GME and the physician pipeline with Sanjay Desai, MD

Moving Medicine

GME and the physician pipeline with AMA Chief Academic Officer Sanjay Desai, MD

Aug 2, 2023

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Are there enough GME programs to sufficiently meet the needs of residents and what are some innovative programs to advance resident training? This Moving Medicine episode, in collaboration with the PermanenteDocs Chat podcast, is hosted by family physician Alex McDonald, MD, featuring guest Sanjay Desai, MD, chief academic office and group vice president of medical education at the AMA.

Speaker

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

Host

• Alex McDonald, MD, family medicine physician and host of PermanenteDocs Chat, Kaiser Permanente

Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.

Unger: Welcome to Moving Medicine—a podcast by the American Medical Association. Today’s episode was produced in collaboration with the PermanenteDocs Chat podcast, featuring Dr. Sanjay Desai, the AMA’s chief academic officer. Here’s the host of PermanenteDocs Chat, family medicine physician, Dr. Alex McDonald.

Dr. McDonald: Hello everyone. Welcome to 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 KP. 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. So, I'm very excited to welcome our host, or excuse me, I'm your host, 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 Chief Academic Officer and Group Vice President of Medical Education, Dr. Sanjay Desai. So, Dr. Desai, welcome so much to the podcast and thank you for being here.

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

Dr. McDonald: Wonderful. For any out there listening live on the webinar, if you have questions, please drop them in the chat—excuse me—in the Q&A and we'll get to as many as we can. This is going to be pretty quick. It's about 20-minute discussion, so get your questions in early and we're just going to jump right in here. So, Dr. Desai, in your own words, tell us who you are and what you do.

Dr. Desai: Thank you. Actually, GME is my home, so this is a great topic to be part of. I'm—as you said—the chief academic officer at the AMA and 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 and critical care medicine. So, I still do clinical work there and all of my professional activity really was in GME, and July 1 was the day of the year that that was most important to me. So, it really is, being in July is a celebratory month I think in many different ways. Here at the AMA, Dr. McDonald, we do four 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 and GME. We actually are the co-sponsors also of the LCME.

There's a whole alphabet soup I think that probably people are aware of, but LCME is an important one. Yeah, that's the organization that accredits MD granting medical schools in the country. And so, we're a co-sponsor of the LCME. We also have a large effort in innovation and that's really where much of our work and creativity 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 as well. And so there are multiple areas. The last one, which is not GME, is we actually look after the CME credit system as well in the country. So those are all AMA professional activity credits that the physician reward activity credits that people seek in CME.

Dr. McDonald: 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.

Dr. Desai: Now, I like the way you said it because we too often think about medical education and compartments, and those compartments don't talk to each other very well and that leads to these really abrupt transitions. I know going to focus on GME, but once you getting into it is abrupt and then 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.

Dr. McDonald: Yeah, that makes perfect sense. One thing, as many of you on the ... listening know that I'm one of the faculty members for our family medicine residency in our sports medicine fellowship here, and one of my things I always impress upon my residents is the fact that if you ever get to the point where you feel like you don't have to look things up or you feel like you know everything, then something has gone horribly wrong and that you should be continuing to be learning and continue to look things up and learn for the rest of your career. And that's really what is probably, I think, most challenging but also most rewarding about a career in medicine.

Dr. Desai: I absolutely agree. I mean, 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 you’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, is to try to create and bring back that joy of learning and make it easier for us to do that. I mean, think there's no time now when 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 hopefully we can bring that energy to this.

Dr. McDonald: Exactly. Well, you mentioned innovation and so let's kind of start there. Graduate medical education has been growing and evolving. There was … restrictions about 10 years ago, which sort of threw everything on its head, but there've been multiple other changes and maybe a little bit more incremental since then. So, tell me, what are some of the most innovative changes within GME in the last couple years and then also what might be coming in the future or in the near future?

Dr. Desai: No, that's great. I think we're finally making progress and we need to make much more against what really matters in GME. I think 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 four years of medical school and you go through X number of years of residency as deemed appropriate 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. And the simple way I explained it is if you ask any patient what would they 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, but that's where innovation is occurring. There's innovation in the UME space, the medical school space, and there are multiple schools that have gone and started to implement competence-based medical education. In fact, some like OHSU have been graduating the vast majority of their students before four years because they have a rigorous competency-based model. It gets much trickier when you get to GME. So residency is 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 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 of workforce because you keep them employed even though they go forward. And so that's still nascent in its evolution. There's another model at Stanford with emergency medicine using competency-based medical education. So the 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 that in which we immerse these trainees so that we can do this more effectively.

Dr. McDonald: Yeah, I think that's such an interesting point about 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 kind of 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 kind of cognitive functions.

And everyone has a different place along that spectrum of the multiple different aspects of which we expect people to have skills when they graduate. And so rather than 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 sort of saying, "Here's what you have to know, read this book."

Dr. Desai: I think it's exactly right. So, 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. So, in medical school, the two people, one who majored in biochemistry, 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, as you know, 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, the goal is to bring back and fuel, and feed that curiosity. So, you want people to learn continuously that what happens because of randomness of one size fits all is that they have these decelerations in their development because you're in an environment where it's 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? And so, one way to do that and from an innovation perspective is what we're really heavily investing in now is called precision education. So, it's bringing the right education to the right person at the right time. And Dr. McDonald, that was really hard to do before because we didn't have the data and technology to do it well. But if you think, many kids are using Khan Academy now. 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. And so, bringing those types of models to medical education is one of our aspirations. And we're working with a number of schools that are actually moving pretty fast in this space. So, it's pretty fun.

Dr. McDonald: 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 just wellness, physician wellness, resident wellness. And if you're being forced to do menial tasks which don't meet your need, which 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 there, and 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 attendings also, quite frankly.

Dr. Desai: And you link two really important notions that we're thinking about together here and they're interdependent, one is burnout. I would, and 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 and I feel that viscerally. When you think about that, what a tragic situation that we're in. And that's fueled by burnout, which is fueled by the admin and all the other work environment circumstances that we're in. So, 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. And so, we are doing work in this space. In fact, we started about 10 years ago developing what we call the third pillar of medical education, health system science.

So, there's clinical sciences, there's basic science and there's health system science. And actually, 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. And so, 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.

And there are a number of the mental health, so we were strong advocates for the Lorna Breen legislation that just came through Congress trying to take all of the stigmatization of mental health off of credentialing and off of licensing. That's another important step that again, is upstream and administrative. Thinking through prior auth, and all 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.

Dr. McDonald: Yeah, that's so true. I got a chance to actually meet Dr. Lorna Breen's brother-in-law, actually, 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 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 kind of chaotic, high pressured world where—let's be honest—lives are at stake and how can we help provide some sort of autonomy or at least sense of locus of control, which we know is a recipe for burnout and challenges with our residents. Do you have any thoughts regard regarding that ability?

Dr. Desai: No, I think 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? And again, we stopped 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 believes we want them to learn and that's why they're here. But we have certain number of physicians that need to take care of 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 will continue and 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 dependency so that we can 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 base, there's university base. They're funded by different mechanisms, most by Medicare as you know, but also by other mechanisms as well. So, it is a fragmented system that's hard to have one solution for it.

I mean, if it was easy, obviously we would've figured this out sooner, but I would say along with you that the need to figure this out is urgent. And so, I think that starts in 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. And 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 for, generalizably better, for residents in the country.

Dr. McDonald: So just like health care in general, it turns out that GME is complicated also. Well, it's funny, actually, I did my intern year at a very large academic institution that really relied very, very heavily on their resident workforce. And then I came actually 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 I got things out of both systems. I'm not going to sugar coat it, but one was maybe a little bit more gentle than the other. Let's put it that way. So, your point of—

Dr. Desai: I think, just on that point, I think that you used 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 healthier or less burnout, but I don't think they're always what we think that they are. So, for example, work hours comes up often. And so, what we know is when you look at the U.K. or when you look at other countries that have much more strict work hour regulations, the burnout is equal or higher, right, than this environment. And 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 is one of the factors for sure. But I think it's hard to say or I think it's not possible to make a linear relationship from any one attribute and say, "If we change this one, this will bring..." Because what we need to do is we need to bring back meaning, we need to 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 where the paper chart was. And I'm not advocating that we go back to paper charts, but in the world of EMR, how do we bring that experience back? How do we bring back the time that we spent with patients so that we can get the joy of knowing them and feeling the reward of helping them?

So 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.

Dr. McDonald: Yeah, I completely agree with you. And perhaps gentle isn't the best word but having more meaning. So, I completely agree with you that it's about that connection and that meaning, 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 that we need for our country both now and in the future as the baby boomers are getting older and older?

Dr. Desai: That's such an important question. Again, we are a self-governed profession, so 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 anytime in the near future going to have a physician workforce that's capable for caring for all of our patients and communities. It's just the reality of having a self-governed 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 have to go way upstream, well before GME, 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. And so, this is equally urgent. It's just that the effects won't be seen for some time.

Dr. McDonald: Right. Wonderful. There was a question here in the chat that I want to get to as well too. 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?

Dr. Desai: Yeah. Well, I mean, I hope what we can let them know is that we are going to create a system that lets them care for patients and meet the aspirations that they have for pursuing this field. In terms of what they should know, 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? So, for me, it would've been spending more time with communication, or it may have been more time with underserved or more communities. Those skills that really, 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 those spaces 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 the gate, you 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 environment to let them pursue that.

Dr. McDonald: Yeah. Well, that's so well said. Every system is perfectly designed for the result that it gets. 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?

Dr. Desai: 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 it is, I mean, every day, 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 think that's wonderful. 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 eliminate anyone else in that exam room. 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. And so, they are tireless in their mission and activity, and advocacy to bring back that relationship between a physician and their patient. And so that makes me proud.

Dr. McDonald: That is just the perfect ending for today's chat. Thank you so much. I feel like we just scratched the surface. We'll have to have you back again sometime.

Dr. Desai: I would very much enjoy that.

Dr. McDonald: Well, thank you so much for Dr. Desai for joining us today, sharing your expertise and your insights.

Dr. Desai: Thank you very much.

Dr. McDonald: The views expressed in this podcast are those of the speaker and are not meant to represent the views of the Permanente Federation, the Permanente Medical Groups or Kaiser Permanente.

Unger: Subscribe to Permamente's Docs Chat podcast to never miss an episode or register to take part in upcoming live chats. Visit permanente.org/amadocschat.

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.