With the fight to tame the COVID-19 pandemic ongoing, medical schools are graduating students early to strengthen the workforce within their health systems.

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For most schools, this groundbreaking step is in response to historic circumstances. For Oregon Health & Science University School of Medicine (OHSU), off-cycle graduations are an initiative the medical school has already examined and implemented. In 2018, 25% of the medical school’s fourth year students graduated early. In 2019, that number was 48%, and in 2020 it was 68%.

A recent AMA Innovations in Medical Education Webinar, featuring speakers from NYU Grossman School of Medicine (NYU), the AMA and Oregon Health & Science University, looked at how early graduation is being approached. A recording of the webinar is available in the resources area of the Accelerating Change in Medical Education Community (registration required). The community also is host to an ongoing discussion with leaders in medical education about the impact of the COVID-19 pandemic on training.

Time-based advancement

The AMA and member schools of its Accelerating Change in Medical Education Consortium have long advocated for medical school graduation to be based on competency attainment rather than time.

Initiatives like the Program to Accelerate Competency-Based Education (PACE) at OHSU, a consortium member school, have worked to follow a competency-based approach to medical education advancement that includes frequent and rigorous assessment of readiness.

The 104 OHSU students who graduated early this year did so after all graduation requirements were met. This differs from other programs that fast-tracked graduation this year and were asked by the Liaison Committee on Medical Education to find activities that might meet requirements for graduation across a school’s curriculum in instances where students had not yet met those requirements.

“Those students over a four-year period experienced a different way of learning,” George Mejicano, MD, OHSU’s senior associate dean for education. “And more importantly, a different way of progressing with regards to their medical education.”

OHSU’s medical school curriculum includes several mechanisms, such as allowing students with health professions experience prior to entering medical school to skip portions of clerkship training, that create a track on which students can graduate at a faster pace.

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What do OHSU’s early graduates do?

While most of OHSU’s early graduates have time in between the completion of medical school and the beginning of residency training, the PACE program’s aim is to change this reality.

“One of the questions we often get when we detail these concepts is why would these students graduate early if there’s no place to put them?” Dr. Mejicano said. “Our goal is certainly to have them enter residency off cycle. But there are other options whether it’s personal enrichment, building skill sets or potentially even earning some money that they may need. The idea is that there are many things an early graduate could potentially do even if they are unable to start residency early.”

The key change during the COVID-19 pandemic is that a small number of OHSU’s early graduates, who matched with residency programs at OHSU, are being afforded the opportunity to start their graduate medical education training early.

“The COVID-19 pandemic has opened the door a little wider to implementing competency-based, time variable progression,” Dr. Mejicano said. “Early graduation not only is feasible; we can now couple it with early start of residency training. But it has to be done carefully and be done in a system that will allow that to occur without disturbing patient care and distracting the health care professionals taking care of these very sick patients.”

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How OHSU is advancing this year’s early graduates

In total OHSU is moving six graduates who matched with three programs at the institution to residency begin their training early. The move is less aggressive than other institutions, some of which are allowing any early graduate to work in their health system during the time window between their graduation and the beginning of their formal residency training.

Local realities have allowed OHSU to be judicious with advancing students into residency training early.

“The situation in New York city and the situation in Portland, Oregon, is quite different,” Dr. Mejicano said. “We have nowhere near the level of COVID-19 patients that they are seeing in New York or New Jersey. We have been fortunate that way.”

Some key differences to what OHSU is doing that other institutions calling on early graduates are not, include:

Staying local: Early graduates who start residency at OHSU early must have matched at a residency program within OHSU’s health system. Of the 104 graduates, that included 18 students. Students who matched elsewhere will not be working at OHSU prior to starting another residency.

Capacity is key: Three OHSU residency program directors said they had the bandwidth to on-board early graduates. Meaning the majority of programs were unable to do so.

Workload: Early graduates will do the rotations the same as any new resident and do so based on the instruction of their program director. At other programs taking early graduates, those students may treat COVID-19 patients. “What the program directors have told us is they are actually going to deploy these brand new interns in other areas so that more senior residents can be deployed into the areas of greater stress and need because of the pandemic,” Dr. Mejicano said.

Early residency completion: Students who graduate early and begin residency early will be on track to complete their training earlier than residents who begin training on the traditional July 1 start date.

The AMA has curated a selection of resources to assist residents, medical students and faculty during the COVID-19 pandemic to help manage the shifting timelines, cancellations and adjustments to testing, rotations and other events at this time. The AMA has also issued guidance on early graduation and trainee safety during the COVID-19 pandemic.

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