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Looking at Graduate Medical Education Through a Different Lens: A Health Care System’s Perspective

Roemer, Beth M. MPH; Azevedo, Theresa; Blumberg, Bruce MD

doi: 10.1097/ACM.0000000000000828

In the era of the accountable care organization, U.S. models of physician practice are shifting from the solo, independent practitioner to the physician who is part of a multispecialty group practice or is employed by a health care institution, and from paper-based small offices to practice settings that emphasize technology-enabled, team-based systems of care. In this light, Kaiser Permanente’s (KP’s) long experience as an integrated, population-based health care delivery system makes it an increasingly relevant model in which to consider how graduate medical education (GME) can best prepare physicians for 21st-century health care. KP’s multiple perspectives—as a GME setting, a health care delivery system, a health research enterprise, a community benefit organization, and the nation’s largest private, multispecialty group practice of physicians—provide a multifaceted opportunity to consider GME in the context of health care transformation. The authors suggest that all participants in medical education have a role to play in preparing physicians for this future. They recommend that partnerships between universities and health care delivery systems serve as a highly effective model for education; that to better serve the needs of society, medical education institutions must adopt a broad community benefit mindset; and that, when medical groups and other institutions that employ physicians take the baton from GME, they need to commit to ongoing development and lifelong learning to enable their new physicians to reach their full potential.

B.M. Roemer is executive director of medical education implementation strategy, Kaiser Permanente Program Office, Oakland, California.

T. Azevedo is associate institutional director of graduate medical education, Kaiser Permanente Northern California, Oakland, California.

B. Blumberg is institutional director of graduate medical education, Kaiser Permanente Northern California, Oakland, California.

Funding/Support: None reported.

Other disclosures: B.M. Roemer is an employee of Kaiser Foundation Health Plan, Inc. B. Blumberg is a shareholder of the Permanente Medical Group, Inc. T. Azevedo is an employee of Kaiser Foundation Hospital. All entities are part of Kaiser Permanente’s integrated system.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Beth M. Roemer, Kaiser Permanente, One Kaiser Plaza, Suite 1804, Oakland, CA 94612; telephone: (510) 271-2375; e-mail:

What does it mean to train and practice at Kaiser Permanente (KP)? Our practice resides at the intersection of private practice and public health. Beyond the Hippocratic responsibility to serve the best interests of individual patients, our physicians must never lose sight of the fact that these patients are members of a population for whose health we are collectively accountable. The decisions made in the exam room must be made with full knowledge that every member of our population should have the benefit of the same care. It is our problem if a member of our population should have been in the office today and was not. It is also our problem if a patient was in the office today because we missed an earlier opportunity to reach out to her before she became a “patient.” When physicians participate in the formulation of our practice policies, they must know the implications of these policies for that individual patient in the exam room and for the individual who should, but has not yet, crossed our office threshold. Individual health care and population health are not two separate activities that are conducted in series or even in parallel. Both considerations must be integrated in every decision we make.

In the era of the accountable care organization (ACO), physician practice models are shifting from the solo, independent practitioner to the physician who is part of a multispecialty group practice or is employed by a health care institution. We are moving from small offices with paper-based patient records to practice settings that emphasize technology-enabled, team-based systems of care. In this light, KP’s long experience as an integrated, population-based health care delivery system makes it an increasingly relevant model in which to explore the answers to a number of questions facing graduate medical education (GME) today: How well are we preparing our residents and fellows for the 21st-century practice of medicine? What should medical educators do to ensure that physicians-in-training are equipped with the competencies to succeed in organized delivery systems and provide the best care for their patients and the populations they will serve? How will we prepare them to be the leaders, not the reluctant followers, of health system change? What knowledge, skills, and professional values will be expected by large employers of physicians as the requirements for hospitals, medical groups, health care systems, and ACOs evolve?

KP’s multiple perspectives as a medical education setting, a health care delivery system, a health research enterprise, a community benefit organization, and the nation’s largest private, multispecialty group practice of physicians provide a multifaceted opportunity to explore these issues.

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KP as a Setting for GME

Physician education is an integral component of KP’s mission to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. The year 2014 marked the 70th anniversary of the first KP internal medicine residency in Oakland, California.

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Sponsorship of GME

KP currently invests in GME in five of its regions: Northern and Southern California, the Pacific Northwest, Colorado, and Hawaii. This investment supports about 900 full-time equivalents (FTEs) of residents and fellows in more than 30 fields of training. Of these FTEs, about 600 are full-time residents in KP-sponsored residencies in California and Hawaii serving as Accreditation Council for Graduate Medical Education program sponsors. Each sponsoring region has a designated institutional official and centralized GME office, as well as a director of GME and coordinating staff at each medical center that hosts residents. See Table 1 for a list of residency specialty areas available in KP-sponsored residency and fellowship programs.

Table 1

Table 1

The remaining FTEs are residents who are sponsored by more than 50 affiliated universities and hospitals and who spend a portion of their training at KP, from a few weeks’ duration to a full year. Conversely, to obtain essential clinical training experiences that are not available within our system, our residents in KP-sponsored programs are sent to our affiliated institutions. In total, we train almost 3,000 unique individuals each year in KP GME programs. The size and scope of our programs and the integrated KP model enable us to disseminate successful practices and promote efficiency by fostering regular dialogues across traditional program and institutional boundaries.

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Demographics of KP trainees

Increasing the diversity of the physician workforce is a priority for KP. Currently, the demographics of our resident population more closely mirror those of U.S. medical school graduates than the demographics of the communities we serve. In 2014, we had fewer whites (34%) and more Asians (44%) than national averages; the percentage of African American (8%) and Latino (6%) KP residents slightly exceeded national averages; and more than 50% were female. See Figure 1 for KP resident and fellow racial and ethnic diversity compared with national averages.

Figure 1

Figure 1

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KP support for GME faculty

KP designates a limited amount of protected time for teaching at KP-sponsored sites, at other medical centers that have rotating affiliate residents, and in community settings, such as safety net clinics and neighboring universities. This reflects KP’s commitment to medical education. Teaching opportunities serve as a recruitment incentive for physicians seeking a faculty practice. Faculty have the opportunity to attend KP-sponsored faculty development programs. (See List 1.)

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List 1 Kaiser Permanente Faculty Development Programs, 2012 to Present Cited Here...

  • Educational Research in Graduate Medical Education (GME)
  • Primary Care Teaching Program (cosponsored by the University of California, San Francisco)
  • Evidence-Based Diagnostics
  • Research Mentorship Program
  • Fellowship: Social Mission in Medicine (cosponsored by George Washington University)
  • Semiannual Regional Faculty Development Conference
  • Innovation in GME
  • Introduction to Research Methodology
  • Teaching/Feedback Skills
  • Modeling Mentorship for Resident Performance Improvement
  • Teaching Quality Improvement
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KP trainees’ career paths

KP’s GME is not simply a pipeline program for KP physicians. About one-third to one-half of KP residents join a Permanente Medical Group and provide care to KP members after they complete their training. The rest go on to practice in communities across the country, carrying their knowledge of practice in KP’s integrated care delivery system to other environments.

KP is committed to providing training in primary care specialties. We are one of the top producers of family medicine residency graduates in the United States, with a total of 50 new residents per year in seven California family medicine residencies. In 2013, Chen and colleagues1 ranked U.S. GME programs by the number of primary care graduates and found that KP’s Southern and Northern California GME programs were 3rd and 10th, respectively, out of the 161 GME programs with more than 200 graduates.

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KP as an Integrated, Population-Based Health Care Delivery System

KP provides health care services for over 10 million members in eight states and the District of Columbia. KP comprises three entities: a nonprofit health plan, 38 nonprofit community hospitals with more than 600 medical office and other facilities, and seven self-governing Permanente Medical Groups, which are partnerships or professional corporations.

The KP care model embraces the “Triple Aim” of better care, better health, and lower cost.2 The model is built on an enduring partnership among a health plan, hospitals, and medical groups; a focus on population health; and a system of care coordinated across settings, across specialties, and over time. (See Figure 2.)

Figure 2

Figure 2

From the standpoint of a health care delivery system, the growing focus on populations and systems in undergraduate medical education and GME is a most welcome development.3,4 To make the leap from concept to practice, an effective training program must have access to a cross-sectional population and to a broad-based system of care. To the extent that these resources do not exist at all traditional training sites, partnerships between universities and community sites can serve to close this gap, as is the basis of KP’s mixed model of sponsored and affiliated programs.

The availability of a large, diverse, longitudinally managed population and a high-functioning system of care provides KP with training opportunities in the domains of systems-based practice and population health. In conjunction with the University of California, Berkeley and University of California, Los Angeles Schools of Public Health, four KP residency programs in three specialties (internal medicine, pediatrics, internal medicine/preventive medicine) offer tracks that include an MPH degree, with trainees’ salary and tuition covered by the residency programs. Fellowship programs in patient safety and in health care delivery science offer additional examples of an educational focus on systems of care and quality improvement. Further, KP is partnering with George Washington University to pilot training programs in health policy and the social mission of medicine for residents and faculty.

Training residents in a system unfettered by the demands of fee-for-service payment offers faculty and residents the opportunity to practice in a highly efficient manner by, for example, using telehealth modalities such as e-mail or Skype visits and digital photography. However, training in a health system that does not focus on diagnosis-related groups and billable encounters may leave residents less than fully prepared for subsequent practice in a fee-for-service environment. Training residents in a system that places a high value on efficiency poses its own challenges. Residents are inherently inefficient, and attendings sometimes must sacrifice their own efficiency to teaching time. While the maintenance of an efficient health care system creates a learning environment most conducive to the transmission of efficient practice skills to residents, tomorrow’s efficiency simultaneously requires educators to take the time today to train an efficient future workforce.

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KP as a Health Research Institution

KP’s stable relationship with a large and diverse population and its densely populated, longitudinal electronic health record create an ideal environment for clinical and epidemiologic research. Each year, thousands of KP health plan members and patients participate in research that employs a wide range of study designs, including randomized controlled trials, prospective or retrospective cohort studies, interrupted time series analyses, nested case control studies, and cross-sectional studies. In 2012, KP research funding totaled almost $200 million, more than $160 million (80%) of which was derived from external grants, and over 1,200 active research projects were in progress. This research portfolio has produced over 400 peer-reviewed publications first-authored by KP researchers per year over the past decade.

Residents’ and fellows’ research participation is fostered by the availability (and in some programs, the required completion) of an online course in basic research methodology. Several biostatisticians and programmers/analysts are devoted to supporting resident research, and a facility-based research assistant facilitates research project management. Regional symposia showcase trainee research, with awards presented by faculty juries. Trainees are encouraged to present their work at regional and national meetings and to publish when appropriate. (Representative examples are included in the reference list.5–8) An educational researcher supports curricular innovation and focuses on the link between curricula and patient outcomes.

The Permanente Journal,9 a national, peer-reviewed journal of medical science, social sciences in medicine, and medical humanities, provides a forum for scholarly review and publication of faculty, resident, and other research.

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KP as a Community Benefit Organization

In keeping with its nonprofit status, KP’s community benefit arm goes beyond investing in clinics serving poor communities or uncompensated care. The development and dissemination of knowledge are as much a benefit to the community as providing charitable care for the underserved, making grants to community organizations for community health initiatives, or working to improve the environment. At KP, the broad goal of “developing and disseminating knowledge” includes research, health policy, environmental stewardship, and educating the health professions workforce.10

KP subsidizes medical education as part of its mission. Like most other teaching hospitals, KP receives reimbursement from the Centers for Medicare and Medicaid Services. That revenue is essential, but does not cover the full costs of operating the educational portfolio. Faculty time diverted from clinical practice for administration, teaching, research, and supervision constitutes the cost not covered and not fully offset by resident service contribution. A fair share of the organization’s resources has been and will continue to be allocated to medical education, developing the community’s future physicians.

As a natural outgrowth of the organization’s treatment of medical education as a community benefit activity, KP residencies are designed to extract trainees from the hospital setting and bring them face-to-face with underserved communities. Community Medicine fellowships place advanced trainees in safety net settings full-time, allowing them to serve as preceptors for residents without adversely affecting the scarce supervisory capabilities native to these settings. An active and fully subsidized (including salary and travel costs) global health program promotes a global view.

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KP as a Physician Multispecialty Group Practice

Permanente Medical Groups, the physician component of KP, are independent, self-governed, multispecialty group practices that, collectively, are the largest private group practice of physicians in the nation, with 17,000 physicians and with more than 1,000 physician hires per year from residency programs across the country and from other practice settings. The GME programs contribute to the recruitment, retention, and professional satisfaction of Permanente physicians while minimizing recruitment costs associated with external searches. According to one search firm, the interview cost alone is more than $30,000 per vacancy.11

KP’s mission is to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. As a large group practice with this social mission, KP is playing an active role in producing a workforce fit for 21st-century practice, with special attention to increasing diversity and inclusion, promoting primary care specialty choice, and developing physician leaders. See List 2 for examples of residency and fellowship leadership training.

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List 2 Kaiser Permanente Residency and Fellowship Leadership Programs Cited Here...

  • Chief Resident Leadership Communication Course
  • Community Leadership Training in Family Medicine
  • Community Medicine Fellowship Curriculum
  • Resident Performance Improvement Course
  • Health Policy Elective
  • Clinical Teaching Course
  • Leadership in Outpatient Internal Medicine (CHOICE track)
  • Chief Resident Advocacy Program in Pediatrics
  • Resident Performance Improvement Course

KP has an abiding interest in the knowledge, skills, and professionalism of residents completing GME in KP-sponsored programs. In 2010, using the framework created by Cooke et al,4 KP conducted a study of the training gaps of new physicians hired by the Permanente Medical Group in Northern California. It showed seven areas in which the new physicians were not well prepared to practice in an organized system of care. The most frequently identified gaps were (1) care coordination, (2) office-based practice competencies, (3) continuity of care, and (4) systems thinking. Our clinical chiefs of service observe that immersion in a population-based care system during residency develops graduates who are better prepared in these areas. Chiefs also find that these same skills can be learned in the early years of practice in an organized system by any well-trained graduate.12

Today’s health care environment requires physicians to be lifelong learners. It has always been true that a graduating resident or fellow finishes training with a great deal to learn, but there are many forces in medical education and medical practice that have magnified this reality. Duty hours restrictions arguably have produced a generation of residents who are graduating with less experience than their predecessors. Less arguably, the pace of knowledge creation has accelerated to the point that knowledge “mastery” is an impractical goal for a graduating resident. Furthermore, medical practice has evolved at a more rapid pace than has medical education, and this mismatch often places graduating residents in practice settings that look very little like their training environments. The wide availability of practice-related data makes the inefficiency of the graduating resident all the more visible.

With the pace of change in biomedical science, technology, and health care delivery science, one cannot think of a physician who has completed residency as a “finished product,” a master physician whose training has largely ended other than the requirement to maintain licensure. Rather than imagining a graduating resident to be at the pinnacle of accomplishment, continuous professional development will be the mode of the future. While considerable attention and literature has been devoted to the transition from medical school to residency, the transition from residency to practice and from GME to continuing medical education has been less of a focus among medical educators. To become successful lifelong learners in a systems-based practice, new residents must have skills in the domains of resiliency/adaptability, resource stewardship, and leadership/followership.

Graduate medical educators need to prepare physicians-in-training for a life of continuous learning if the graduating resident is to grow from competency to mastery. Specialty societies and boards, policy makers, licensing agencies, health care organizations in which physicians work, and physicians themselves all have a role to play in lifelong learning. As a physician organization with a large number of newly minted physicians, Permanente Medical Groups support their new physicians with formal nonevaluative mentoring and acculturation programs, reduced patient panels in the early years of practice, skill-building workshops, and a wide array of professional development activities, with an emphasis on faculty development and leadership skills.

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From KP’s multiple perspectives—as a GME program, a population-based health care system, a research enterprise, a community benefit organization, and a large group practice of physicians—the future of medical education and physician practice is bright. As the care delivery system evolves in an era of ACOs, physicians increasingly will be practicing in settings that emulate KP’s emphasis on quality, population health, and health care value and affordability. Stakeholders in physician education are becoming more aligned on the importance of systems-based practice, population health, and lifelong learning.

All participants in GME have a role to play in preparing physicians for this future. Partnerships between universities and health care delivery systems serve as a highly effective model for education. Like a young learner of a first language immersed in a family and culture, residents need to gain experience in the environments of the future, especially in population-based organized systems and new models of care and financing. To better serve the needs of society, medical education institutions must adopt a broad community benefit mind-set. Finally, when medical groups and other institutions that employ physicians take the baton from GME, they need to commit to ongoing development and lifelong learning to enable their new hires to reach their full potential as physicians.

Acknowledgments: The authors thank Kaiser Permanente Southern California graduate medical education leaders Marc Klau, MD, and Felice Klein for contributing program information and data.

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