Kroboth, Frank J. MD; Zerega, W. Dennis EdD; Patel, Rita M. MD; Barnes, Barbara E. MD; Webster, Marshall W. MD
The University of Pittsburgh Medical Center has seen continuous growth in the number and types of graduate training programs not accredited by the Accreditation Council for Graduate Medical Education (ACGME), the American Board of Medical Specialties, or the American Osteopathic Association. For the purposes of ensuring best educational products and of controlling unrecognized competition with our accredited programs, a sequential process of centralized oversight of these nonstandard programs was undertaken.
The first step involved programs whose fellows were hired and tracked like accredited fellows (i.e., not instructors). The basic process began with consensus among leadership, writing of policy with consultation as necessary, establishment of a registry of programs and graduates, and a committee to allow sharing of best practices and dissemination of policy. The second step applied the same process to instructor-level programs. Whereas the previous group of programs was made subject to ACGME regulations, more latitude in duty hours and progressive responsibility were allowed for instructor programs. The final step, in progress, is extending a similar but modified approach to short-duration clinical experiences and observerships.
The outcomes of these efforts have been the creation of a centralized organizational structure, policies to guide this structure, an accurate registry of a surprising number of training programs, and a rolling record of all graduates from these programs. Included in the process is a mechanism that ensures that core program directors and department chairs specifically review the impact of new programs on core programs before allowing their creation.
The University of Pittsburgh Medical Center (UPMC) began an initiative in 2006 regarding nonaccredited programs in graduate medical education (GME). The goals of the effort were twofold. First was to ensure that all training programs at UPMC offered the best educational experience possible, with central oversight as a significant step toward that goal. Second was the desire to have centralized census and control over the number and types of trainees who might potentially compete for resources with accredited programs. Additional issues that were uncovered as the process unfolded included financial aspects, visa issues, and the need for open dialogue between GME, continuing medical education (CME), and the offices of credentialing and medical staff. This article describes the evolution of the organization of nonaccredited medical training programs and the lessons learned in the effort.
Despite continuous need for an expanded primary care base, the practice of medicine in the last 30 years has evolved continuously into subspecialized and often into sub-subspecialized care capabilities. Demand for the most specialized and least invasive surgery, as well as the most advanced medical care for difficult cases, has created the need for training physicians beyond their specialty and sometimes their subspecialty programs. The literature in these areas has described the dramatic rise in postgraduate training programs, the limitations of present accredited programs, and the conflicts that may arise.1–3
GME is traditionally considered to be training after medical school graduation in a program accredited by the Accreditation Council for Graduate Medical Education (ACGME), the American Board of Medical Specialties (ABMS), or the American Osteopathic Association (AOA). However, physicians in the past few decades have increasingly pursued additional training, often in programs not accredited by the ACGME, sometimes not overseen by any specialty board or medical specialty society. These opportunities range from formally constructed multiyear fellowships certified by a specialty board to procedure-specific, short-duration apprenticeships. Furthermore, these programs can be conducted and salaried similar to an accredited program, or they may involve trainees given staff attending privileges, sometimes paid by outside sources. The shortest versions which train attending physicians bridge the boundaries of GME and CME, and their funding can require reconciliation with institutional conflict-of-interest policy. Complicating the picture further are fellowships designed for research such as T-32 supported years, with minor clinical components. Lastly, there are an endless variety of persons coming to a major medical center to observe for variable time periods.
The ACGME has developed program requirements for many of these new training opportunities, such as in palliative care, to become accredited programs. However, there remain a large number of very specialized training programs that are not accredited by the ACGME, the ABMS, or the AOA. For the purpose of this article, we will refer to nonstandard programs as any physician training program not ACGME or AOA accredited. Some of these have oversight and accreditation by medical specialty boards or by specific societies and associations; many do not. Some train only one trainee at a time; others take trainees every year in numbers similar to accredited programs. Trainees include both U.S. medical graduates and international graduates. Indeed, the Educational Commission for Foreign Medical Graduates (ECFMG) estimates that 500 J-1 physicians participate in nonstandard programs each year.4
All nonstandard programs have the potential to compete with accredited programs for resources, both patient and faculty, while at the same time offering teaching and patient care opportunities to their institutions. There are many other complexities in the operation of nonstandard programs: Although their graduates may serve to upgrade medical care in the region, they may eventually divert the referral base of the tertiary care center offering the program. Some programs have the capacity to enhance the reputation and balance sheet of an institution, but if pursued in excess, to dilute the standards and morale of the accredited programs. Moreover, it is often not clear who has institutional oversight and responsibility for nonstandard programs.
At UPMC, we conceived multiple potential advantages of centralized oversight and organization of nonstandard programs (List 1). The purpose of this article is therefore to describe the approach we adopted to organizing our nonstandard training programs. We include significant steps in the evolution of the organization of our nonstandard programs as well as the completed oversight structure itself. We provide enough specificity about types of programs, problems encountered, and realizations and decisions made in the process to allow generalization, adoption, and adaptation at other institutions.
UPMC is an international enterprise affiliated with the University of Pittsburgh and its School of Medicine (UPSOM). It includes 20 regional hospitals and multiple international sites. UPMC has placed all GME across the network under the auspices of the UPMC Medical Education Board (UPMCMEB). The UPMCMEB spans the corporate UPMC and the affiliated medical school of the University of Pittsburgh. Board members include the chief medical officer of UPMC, the dean of the medical school, hospital administrators, and representatives from GME leadership. UPSOM alone has responsibility for medical students and research fellowships. The hospitals of UPMC train approximately 1,600 trainees annually and by ACGME statistics rank among the top three largest GME training institutions in the United States. These figures do not include nonstandard programs. In this article, we have chosen to exclude non-MD programs such as osteopathic medicine, pharmacy, and dentistry in the definitions of nonstandard programs, although they are important parts of our graduate education structure.
Desired Goals of Nonstandard Program Organization: The Beginning
The overarching goal of the nonstandard program initiative was to produce the best learning experience for trainees in every program at UPMC, regardless of the program's accrediting body or lack thereof, as stated by the chair of the UPMCMEB. Specific objectives were set by a small working group: the designated institutional official, the vice president for GME, and the assistant dean for GME. Progress in attaining the measures ultimately was reported to the chair of the UPMCMEB.
After establishing specific objectives based on the potential advantages stated in List 1, in late 2006 we conducted a survey of 10 institutions of similar complexity, including ours, in order to appreciate the status of nonstandard programs. (For reasons of confidentiality, we have not named those institutions here.) This was a telephone interview using both open-ended queries and specific details that we were considering. The interviewees were nearly all designated institutional officials, all of whom were most generous in sharing experiences. Of these 10 institutions, all believed some degree of regulation of nonstandard programs was desirable, and 9 of 10 placed these programs under the purview of GME. Although 7 of 10 institutions expected nonstandard programs to follow ACGME regulations, only 4 of them included nonstandard programs under the auspices of their graduate medical education committee (GMEC) and enforced ACGME requirements. Only 3 conducted formal internal reviews. We explored further the types of trainees in these programs. Specifically, some trainees had not entered practice but, instead, were hired much like traditional fellows. Some, however, were enrolled as instructor-level faculty after becoming licensed independent practitioners. They were often allowed some attending staff activity. Five of 10 institutions avoided specific duty hours limits for these attending-level fellows.
Results of a query on the Association of American Medical Colleges (AAMC) Group on Resident Affairs (GRA) listserv reflected similar disparities in practice (personal communication, Julia McMillan, MD, September 5, 2006). Three subsequent presentations by other institutions at the AAMC 2007 GRA meeting confirmed the feedback we were receiving from the institutions we surveyed.5–7 Data from a GRA national survey showed that 76% of nonstandard programs were approved by the GMEC, but only 49% received internal reviews.8
After the decision was made to organize nonstandard programs at UPMC in early 2006, responsibility was assigned to a newly appointed assistant dean for GME. A leadership group was formed consisting of the assistant dean for GME, the designated institutional official, and the vice president for GME as noted above. After collating the experiences of the institutions above, it met sequentially during academic year 2006–2007 to define targets, compose a policy, and present to the Council of Clinical Chairs of the UPSOM and to the GMEC. It was soon obvious that this entire initiative required active support from both the academic leader (dean) and institutional medical director (chief medical officer).
Our efforts at institutional reorganization unfolded in a step-by-step fashion, with categorization and implementation for each type of program taking more or less a year of work. This progression was primarily attributable to realistic time and resource availability. However, there was also an element of gradual acclimatization of departmental leadership to our efforts. The leadership group began by reviewing the categories of nonstandard programs in place at UPMC and constructing a schematic to simplify the task and depict the relationships between accrediting boards and types of programs (Figure 1). As noted above, the decision was made to identify but not further include non-MD programs. Therefore, fellowships that are not ACGME accredited and also not targeted toward instructors eligible for staff appointment were designated Special Institutional Education Programs (SIEPs), in recognition of the special expertise of our teaching faculty and the institutional learning environment. These may either have ABMS oversight, which we designated type I, or not have oversight (type II), and may either be associated with a professional society or not. When present, such oversight is primarily to ensure that the program fulfills the need of its fellows to meet board requirements, and may not even involve site visits. This is quite different from the ACGME program accreditation process.
Programs employing staff-appointed instructors as fellows were named by their categories of employment (O and Z are two categories in the nomenclature of UPMC employment for which they would qualify) as an easily remembered moniker: University of Pittsburgh Physicians Clinical Instructor Programs (UPP-OZ). The choice that a program faces when deciding to be an SIEP or UPP-OZ depends somewhat on what pool of applicants the program expects to tap and to some degree on funding being available (versus the need for billing to generate support). Indeed, some programs are hybrids, accepting some candidates as SIEP fellows (often because they wouldn't qualify for staff privileges as an instructor) and some as UPP-OZ, adapting the employment arrangements in order to offer training experiences to highly desirable candidates.
Figure 1 illustrates the institutional categorization that we ultimately adopted. Accredited programs and SIEPs fall under regulations and oversight of the GMEC. Instructor-level programs (UPP-OZs) and mini-fellowships receive oversight at the corporate institutional level. Postdoctoral students are governed by cooperative policies with the University of Pittsburgh, GME, and UPMC. Table 1 shows the number of trainees in each type of program at UPMC as of 2009.
Special Institutional Education Programs
SIEPs were the first target chosen for attention, beginning in 2006–2007. This category of fellowships employs participants on GME payroll similar to accredited program fellows. After considerable discussion, it was decided that these programs must follow GME policies (essentially, ACGME policies) in all areas: curriculum, evaluation, faculty, and duty hours.
An SIEP Program Director Committee was therefore created as a subcommittee within GMEC. The initiative for policy adherence was presented to key individual chairs, then the Council of Clinical Chairs, and then to the GMEC. An enrollment document was written to ensure that programs had the required elements and documented support of the core program director and chair. A census of all SIEPs was conducted using direct connections to departments and administrators, review of the entire UPMC GME and faculty payroll, and persistent communication. Several programs emerged that had not been in our original catalog. As we designed it, enrollment involves concise description of the key elements of the program as well as the elements necessary for ECFMG acceptance in order to facilitate attestation when necessary. Signatures of the program director, chair, and core program director are required, because one of our central themes is monitoring nonaccredited programs for excessive competition with our core programs. The program descriptions are reviewed and approved by GMEC.
As anticipated, we found that enlisting enthusiastic support for our interventions was difficult. Significant time and effort were expended in gathering the involved parties, explaining, distributing, and especially collecting what was likely regarded as unnecessary paperwork and intrusion. Eventually, half of a full-time equivalent (FTE) in administrative support was recruited to advance the project. Incentives and rationale for cooperation included the overall goal of sharing attributes to strengthen the academic offerings to all trainees. In addition, we offered
* assistance with visa and other administrative issues,
* facilitation of ECFMG interactions,
* assistance with grievance issues,
* participation in GMEC events,
* continued payroll services (versus changing to instructor status and balancing income/expense),
* continued housestaff benefits and access to the Resident and Fellow Assistance Program, and
* institutional graduation certificates.
The SIEP committee began a regular meeting schedule (every four months) as well as an annual and ad hoc electronic communication schedule. The agenda progressed from defining the purpose of the organization to review of the GME regulations expected to be followed. Duty hours were the issue of most discussion, especially in specialties like hepatic transplantation, where prolonged procedural hours could be involved. Concepts such as on-site sleep and other solutions were reviewed.
Each meeting included an update on GMEC activities and pertinent GMEC discussions. From these basics, the agenda moved in subsequent meetings to sharing of best practices across SIEPs, starting with recruiting and contracting, then curriculum and eventually evaluation. Program directors also shared a discussion of research opportunities, practices, and problems.
A series of internal site visit reviews was conducted by the assistant dean in 2007 and 2008. The key elements of each review were curriculum and evaluation. The program director and select fellows were interviewed, and their documents were reviewed. The most common deficiency found was documentation of evaluation, especially in smaller procedural fellowships where everyday interaction and constant feedback were the norm. Fellows were content overall with duty hours. Written curricula were modest by ACGME standards, but practical. Research opportunity varied by the program and its length and was the exception rather than the rule.
Lastly, a Fellows' Interdisciplinary Conference Series was designed and implemented throughout the next year (2008–2009). Topics included biostatistics and research design, ethics, legal issues, and areas pertinent to ACGME competencies for fellow-level trainees. Conference proceedings were recorded and posted on the UPSOM Web site. The series was followed the next year by a course which used 11 modules from year 1 as prerequisite information. These are available to fellows from all programs as well as residents.
Clinical Instructor Programs
At the end of a year's actual experience with SIEPs, our leadership team decided to address staff instructor-level programs beginning in 2008–2009. Extensive efforts were expended in writing policy for this group of nonstandard programs, including legal consultation. The two most important issues were duty hours allowances and supervising the gradual progression to independent function for the instructors with staff appointments who often had been in or were eligible for independent practice and were coming to us for additional, concentrated experience in their area of interest. After considerable debate, it was decided that safe hours and advancement of credentialing would be the responsibility of the program director and chair, without specific hours prescribed or any special credentialing process. Although comfortable with the oversight of the program directors, the leadership group also instituted a quarterly display of each fellow's billings to be reviewed and signed off by the program director attesting to appropriateness of independent function. Increased activity over successive quarters was anticipated as evidence for a supervised increase in responsibility for the fellows.
Having set the ground rules, the group again presented the initiative to the UPMCMEB, the Council of Clinical Chairs, and the GMEC. By querying the latter, consulting our prior registry, and again reviewing the entire faculty payroll, every UPP-OZ fellow was identified. In the process, as we had with SIEPs, we discovered several programs whose existence had been unknown. After studying the operation of our programs, it was clear that several needed the latitude to employ some fellows who were SIEP fellows and some who were UPP-OZ fellows. They were designated hybrid programs, and for the SIEP fellows, GMEC regulations are followed.
Organizationally, UPP-OZ program directors were invited, and actively began contributing, to the SIEP committee. Very informative discussions centered around
* salary paid to UPP-OZ fellows (billing dependent or straight salary),
* resources for training,
* outside financial support and tuition fee for specialized experiences,
* conflict-of-interest issues regarding such supports,
* coordination of all nonstandard programs with core ACGME programs, and
* the exact mechanism for advancing UPP-OZ fellows to unsupervised roles in procedures.
For oversight, a separate leadership advisory group was created (named the Mini-Fellowship, Observership, and OZ Committee). Members included the assistant dean, the vice president for GME, and representatives from CME, the corporate administration, the medical staff office, and the credentials verification office. As described above, review of complete billing records for all UPP-OZ fellows by the advisory group revealed a baseline of 12,000 separate charges for over 6.5 million dollars in the first quarter alone. This indeed increased by 25% in quarter 3.
One particular area of interest from an institutional perspective was converting SIEP fellows to UPP-OZ fellows (instructor-level fellows). In so doing, fellows would generate their own support, overall clinical throughput might increase, and faculty policies could apply to all. The SIEP committee responded with a robust list of reasons not to do so (List 2).
At the conclusion of the year's efforts on instructor-level programs, a central graduate registry was established for all SIEP and UPP-OZ graduates. Documentation included attestation to achievement of six to eight objectives from the curriculum, as well as the six ACGME General Competencies. Seventy-one fellows graduated in 2009 from SIEP and UPP-OZ programs. The Physician Services Division (University of Pittsburgh) can now handle reference requests centrally without inefficient referrals.
We also reviewed the growth of new programs, both SIEP and UPP-OZ, between 2006–2007 and 2008–2009. An average of four new SIEP and two new UPP-OZ programs per year were created and credentialed. Several proposals required multiple revisions or were denied. We agree with others in our unpublished survey described above, that du jour creations should be discouraged and carefully reviewed for merit, and that any program that doesn't enroll fellows for three years should be administratively withdrawn. Lastly, since completion of the UPP-OZ registry and associated communications, not a single controversy over fellows' independent function has arisen, a distinct improvement over previous years.
The next targets (2009–2010) for our initiative were short (six months or less), competency-specific fellowships, termed mini-fellowships by the surgical literature,9,10 although existent in other specialties. With the work for categorizing instructor-level programs completed, the mini-fellowship policy followed easily. Duty hours responsibility became the same as for UPP-OZ programs. Supervision was required for all activities, except in those few programs fully described and registered as UPP-OZs with optional shorter duration.
The concept of brief interventions aimed at specific expertise, often for practicing physicians, raises a host of issues which an institution must weigh (List 3). Financial aspects of mini-fellowships are limited by conflict-of-interest compliance as well as the value of the skill imparted, making uniform tuition rates impossible. Indeed, ongoing conflict-of-interest issues have put several of our mini-fellowships on hold.
Observerships are being addressed by the leadership group for mini-fellowships and UPP-OZs. However, the conduct of observerships is entirely department-dependent, and the goal of our modest intervention has been to monitor overall census and to discover unusual activity. Departments are referred to the American Medical Association Web site11 for example templates. A draft policy has been written and presented, but implementation will require additional support.
We were surprised to find in our census from the first quarter of 2010–2011 that, excluding day visitors and excluding medical student and housestaff rotations, we had 104 postgraduate observers in 10 different departments. We also found a great variation in length of observerships, from three days to two years. Full centralization of oversight for these short programs will require another half-FTE of administrative support, presently under discussion.
Fellows Supported by Grants
Fellows on grants generally are subsidized by federal grants or industry grants. The latter are discussed below, as they relate to CME issues. Federal or similar grants are administered through the University of Pittsburgh rather than UPMC. Therefore, extensive discussion of benefits, taxation, and clinical activities took place between GME (UPMC) and the university regarding nonequivalence of salary and benefits. A policy was jointly written, and case-based discussions continue to the present. For medical staff, a nonfaculty staff status was created, to allow fellows clinical activity and billing if applicable, but under strict interpretation of the grant in question.
GME and CME are governed by different accrediting bodies, and their domains have traditionally been viewed as being discrete (preparation for practice versus acquisition of knowledge, skills, and competence while in practice). However, the acquisition and maintenance of competence, in reality, require career-long iterative experiences. Although the AMA has formulated guidelines for providing AMA PRA Category 1 Credit for training on new procedures,12 CME certification is customarily limited to brief learning interventions, most often less than 7 to 10 days. Mini-fellowships therefore represent a gap between the traditional purviews of CME and GME. Collaboration between these two units at UPMC, formalized by the creation of the advisory committee described above, has permitted greater institutional oversight of trainees as well as an opportunity for provision of educational consultation to sponsoring departments.
A second issue at the interface of GME and CME is conflict-of-interest policy. The device industry has traditionally offered financial support for fellowships and observerships related to procedural training, often in nonstandard programs. A task force convened by the AAMC, while recognizing the value of this funding, cautioned that institutions create centralized mechanisms for procuring and overseeing these relationships with industry in order to minimize the potential for personal and institutional conflicts of interest.13 The UPMC industry relationships policy mandates such a process.14 Funds from industry must be processed through either the Medical and Health Sciences Foundation or the Center for Continuing Education in the Health Sciences, depending on the nature of the experience. Selection of participants is controlled at a level of the organization discrete from that at which funds are managed and overseen. We do not allow industry to directly compensate trainees for travel, lodging, or other expenses, unless such arrangements have been defined in an equipment purchase contact. Again, operationalizing a unified consistent approach between GME and CME has been important for moving forward in this area, and our policy has been uniformly applied.
Remaining Objectives; Conclusions
As of 2010, when we wrote this article, the nonstandard program initiative at UPMC continues to grow. Future areas of interest will include internal reviews for all SIEPs, uniform graduation certificates for participating fellows, surveys of graduates from all nonstandard programs, and deeper exploration of the fiscal aspect of nonstandard programs. Of interest will be more detailed assessment of billing and collection versus the expenditures of the UPP-OZ programs and centralizing and weighting the tuition schedule. Lastly, we will explore the role of arbiter between departments as subspecialty training opportunities conflict.
Nonstandard training programs pose many potential dangers to an institution's GME structure. Competition for faculty time and for patients is foremost. Creation of unregulated experiences may impact accredited trainees rotating through, may allow unsafe working environment issues, and may invite overextension of clinical privileges, especially when instructor-level fellows are involved. If nonstandard trainees are not of the caliber of core programs, morale may suffer. Unregulated programs may create human resources issues if proper contracting, evaluation, tracking, and discipline are not practiced. Funding sources for these programs may involve conflict-of-interest issues, and, lastly, a medical center may erode its own referral base by saturating the locale with sub-subspecialty expertise.
At this point in our process, we can summarize the lessons we have learned in the effort:
* All levels of the institution's leadership must support the effort.
* In order to be successful, the effort must involve multiple areas of GME, faculty, and hospital offices and administration working together, with approval of involved institutional oversight bodies.
* There are programs of many types that can benefit by proper categorization and oversight, which may only be appreciated as the effort is undertaken.
* There is endless potential for new programs (of variable educational value) to arise.
* Resistance is to be expected and incentives/authority are necessary, but improvement is possible. Gains we appreciated included improved curricula, improved evaluation, improved adherence to credentialing details, a reliable database of programs, fellows, and graduates, a consistent process for new programs and for questions about old ones, increased awareness by all program directors and chairs, and a functional communication network.
* In addition to the primary educational impact of this effort, there can be significant fiscal and legal aspects to these programs.
* Designated resources are necessary; specifically, one-half of an administrative FTE, one-third of a faculty FTE, and considerable committee time from a core group of participants have been our minimum need.
At each step of the way, the issues were more complex than we expected and the time and effort were greater than anticipated. Overall, we believe we are in a stronger position to make educated decisions about questions that arise amongst our training programs. We have already set a higher bar for the nonstandard programs that currently exist and for those that are arising at a surprising rate in a dichotomous era of primary care need and sub-subspecialty technology.
The authors wish to thank Dr. Arthur Levine and Dr. Anna Roman for support of the project. Parts of it were presented in a workshop at the Association for Hospital Medical Education; April 15, 2009.