These are heady times in medical education. Health systems science is taking root in medical school; AI is helping medical students learn on the fast track; and leadership opportunities are helping undergraduate learners transcend their clinical training.
But while there is often ample room in undergraduate medical education (UME) to innovate, graduate medical education (GME) can be a tougher environment for change-making because of its rigid service demands and financing.
A peer-reviewed supplement to the May issue of Journal of Graduate Medical Education highlights learnings from a six-year, $20 million effort funded by the AMA to transform GME through collaborative innovation.
The supplement—“Reimagining Residency: An American Medical Association Initiative to Transform GME”—features in-depth summaries of 11 projects in different geographic areas, at institutions large and small, and across numerous physician specialties.
The articles focus on real-world applications of ideas to address pressing issues for trainees, program leaders, health care systems and patients.
“As you delve into the supplement, we challenge you to dispel the belief that ‘this can’t happen here,’” the supplement’s editors wrote. “Our purpose is to encourage readers to consider the possibilities for transformation in their own environments. We hope you will find an idea to catalyze reflection and encourage adaptation to fit your needs.”
Building on success
All the projects highlighted were funded by the AMA Reimagining Residency initiative, which grew out of the AMA Accelerating Change in Medical Education initiative, a five-year effort launched in 2013 to modernize UME that awarded $14.1 million in grants to 37 medical schools with some 23,000 medical students.
“As it wound down, in 2018, we wondered: Can we do something like this in GME?” said John Andrews, MD, vice president for GME innovations at the AMA.
“We set three goals for the initiative,” Dr. Andrews said. “We wanted to improve the transition from medical school to residency. We wanted to better prepare residents for independent practice. And we wanted to support well-being in the learning environment for residents and all the people who work with them.”
More than 300 U.S. entities with oversight of GME applied for grants. From those, 11 projects made the cut. It was originally a five-year program, but an additional year was given to select projects because of interruptions stemming from the COVID-19 pandemic.
Embracing the vastness
Variety was a key feature of the initiative, Dr. Andrews said, noting that one of the projects was a collaboration with a medical society.
“I don't think it was in our minds that we would do that when we initially sent the RFP [request for proposals],” he said. “We thought we would be collaborating with institutions and GME programs. But this proved to be uniquely productive because they had influence over their entire specialty across the country, and it effectively raised standards and established some consistency around the residency application process, which wouldn't have been possible working with a single program or even a couple of institutions.”
Another project explored putting resource-locator badges on a resident program’s interns to learn where they spent every minute of their days.
“They gathered over 300,000 hours of data about where residents spend their time,” Dr. Andrews said. “One thing that's fascinating is how much variability there is. In a class of 20 interns, you've got one intern who spent 9% of their time at the bedside and one who spent 15% of their time at the bedside. “It raises questions about whether that difference in exposure leads to any differences in the evolution of clinical skill or well-being.”
A third was an effort to examine the feasibility of time-variable advancement out of residency and into independent practice based upon the attainment of competency rather than traditional time in service.
“They raised the bar for the debate about competency-based medical education, which is something we've been talking about for 20 or 30 years now,” he said. “They demonstrated that this is feasible and created a roadmap for programs that might consider this going forward. There are a couple of other specialties that are now interested in creating models like this.”
Connecting the dots
The Journal of Graduate Medical Education supplement features a dozen additional articles, each a collaboration between multiple principal investigators.
“Rather than have a dry accounting of the individual projects, we asked the principal investigators to collaborate to draft manuscripts that described common challenges or areas of common interest or ways that their projects were synergistic,” Dr. Andrews said.
But don’t expect a collection of victory laps, he noted.
“It certainly is a theme that not all of the projects ended up where they thought they would,” he said, noting that the grants allowed for course changes because the overall goal was to learn what works.
“You come up with a good idea and you say: This is the goal, and this is how we're going to get there. And then reality sets in and you realize that's not feasible,” Dr. Andrews noted. “What our projects did well was they maintained their focus on what they were trying to innovate around, but in many cases, they changed their approach or their tactics as they learned about the practical implications of things they had proposed. That ability to pivot without abandoning where they were trying to go was a real strength.”
The other articles in the supplement are:
- “Reimagining Residency: An Initiative to Transform GME Through Collaborative Innovation.”
- “Large Language Model-Augmented Strategic Analysis of Innovation Projects in Graduate Medical Education.”
- “Coaching in GME: Lessons Learned From 3 Unique Coaching Programs.”
- “Training More Physicians for Medically Underserved Communities: The Power of Regional Medical Education Collaboratives Across the Training Continuum.”
- “Integration of Interprofessional Education Into Routine Resident Practice: 2 Cases of Successful Implementation.”
- “Seven Tips for Successfully Operationalizing GME Innovations at the System Level: The iPACE Experience.”
- “Avoiding the Storm: Recommended Practices for Building Cross-Institutional Teams and Collaboration in Graduate Medical Education.”
- “Change Management and Innovation in Graduate Medical Education.”
- “Systems-Based Practice and Health Systems Science in Graduate Medical Education: Recommendations for Embracing This Critical Core Competency.”
- “Program Evaluation for Graduate Medical Education: Practical Approaches From the Reimagining Residency Evaluation Community of Practice.”
- “Implementing the 5 Core Components of Competency-Based Medical Education in US Emergency Medicine Residency Programs.”
- “Lessons From Reimagining Residency and the Future of Innovation in Graduate Medical Education.”
“We hope the variety of projects represented and the environments in which they took place give people the courage of their convictions and they think: I had an idea like that—maybe I can pursue it,” Dr. Andrews said.
Funding from the AMA might have kicked off the effort, Dr. Andrews noted, but it was the collaborative spirit among the principal investigators that gave the initiative legs.
“I don't have any illusions that a $20 million investment on the part of the AMA is going to suddenly be replicated in institutions all across the country,” he said.
He said he hopes this AMA-funded work will create “a sense of potential that if someone has a good idea and people to talk to about it, there are ways to move it forward.”
A Journal of Graduate Medical Education podcast features a conversation with three contributors to the supplement.
