
3. Use software to plan in real time
Let your computer assist you when organizing gradua-tion activities. Use a software program such as MedRez or New Innovations, or your email client’s scheduling features, to help keep track of the changes you want to make for next year’s graduation planning process, says Mann. “In the midst of graduation festivities, I used my software’s comment feature to make notes on the checklist reminding me of things I wanted to change, improve, or cut for the next year,” she says.
As pieces of information or changes for next year trickle in for each resident, such as addresses or preceptors who might be invited to graduation, input data and respond to requests as promptly as possible to stay on top of the daunting graduation tasks that lie ahead.
“I updated information as it came in. This reduced the amount of effort and time necessary for preparing and mailing invitations,” Mann says.
4. Create a graduation folder in your email
To deal with the flurry of information arriving in your email inbox, separate graduation content into its own folder to help keep yourself organized, says Mann. Direct all graduation-related email into this folder. If you cannot get to the email immediately, the folder serves as a reminder of the tasks you need to com-plete, she says. Since each email has a time stamp, you can prioritize requests and responses.
The folder serves as an effective landing spot for graduation material, enabling coordinators to access information quickly without having to filter through the entirety of their inbox, says Mann.
5. Get personal with ERAS statements
The more you can personalize graduation for the residents, the more fulfilling the event will be, says Lesniak. Connect with the residents by reading their personal statements made at the beginning of their time in the program.
Print out the personal statements saved on ERAS immediately after the matching process concludes in March. Make them available for the graduation emcee to read during graduation festivities. Coupling this statement with the residents’ future employment or fellowship information—announcing where the residents started and where they are going—brings the residency experience full circle.
6. Consider options for graduation emcee
Think about the appropriate person to act as emcee for the graduation ceremony, says Lesniak. The right emcee—or emcees—can bring more meaning to the
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4 |Residency Program Alert June 2017
event. “Sometimes a program may choose a mentor or advisor to emcee the graduation,” she says. “Other times it is more fitting to have the faculty select which residents to give the awards to for a more personal touch.”
Creating and circulating a sign-up form among faculty to participate as emcee or award presenter during graduation can lessen the burden of having one person handle all of the responsibility. If there is a long-stand-ing tradition of a certain person or position acting as emcee, such as the program director, make sure to discuss the proposed change with him or her first.
“Even though it [may] cause him great stress, he may not be willing to change,” Lesniak says. “It’s a respon-sibility, so they are just going to do it sometimes.”
7. Have the program director conduct a ceremonious last evaluation
The ACGME requires each program to deem the residents ready for independent practice. Have the official form stating that the residents are ready for independent practice typed up and ready for the last resident evaluation. Have the program director perform the final evaluation so the resident receives an overview of his or her strengths and challenges ahead as an independent practitioner.
“We are giving [the program director] the umbrella view of this resident to make sure the resident will know where he will be successful, post-residency, and where his pitfalls may be as an employee,” says Lesniak.
Include dates of graduation and residency for each resident on these evaluation forms. This way, when the coordinator is gone and credentialing verification forms come to the program, the program director can refer to the evaluation form to complete the verifica-tion information, says Lesniak.
Have the program director finish the evaluation form in front of the resident so the resident knows the file is complete and is not surprised as to its contents.
8. Invite incoming residents to graduation
Medical school graduates join residencies to become independent physicians. Invite all incoming residents
to the graduation lecture and dinner to give them a glimpse into the program, says Dieann Sangster, residency coordinator in the Department of Otolaryn-gology at New York University Langone Medical Center. “This allows them to [meet] the entire faculty and [all of the] residents,” says Sangster. “This also allows them to see the end results of their hard work.”
Send information to incoming residents about attend-ing graduation activities with all other materials following matching season.
9. Set dinner date by early March
The graduation dinner requires advanced planning, regardless of whether your program sticks to the same itinerary each year. Setting the dinner date months in advance allows residents to give their invitees time to plan travel arrangements.
“What’s happening now with this generation is that they want to invite their mom, dad, and dog to this dinner,” says Lesniak. “Their parents a lot of times are still in the workforce, and they want the best price on airfare and other considerations. The parents appreciate that.”
Coordinators should decide on the date of the gradua-tion dinner somewhere between the last week of February and the first two weeks of March, she says.
10. Acknowledge resident stress
Graduation is a time of great joy, but it also signifies an important shift that is stressful for many residents, says Lesniak. Transitioning into the real world comes with some challenges. “Their stress level is going to be very high, and they will be very free to show that to the coordinator because they have built a rapport with the coordinator,” says Lesniak. Having a strong relationship with coordinators allows them a chance to show that stress without fear of reprisal. As a coordi-nator, recognizing residents’ stress helps defuse some of the tension they might feel during a bittersweet time of year, says Lesniak.
“I thought at first [graduation time] would be all celebration, but it can be very stressful,” she notes.
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Residency Program Alert | 5June 2017
11. Celebrate informally during festivities
A graduation ceremony, such as a dinner, is dressy and formal to reflect the professionalism of the institution, program, and residents. Although these activities are great ways to welcome residents into their post-gradua-tion careers and say goodbye, adding an informal get-together helps make the graduation experience more enjoyable, says Lesniak.
Such a get-together should not be residency- or hospital-sponsored (and be clear about this while planning and inviting people to come). Make it casual dress and invite everyone involved in the residency program, including program directors, faculty members, nurses, and all residents. Have everyone chip in a small sum of money ($20 or so) and hold the event away from the residency site to promote its informal nature, says Lesniak.
12. For graduation gift, skip the customary chair
In many programs, it is customary to give graduating residents captain’s chairs adorned with brass tags as gifts for completing the residency. It’s a nice tradition, but it can also be a bit impractical, says Lesniak.
“Don’t do that because [the new graduates] travel too much. To take a chair wherever they relocate is going to be too difficult,” she says. Keep the gifts small and personal.
Enjoy the hard-earned fruits of the residency program’s labor. Follow these tips to ensure graduation planning is efficient and enjoyable for everyone—including you. H
Sample resident graduation formResident name:
_______________________________________________
Where will you work—hospital name, city, state:
_______________________________________________
_______________________________________________
Name of the physician group if there is one:
_______________________________________________
Academic or not: _________________________________
Full time or not: __________________________________
Fellowship: _____________________________________
New Home address:
_______________________________________________
_______________________________________________
Telephone: (_____) _____-__________
Email address: ___________________________________
New Hospital/business address:
_______________________________________________
_______________________________________________
Telephone: (_____) _____-__________
Email address: ___________________________________
Name of immediate supervisor: _______________________________________________
Contact information of supervisor:
_______________________________________________
May we list your name, position, hospital/business address information in our alumni list? _____Yes _____No
Source: Denise Lesniak, C-TAGME, medical education coordinator for emergency medicine at MetroHealth in Cleveland.
We’re seeking experts for books, audio conferences, and seminarsWriting books and speaking on audio conferences and at semi-nars are great ways to share your industry knowledge with peers. With the guidance of a solid publishing company, you’ll see your thoughts and tips become beacons to others in your field.
Contact me at [email protected] and let me know your areas of expertise and interests in publishing or training.
Please do not send unpublished manuscripts or specific proposals for future works. —Son Hoang, Editor
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6 |Residency Program Alert June 2017
Orientation planning: Preparing to prepare your new traineesby Crys S. Draconi, C-TAGME, education manager for neurosciences at Tufts Medical Center and independent consultant for C.D. Consulting. She can be reached at [email protected].
We all know this is a busy time of year with residents leaving and other residents getting onboarded. Just when you see the light at the end of the tunnel, you need to worry about orientation. Of course, nearly everyone says, “Just look at last year’s plan and copy it.” If only it were as simple as that. While drawing on previous plans is the first step in planning orientation, it certainly is not the last. Read on for 15 steps for planning and running a successful and fun orientation!
Step 1: Pull last year’s schedule
Find the previous year’s orientation schedule, whether it was you who planned it or someone else. Before you do anything with it, meet with your program leader-ship team, including rising chief residents. You should also have notes that were taken at the end of the previous year’s orientation regarding areas for improvement. Bring those notes to your meeting.
Step 2: Consider the calendar
Since the Fourth of July always seems to interfere with orientation somehow, factor in not only the holiday itself, but the working days you have available. Most institutions will have a day off for the holiday if the Fourth falls on a weekend.
Intern scheduling is a bit easier. Depending on your hospital, intern orientation typically starts two weeks earlier than other residents. Interns need to learn the basics, and there are a lot more trainees. Also, the departing and current residents will help to train the next class, so lead time is needed for this handoff.
Step 3: Find out when hospital orientation is
All trainees spend their first day in hospital orientation,
which is typically run by the GME office. Most of your residents’ questions about general information, includ-ing insurance, benefits, payroll, and parking, will be answered during this time. However, a trainee might experience a late start due to delays in visas, licensing, etc. If for some reason a trainee is unable to start by the orientation date, you will need to work with your GME office accordingly. It can be difficult for these trainees because there are so many important aspects covered in hospital orientation, so do your best to have them start on time.
GME offices will usually tell programs what their orientation days are months ahead of time, so be sure to put the date on your itinerary and notify your residents. Intern orientation dates vary from year to year, but post-graduate year two and above orientation always starts on July 1 or the closest working day to it. If the Fourth of July throws the July 1 date off, your GME will tell you when orientation begins. Your trainees usually cannot start prior to July 1, as their contracts and all liabilities become effective on that day.
Step 4: Determine program and department orientation locations
Find out where all of your trainees need to be oriented within your program structure. If you have a complex program with multiple sites (institutions), there will be orientation that needs to be done at each site. If your program is primarily at one institution, trainees might still need to visit multiple orientation sites if they have clinic or rotation at a satellite office. Make sure you check on this, and verify how it was handled in previous years.
Step 5: Start scheduling rooms and difficult-to-schedule items
You should look at previous orientation schedules and factor in notes or comments for improvement from last year. The hardest part is making sure you have all of your rooms scheduled. If your institution has key items that are hard to schedule, you might need to
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Residency Program Alert | 7June 2017
take them into account many months, or even a year, in advance—once they’re scheduled, you probably won’t be able to move them. Examples of these items include computer trainings, simulations, objective structured clinical examinations, large auditoriums, and outside venues.
It is a good idea to start building your schedule right on your itinerary. There are many moving parts as you schedule, including rooms, presenters, resources, other attendees, and of course food. Make a schedule that is split up by day and write down the times, orientation item, presenter, and room. (See Figure 1 for a sample.) Make another column to keep track of scheduling and related notes. This column can be deleted off of the final itinerary.
Also factor in any social events that might need to be catered or planned. You might need to book special venues for these events.
Step 6: Fill in the gaps
Now you can fill in items that are a bit easier to sched-ule—events that are in your own conference rooms or those that the personnel from your own program are expecting to be part of. Be sensitive of routine items that might conflict with your orientation plan. Remem-ber, even though orientation is something special, the rest of your program is still running as usual.
Make sure you take into account the notes on improvement compiled during previous years. Addi-tionally, the program might want to add some more events to provide the trainees with information.
Remember that most of the information you give your new residents during this time will likely be forgotten, simply due to information overload. Keep the informa-tion very broad, and limit it to what they need to know immediately. It is tempting to dish out everything at once while you have all your residents together with no scheduling conflicts, but limit yourself to need-to-know information, and plan on reminding or retraining residents once they have a better handle on why the information you’ve provided is important.
Step 7: Review the schedule with your program
Now that you are mostly done with the orientation schedule, review it with the stakeholders in your program: your program director, the associate pro-gram director(s), and of course your chief residents. During orientation, even if you do not have their names specifically on the schedule, these people are your representatives as well. They should be present as their schedule allows.
Keep in mind that you might need to make some adjustments to the schedule; don’t get frustrated, and be sure to offer your feedback. Just like everything else in the program, this is a team effort, and you are part of the team!
Step 8: Notify everyone who needs to be present
Let everyone know where you have placed them. You can send emails, the full itinerary, or calendar invites. I have found it most useful to send an email with the details to let people know what they are signed up for, then follow up with a calendar invite. If you send just a calendar invite, they might ask a lot of questions about what is expected of them. If you send just an email, they will forget later on. By putting it on their calen-dar, their email client will remind them of the event.
Step 9: Where’s the food?
Figure out what events will have food. You’ll need to take into account not only specific social events, but also any event where you’ll need to serve breakfast, lunch, snacks, and, of course, coffee and refreshments. Order from someplace reliable that is cost-effective. Stay within your budget, and see if you can find a place where you can save a few dollars.
Step 10: Send out initial notifications
Let everyone know where to go, be, and show up. You probably already notified all of your presenters, but double-check to make sure you did. Include information that the presenters will need to have as they prepare.
Make sure your incoming residents know generally when and where to be, but don’t send the full itinerary—
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8 |Residency Program Alert June 2017
just give them enough information to plan without making them too anxious. Chances are they are moving from another city, state, or even country shortly before orientation begins. They can better plan their moving period if they know when to show up for your program.
Remember to include information about locations, as they are most likely not familiar with the area or your institution and its structure. Also, if they are coming from another training program, they’ll need to make sure their program is going to let them out in time to start your program. This is especially true for interns, as their orientation starts two weeks earlier. Some interns might be doing a preliminary year that does not count toward training, and they might need to be released from it early.
Make sure current residents and the department know when they should be present to meet and greet the new residents. Make sure they know who the new trainees are, too! You probably can’t put your roster together yet, as most professional pictures are done during orienta-tion. However, you can assemble a mini-roster that includes the new trainees using their ERAS photos.
A “changing of the guard” email is also a great idea. This can tell current residents, and the entire depart-ment and program, all the happenings of the busy season. Include in this email:
• Who is graduating
• The last day for graduating residents
• Graduation events
• List of new residents with pictures, their medical schools, and previous programs to help current residents when talking to them for the first time
• The new residents’ first day and their first day in the department
• Orientation events that current residents and department members need to know about
• Meet-and-greet events
You might need to send this email out several times over the course of the season. In general, the first notification should be sent around mid-May.
Step 11: Reminders, reminders, reminders
Remind everyone! As we all know, something that is different from our normally busy days can be very easy to forget. Orientation is just that type of event. You will need to send several reminders.
The first reminder should go out about one month before orientation. This will put the event on every-one’s minds. If you are planning your orientation late, then a month out might be your initial notification, so in this case there’s no need to send a reminder as well. Scheduling your orientation a few months out is a better idea to ensure room and presenter availability, but sometimes it just cannot be helped.
Send another reminder about a week before orienta-tion. Any last-minute plans, preparation, and the dreaded—but hopefully rare—schedule change can be combatted at that time. Remember that trainees are likely moving around this time or getting ready to, so the reminder will be great for them. This will also let presenters ensure they are on target with their prepa-ration. Ask presenters to send you slides or give them instructions for special presentation materials. You probably won’t receive the slides early, but it doesn’t hurt to ask! Have a plan in place for presenters who bring their slides to their presentations.
Sending another reminder the day before orientation is a great idea, just to remind everyone where they need to be. There should not be any last-minute preparations involved here—it’s just a formal notifica-tion in case recipients have lost your other reminders.
Some presenters might need to be reminded the day of orientation. Not everyone will need this, but you should know which presenters might. Keep in mind that coordinators are swamped during orientation, so assign someone else in your office or have cell num-bers available to remind these people when they are about to present or if something is running late.
Step 12: Welcome packets
Prepare welcome packets a week before orientation. Talk to your director and chiefs about what should go into these packets if you are unsure. Remember what
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Residency Program Alert | 9June 2017
it was like for you on orientation day—no matter how the program tries to smooth the transition, trainees will be experiencing information overload. Expect them to retain about one-quarter of the information provided to them. Put backup documents in the packets that will support what is being said. This will ensure the trainees know where to find the informa-tion later. It also gives them a place to stick other items they will get throughout orientation.
Items you could include in the welcome packet are:
• Orientation agenda
• Program contact sheet
• Instructions to access the virtual private network, electronic medical records system (e.g., Epic, eClinicalWorks, and Sorian), and email
• Presentation slides, if available
• Instructions for residency management software (e.g., New Innovations, MedHub, and eValue)
• Instructions to access information for residents (e.g., shared drives, resident wiki, and Google Drive)
There’s no need to include name tags in the welcome packet, as trainees will most likely have their ID badges.
Remember, even if it seems like you are not putting enough in the packets, trainees will fill them up later!
Step 13: Dry run, if necessary
The day before, do a dry run. The trainees’ first day is usually hospital orientation, which you won’t usually be involved with unless you’ve volunteered, so you have that day to do any dry runs or final preps for the pro-gram orientation. (Regarding hospital orientation: Many GME offices will ask for coordinators to volun-teer to help with hospital orientation—it usually entails getting a group of people from one place to another. If you coordinate a large program with a lot of trainees starting, it is a good idea to volunteer. This will help the GME office and show your new trainees that your program and the GME office have a good relationship.)
You can do a physical dry run by actually walking around as if you were a resident. Go through the motions as if
everyone is there. This will help you note any necessary small changes in setup or flow ahead of time. Also, have meetings with your program leadership in which you go through every part of the agenda and discuss as needed. You should do the same with your chief residents.
The dry run will make you more confident about the day. You will have a better handle on answering questions throughout orientation—and you will be asked a lot of questions! You might think you know what questions you’ll be asked, but there are always surprises. Trainees like to keep us on our toes.
One more thing: Have contact numbers available to you. These numbers include catering, environmental services, the department that sets up the tables, security, audiovisual, your program director’s cell phone, your chief residents’ cell phones, and your department or office backup person.
Step 14: Orientation day
It’s here—the day for which you have prepared for months! Show up early. Have everything done before you arrive. Make sure the room is being set up prop-erly, especially if you are in a room that belongs to another department and you are depending on that department to set up.
Presenters will start showing up, so make sure all of your anticipated trainees are there. They might ask a lot of questions in the morning, but assure them their questions will be answered. Remember to be welcoming and friendly to everyone, no matter how stressed you get.
For the rest of the time, you are the timekeeper, the resource provider, and often the tour guide. Have a system in place (e.g., a signal) to let presenters know when they’re running over on time. For the higher-profile presenters (i.e., your chairman or other higher-ups), though, let them run over. The trainees will not have much face time with them, so take advantage of this opportunity. These presenters always have great advice!
If others do not remember to, continue reminding the trainees to relax, and let them know of the support system you have in place. As the orientation period
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10 |Residency Program Alert June 2017
by Deepak Gupta, MD, anesthesiology clinical assistant professor; and Sarwan Kumar, MD, internal medicine assistant professor, Wayne State University, Detroit
After enrolling in medical school, future physicians in the United States undergo multiple examinations before they are allowed to independently practice medicine. These examinations and processes involve medical licensing examinations, medical residency selection processes, in-training examinations (ITE) during residency, and medical specialty board certifi-cation examinations after residency. With an eye toward possible improvements among these processes, we have a few questions about the United States Medical Licensing Examination (USMLE).
Can the three-step USMLE provide the numerical
percentile scores in each discipline (specialty) tested during the USMLE Step 1 and Step 2 CK (Clinical Knowledge) so that GME residency programs can incorporate objectivity into their selection processes while also reviewing applicants based on their highly variable (but subjective) interest in the applied specialty?
Would doing that suggested expansion be logistically too much to ask from the USMLE? The currently generated performance profiles for the USMLE Step 1 and Step 2 CK very limitedly decipher the perfor-mances in all disciplines except for the five major medical specialties—medicine, obstetrics and gynecol-ogy, pediatrics, psychiatry, and surgery. Additionally, that limited data is currently non-numerical (i.e., lower, borderline, and higher) and for examinees’ eyes
Questions about the United States Medical Licensing Examination
comes to a close, you will notice their anxiety levels getting higher. If you are orienting interns, this is especially true. They have just received their medical degree and license, so they will be nervous at the prospect of really taking care of patients for the first time in their lives. For those who already did a prelim, there will be a little less anxiety, but this orientation will still represent the first time they get to treat
7:00 AM - 4:00 PM Hospital Orientation Main Auditorium Physical Location
Enjoy your Holiday
Figure 1: Sample orientation scheduleSAMPLE SCHEDULE
[Institution Name] [Program Name]
Orientation Schedule
Monday, July 3
Tuesday, July 4
Wednesday, July 5 7:00 - 7:30 AM Program
IntroductionsDepartment MeetingRoomPhysical Location
patients in their chosen specialty. It is exciting and nerve-wracking all at once.
Now you are prepared for your orientation—or mini-conference, I should say! Ask veteran coordinators and people in your program who took part in orientation in years past for advice. But remember, just because they “always did it that way” does not mean you have to.
Step 15: Debrief and wrap up
Once your orientation is complete, meet with your program director and chief residents within a week. Discuss what worked well and what needs improve-ment. Take notes and put them in your orientation folder for next year.
Schedule rooms that need to be booked well in advance. Send thank-you notes to all of the presenters and people who helped in planning. This is especially important for those not in your program—let them know that you will need their kindness again this time next year. Finally, congratulate yourself on another successful orientation! H
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Residency Program Alert | 11June 2017
only. Wouldn’t this expansion in USMLE transcript services be more cost-effective for the examinees, assuming that residency training programs can con-sider exploring alternative initiatives to costly but independent specialty-specific pre-training examina-tions—similar to American Board of Medical Special-ties’ ITE—to gauge applicants’ objective interests in terms of the specialty-specific knowledge acquired, tested, and scored? An example might be a pre-appli-cation independent test in anesthesia knowledge based on either the Anesthesia Knowledge Tests conducted by Metrics Associates Inc., or the ITE conducted by the American Board of Anesthesiology.
Why can’t the three-step USMLE mandate (instead of just recommending) Step 3 application postponement until after the applicant has enrolled in a GME residency training program within the United States or Canada, when the USMLE has correspondingly enforced that Step 1, Step 2 CK, and Step 2 CS (Clini-cal Skills) can be taken only if the applicant has enrolled in or graduated from a medical school at the time of application submission, as well as at the time of the examination?
Why does the USMLE need to transmit applicants’ Step 3 scores to the applied residency programs when Elec-tronic Residency Application Service (ERAS) eligibility doesn’t even mandate completion of any USMLE step before applying to ERAS? Even the National Resident Matching Program’s (NRMP) Main Residency Match only mandates the completion of Step 1, Step 2 CK, and Step 2 CS, while excluding Step 3 completion.
Why do GME residency training programs need to expose themselves to selection bias based on their awareness of applicants’ USMLE Step 3 status? Residency training programs can always defer access-ing the applicants’ Step 3 examination results until after Match Day. And only thereafter, knowledge about the matched applicants’ completion of USMLE Step 3 might be required prior to applying for H-1B visas, as compared to the more preferred J-1 visas, which are potentially not affected by applicants’ USMLE Step 3 status.
What is the purpose of completing USMLE Step 3 after
medical school graduation (from within or outside the U.S. or Canada), given that the completion of GME residency training is almost certainly a must before one can practice medicine independently in the U.S.?
Is passing the USMLE Step 3 essential for fellowship applicants if certain fellowship programs plan to select fellows despite non-completion or absence of GME residency training within the U.S. or Canada?
Does passing the USMLE Step 3 (regardless of uncertain concomitant completion of GME residency training) ensure the availability of doctors of medicine (MD) who lack residency positions for a contingency plan wherein they might be called upon to help ease unexpected shortages of residency-trained MDs?
Can any GME residency training program ever allow its residents to graduate from its program without the completion of USMLE Step 3? This is highly unlikely, considering that passing the USMLE Step 3 is a must for MDs to independently practice medicine in almost all state medical licensing authorities’ jurisdictions. Also, considering the duration of GME residency training is at least three years, it can be tough for residents to fulfill most of the state medical licensing authorities’ require-ments to complete the three-step USMLE processes within seven years or so after processes have been started during the residents’ four-year stint in medical school. The Educational Commission for Foreign Medical Graduates certification process itself places a lenient (and seemingly illogical) seven-year time frame on passing the USMLE Step 1, Step 2 CK, and Step 2 CS before the international medical graduates (IMG) can take USMLE Step 3.
Was the USMLE Step 3 always envisioned to be com-pleted after residency training to test examinees’ readi-ness to practice primary care, even though the stated emphasis of it as an assessor is only toward assessing the their readiness for independent ambulatory patient care?
Did the exhaustive preparatory processes for ITEs during residency, and for the certification examina-tions after the completion of residency training, force the USMLE Step 3 to be stuck in a no-man’s land between the NRMP deadline (January–February) and the GME residency training start date (June–July)?
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12 |Residency Program Alert June 2017
How might the specialty-driven practice of modern medicine have made the completion of the three-step USMLE redundant as a stand-alone medical licensing prerequisite until it accommodates state medical licens-ing authorities’ requirements for residency enrollment and thereafter state healthcare facilities’ prerequisites for medical specialty board certification before allowing licensed physicians to practice medicine in the U.S.?
Can the redundancy of USMLE Step 3 completion without residency instigate such MDs (often IMGs) to ask for alternate options, such as eligibility to practice as assistant physicians or physician assistants (with or without physicians’ supervision)? And if opened to non-U.S. citizen IMGs, would this be seen as encroaching on U.S. citizens’ physician assistant jobs?
Will the USMLE consider self-analyzing its data to quantify the number of medical graduates who have completed the USMLE process but never got into GME residency training programs, especially if that cumula-tive number is large enough to propose avenues for these potential “physicians” as a temporary solution to North America’s shortage of primary care physicians?
In summary, the processes of selecting and licensing the future specialists in medicine continue to amaze us, because one of the primary intentions behind these exhaustive processes is to ensure future physicians are matched to the medical specialties in which they can sustain unrestricted license to practice, potentially throughout their lifetimes, while balancing their work with personal happiness and societal satisfaction. H
GME news roundupFind out what’s happening in GME by reviewing a few recent residency headlines from across the country.
Medical resident guilty of writing fake prescriptions for painkillers
A former medical resident at St. Louis University Hospital has pleaded guilty to illegally writing pre-scriptions for opioids. According to the St. Louis Post-Dispatch, from November 2014 to February 2016, Kyle Betts wrote more than 70 fraudulent prescriptions for painkillers using the names of family members and former romantic partners.
Betts was indicted earlier this year on three felony charges of obtaining a controlled substance by fraud or forgery. According to his plea agreement, Betts pleaded guilty to one felony count of obtaining prescription drugs that contained controlled substances through misrepresentation, fraud, forgery, deception, and subterfuge. He faces up to five years in prison and a $250,000 fine. His sentencing is scheduled for August 17.
Study: Role modeling a barrier to cost-conscious care
A survey of 3,395 students at 10 medical schools found that 90% of respondents believe physicians have a
responsibility to contain healthcare costs, but nearly half also said they would rather order a test than explain why it is unnecessary. The results of the survey, published in Academic Medicine, found that most students observed physicians displaying poten-tially wasteful role-modeling behavior, such as order-ing several tests at the same time (instead of waiting for initial screening test results) and repeating tests instead of obtaining recent test results.
Students did report seeing physicians model cost- conscious behaviors too. About 90% of respondents reported seeing a physician explain to patients why a test was unnecessary, point out examples of waste, and discuss the costs of care with team members when making care decisions.
Advocacy campaign brings more GME spots to Virginia
An additional $2.5 million in Virginia’s 2017 budget will be distributed throughout the state to fund 25 new residency slots beginning July 1. The additional funding was the result of a campaign by physicians, residents, and medical students. Beginning in 2014, advocates for increased GME funding reached out to state legislators through email, social media, and face-to-face meetings to
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Residency Program Alert | 13June 2017
educate them about the role of residents and how GME expansion would ultimately improve the quality of life for the state’s population.
Last year, the advocates received notice that additional funds had been approved for the 2017 state budget. The funding will be used for 13 new primary care and 12 new high-need specialty positions, with a preference for underserved areas.
Incidences of hospital-acquired conditions increased following duty hour reforms
An assessment of the frequency of hospital-acquired conditions (HAC) before and after resident duty hour reforms were instituted found that patients had a 10% increased likelihood of HACs post-reforms. In 2003, the ACGME instituted an 80-hour weekly limit for resident physicians. The retrospective analysis, published in the Journal of Graduate Medical Education, examined data from 2000–2002 and 2004–2006 and evaluated the occurrence of HACs in academic and non-academic centers.
Patients admitted to teaching hospitals after imple-mentation of the ACGME reforms were more likely to contract a HAC. There was no corresponding change found in non-teaching institutions.
Major teaching hospitals associated with lower mortality rates
Medicare patients at major teaching hospitals have better 30-day mortality rates for 15 common medical and six surgical conditions compared to patients at minor teaching hospitals and nonteaching hospitals, according to a recent study in the Journal of the American Medical Association.
Using Medicare data from 21.4 million hospitaliza-tions, the researchers found that the unadjusted 30-day mortality rate at major teaching hospitals—those that are members of the Council of Teaching Hospitals—was 8.1%. The mortality rate at minor teaching hospitals—those with medical school affilia-tion—was 9.2% and 9.6% at non-teaching hospitals. The study did not explore reasons for the differences in mortality rates. H
Questions? Comments? Ideas?
Contact Son Hoang, Editor,
Residency Program Alert at [email protected] or
by telephone at 978-624-4600.
