the mess in akron

Sunday, April 9, 2017

The road to the Final Four culminates in a national holiday and it is also an opportunity for many to consider the plight of the student athlete. While their skill allows coaches and colleges to make millions, the players do not share in the bounty and very few will go on to play professionally. A student athlete is bound by the many rules and regulations of the NCAA and often has little recourse should the coach leave, the school be placed on probation or any myriad other issue that might arise.

But it’s not only college athletes who may fall victim to arbitrary rules that are more about money than equity. Consider the situation of emergency medicine residents training at the Summa Health System in Akron, Ohio. Their training program has been placed on probation by the Accreditation Council for Graduate Medical Education (ACGME) and may lose its accreditation on July 1. The residents in the program could transfer to another hospital or university program but unless they are granted their released by Summa, their new employer won’t get paid to teach them and likely would not open up a spot on their “roster.”

Some background about how medical education works. After graduating from medical school, newly minted doctors continue their postgraduate training as residents at teaching hospitals. Depending upon the specialty, that training can last three to seven years or more. Like an apprenticeship, as the doctors gather more experience in caring for patient, they are given more responsibility and less supervision until at the end of their training, they can care for patients independently. In addition to seeing patients, the hospitals are required to have teaching physicians who are responsible for lectures and research to expand the new docs’ knowledge base beyond what was taught in medical school. Medicare funds those residency teaching programs, including resident salaries and hospital expenses associated with their teaching, from the professors to the office support staff. And to be funded, a teaching program needs to be accredited by the ACGME.

The Mess in Akron

In Akron, Summa, a major teaching hospital, underwent an unusual change in their emergency department on January 1. The incumbent group of emergency doctors who had practiced there for 40 years was replaced by another. It wasn’t about the quality of patient care; it was about a contract coming due, a dispute over money and who would be paid what. The hospital announced a hastily arranged bidding process to find a new group of ER doctors, with a request for proposal due on December 29. The incumbent local group was not chosen and a new national company was awarded the contract that began on January 1. Normally, there is a transition period that lasts 3-4 months so that there is minimal disruption to patient care. In Akron, Summa arranged for a new set of docs to start 48 hours after the contract was awarded. Unfortunately for the emergency residents who were caught in the crossfire, the new group did not hit the ground running when it came to teaching and providing academic structure and supervision. On February 8, the ACGME placed the residency program on probation.

In the world of the NCAA, players have little option when a coach leaves or the college changes its promise to a student athlete. The education opportunity may remain, but the opportunity to play or compete may be lost. Perhaps a worse situation now exists for the emergency medicine resident trainees in Akron. There is no guarantee that their program will regain accreditation and if that accreditation does not occur, those same doctors will not be able to take their board exams so that they can call themselves specialists. Training has to occur in an approved, accredited program to count. And yet, if they try to find another place to train, there may not be funds to allow that to happen, because the hospital can, in effect, block the transfer. It sounds a lot like a student athlete wanting to transfer to another college but can’t because they were being blocked by their coach.

Medical students often begin their journey filled with optimism. As they progress through four years of medical school and then more years of postgrad training, it takes a lot of work and emotional capital to maintain a level minimum level of altruism. For those caught in the Akron mess, it is a sad reminder that too often money takes precedence over common sense, and while it’s hard to consider physician as victim, perhaps this might be one time when it is true.

Reference:Annals of Emergency Medicine April 2017


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the medical draft

Friday, March 10, 2017

The sun sets on the first day of this year’s NFL free agency as rejoicing, and perhaps mourning, breaks out through the country with each team’s fans praying that this…might…be …the…year!  Hope springs eternal for the next season after seminal events in each sport. Whether it is the NCAA signing period bringing high school stars to campus, or the trade deadline in the NBA and NHL where a final push to the playoffs might be a reality. But there is another draft that is happening now that will likely have a much more tangible effect on people’s lives…literally.

The 2017 National Residency Matching Program (NRMP) releases its results beginning March 13 and the lives of thousands of medical students and millions of patients will be forever changed. In the fall of 2016, at the beginning of their fourth and final year of medical school, more than 40,000 soon to be doctors begin the application process for residency training slots and the start of graduate education. Almost 5,000 teaching hospitals offer more than 30,000 training opportunities in every specialty of medicine, from surgery to ophthalmology, psychiatry to family practice, pathology to whatever other type of medicine you can imagine.

The process is relatively simple. The medical students apply to a residency program (usually more than a few), visit and interview at a couple and then on February 22 send their wish list to the “Match”. Residency program directors, and their staff, sift through the applications, medical school grades and interview performance to decide where they rank the soon to be doctors o their draft board and submit their list as well. NRMP computers do the rest, and next week marriages are announced. There will be some rejoicing, some sadness and some mourning. A few students won’t be matched, but like the NFL, there is a supplemental draft since some programs also don’t fill their positions.

But why should the rest of the world care; it’s not like fans fill a stadium every Sunday and have fantasy resident teams based on how well a new doctor cared for a patient in congestive hear failure or assisted on an operation. Aside from the direct care that the residents provide at a teaching hospital, the results of the Match might alter the landscape of a community for a generation to come. Training can last 3 to 7 years or more and during that time, these new doctors start families, put down roots and often tend to stay in the area where they did their training.

The young fourth year medical student that interviewed at your local hospital might be the surgeon who is emergently operating on you in ten years. She might be coaching your basketball team or he might be running for school board. These are the new young professionals who become the fabric not only of the medical community but also of the community as a whole.

Unfortunately, there is a cloud that hangs over this year’s Match. Because foreign medical graduate students also participate in the Match in search of US quality training, there has been concern raised by the NRMP that travel restrictions for some might affect their ability to begin training on the traditional start date in July. From the NRMP press release:

  • …This uncertainty leaves programs the choice of not ranking qualified applicants or risking empty training slots on their program start date. Even if the ban ends after 90 days, there is concern that the consular interviews that are required prior to obtaining visas will be so slow that affected applicants will not be able to start training on time. There also are concerns about whether residents and fellows who are in the U.S. on visas will be able to remain in their training programs. 
  • The consequences of the Executive Order are far reaching for Match applicants, and the upheaval it is causing is extensive. The affected applicants have worked hard for many years to achieve their goal of becoming physicians, and they should not be denied that opportunity because of a blanket policy that does not consider the individual. Similarly, U.S. training programs should be able to select applicants based on their excellent character and qualifications, without regard to nationality. Both applicants and programs benefit from an orderly process for entry into graduate medical education. The Executive Order disrupts that process very considerably.

As NFL free agency winds down and the hype of their draft begins, teams begin reshaping their team to become more competitive in the coming years. The NRMP  allows hospitals and communities to do the same thing when it comes to the quality of medical care available. Perhaps it might be time to appreciate the medical draft that touches health and welfare of thousands of communities in the US. Knowing that your local hospital has filled their training slots in family medicine and surgery should make you feel a little safer for the next thirty years. Wit hall that is at stake, it is surprising that the Match isn’t must watch reality television. I wonder if ESPN might be interested?


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