Transitions in Medical Education

So, and I think like Mariah said on behalf of Jed and I, you know, we're really grateful to have this conversation, especially this time of year. You know, Jed and I were just talking about how, you know, July 1st, everyone talks about July 1st, that's when the new residents start. Um, today was actually when the second year medical students returned back for class. So, it's a really timely time to talk about transitions. Um um you know, I'm an addiction medicine specialist as well as an OB and we always talk about how transitions are really difficult in addiction. I think it's actually true in education. So, um what we're hopefully going to do, you go to the next slide. I we have a couple of objectives. Um you know, I think a lot of this can be reflective, I hope, since a lot of you are very much involved in medical education, but I think a lot of it is identifying these transition points and when they are, and sometimes they're obvious, sometimes they're more subtle. Um, we really want to help you understand and how you can really help understand what those barriers are and how we can facilitate it. But I think really helpful if you can help deploy strategies in your own world or tell us how to deploy strategies uh on sort of a more macro level um of how we do this transition from you know undergraduate medical student through attending physician. Um you know there's so much to it we're not going to do nearly enough justice to it. Um but I think it's just to get us thinking and be a little bit reflective at the least. Um, and at the greatest we'll actually have some good ideas while we can move forward. So, and like Mariah said, you know, if you have ideas, throw them in the chat. If you want to raise your hand, it's hard for us to see that. Um, we want to make this as much of a dialogue as the technology allows. So, um, to start that, we'll go to the next slide. Um, so here's here's a transition. It's a developmental and operational shift where a physician future or current moves from one stage to another requiring adaptation to new challenges and competencies. Transitions involve changes in identity task supervision assessment standards. Um and you can see here's a very simple one from you know college or undergraduate education to undergraduate medical education to GME to practice and GME means both fellowship and residency. So a question for you guys to think about and throw it out during you know either now or during the course of our talk and we'll definitely come to that have that as a discussion piece at the end is what are the top challenges during transition points or on the continuum that you see or you have faced yourself and then you know share them in the chat and you know we might talk about them in real time if we see them as we're talking we definitely want an opportunity to talk about it at the end. So, uh, next slide. I think I'll hand it over to Jed. It's interesting when you read the definition of transition. There's a couple definitions that exist out there in the literature, but the the two words that Arthur highlighted was developmental and operational. And sometimes we think about the transitions. It's like you're driving a car and you you're driving smoothly on one road and then you take an exit. It's a transition. And we think you you get straight on autopilot on that new road. And that's a more of a discreet transition in many ways, but this figure kind of demonstrates that developmental and operationally, it's never a smooth piece. There's always these small iterative experiences and moments that even though you're on that roadway, there's a lot of transitions that are happening even on that smooth roadway. And I I think this figure demonstrates um a couple things. One is that it's never a straight path. It's a ciruitous journey whether it be college to medical school residency. Many of our VTC students by the way we have one of the older classes um in the country by doubleAMC GQ data that maybe they took a year off or there's uh other years that they were in work they were fully employed and transitioned in. So then you think about their transitions um into medical school into that residency practicing position. In many ways our our learners that are metriculating with us here in just several weeks they'll be in independent practice in 2031 2032 depending upon their residency. So the other thing depicted here in the transitions is the length. Um it's not something that happens over one or two or three years. it can be upwards of seven to 12 years when we think about all the way through our own careers because I'm still undergoing several of my own transitions uh as a physician. So with that we'll transition into the space. So Arthur and I as Arthur already highlighted we're going to break it down by to GME and then GME to um CPD um but just providing the framework for it. So please bring your questions along and we'll have more of a a dialogue at the end. There's a lot in the literature around transitions and what are the key um pieces of the transition particularly from college and I put other there just to demonstrate that there might have been other careers or other pieces that happened into me and some of the key themes here are listed I have five of the main categories an academic adjustment uh content itself when you think about learners before they metriculate they're they're majoring in certain disciplines or areas So now they're coming in and the content isn't just disciplinary. It's it's integrated. It's crossing several learning areas, several courses. I mean, we try really hard to integrate all five of our courses in the phase one curriculum. So that's a challenge. The pace may be different than what learners have been used to. And in many ways, it's high stakes. High stakes. It cames it came to be physicians. And there are a number of expectations that make it challenging for a learner. There's a psychological and emotional stress. I mean, I think most most of us, myself included, have gone through periods of uh the imposttor syndrome, uh, if you will, uncertainty for their future. Do I belong here? Um, the first couple months, I mean, I see Leslie on the call here and Amanda and others. that first couple months, what we're coaching learners through is in many ways an adjustment through the psychological and emotional challenges that exist as they just moved uh to a new environment. Most of our learners are not from Ron Oak. So the social and environmental adaptation to be in a new city um to be in a new apartment to where's your family? The family maybe there are no roots or social network in in the geographic zone. So they're creating new networks that leads to time management and life balance issues. All the above to be able to do um high stakes uh academic learning through the psychological and emotional stress. How do you balance that out? And then transition in roles and expectations. Um there's some labels that are placed on the difference between medical school and other higher education that it's a transition from being learner centered. You know, if we're in college, in many ways, it's about developing our own reasoning skills and knowledge base, which is still true in medical school, but there is increasingly integrated manner this this transition to being patient centered. If we're in if our learners are in the longitudinal ambulatory care experience, for example, which Dr. Dr. Schmid Dalton and team run with our great faculty. When when you're in that type of environment, often times the patient comes first and learning is required in that context. But there is a transition there and that can be um different for for learners as they transition into me. But it certainly does not stop at the transition point. It's not as if our learners are going to be here in several weeks for orientation and they'll go right into the our professional medicine course. doesn't just transition straight onto that new roadway. There are all a myriad of transitions. I just wanted to highlight some of them superimposed on our curricular grid here at Virginia Tech Currillion. Our phase one curriculum runs for the first year and a half. This is the new curriculum that our current MS2s are experiencing, but our new MS1s will experience as well. And then they enter that that clerkship year a series of clerkship clusters ends with step two study and then it will end with phase three the career exploration. But just some examples of of what those transition are. Um their first course will be the profession of medicine. We'll be discussing and learning about the identities of what a physician is and what our goals are. Scientist physician system citizen lifelong master adaptive learner. Our research and inquiry blocks are are pretty interesting because they've existed since the beginning of the school. But in that phase one curriculum, what we have seen in our learning is that this is the time when it's not just about the books. Our learners are with mentors. They're on teams. There are deliverables. There are expectations. And that is a transition for our students to meet those expectations while learning at the same time. So it requires us to help facilitate their transition from more traditional coursework into these research blocks to do meaningful work and then that whole phase culminates in step one study um which is pass fail um but you know the fail rate of the step one is going up. There's a lot of anxiety around step one. So that whole phase in there that that two-month plus period is a is a stress time and a transition point for our learners. And then you enter the clerkships and there's all these micro transitions, if you will. The first time rounding uh on a patient on the medicine service at 6:30 a.m. I still remember waking patients up thinking, is this right? Doing an exam by myself. Um a breast exam um and having a nurse and asking a nurse to come in doing that as a as a clerkship student. These are transitions that that that take that take time and thought. first time you scrub into the operating room is a transition. Then the step two study um which is similar to step one but it's coming at a unique time in their journey entering your acting internships where there is more responsibility and expectations of you. all the intentionality in that phase three as you kind of hone in on a specialty and develop mentoring networks with physicians and many way and nurses and pharmacists but department chairs and that's a transition. How do you interact with clerkship directors and core faculty and chairs in a in a different in a different modality as you're thinking about your transition into your specialty? And then the match is a um really an eye-opening experience to go through the match and I still remember my own transition moving to a different place preparing to be a position. So there's all these these lightning bolts are indicating all these transitions. It's not just a binary zero to one that switches um that we need to be valitional and intentional about. All right. So, you know, that's a perfect sort of segue to what life is in GME and and there's a lot as you go into GME. Um, you can go to the next slide, Jed. Um, you know, first of all, you're a physician. You've now gone from, you know, a medical student to a physician. You are licensed, albeit with a training certificate, but still with a certain level of responsibilities. Um, and as you look backwards from the slide, and I'm not going to really go in order. You know, that new role is really daunting. I mean, there's a lot within GME. I'm not even talking about, you know, transition from an intern first with six months, the second six months to being a junior resident, being a senior resident. If you're in a procedural specialty versus non-procedural specialty, there's so much difference in GME. Um, the curriculum, you know, I jokingly say GME, at least at Curly, I have 30 different FFTs. I have 30 different program directors doing 30 different things that they're being told by their specialties to do. And there's really there's some unified experiences. Um, but when you really think about this, you know, the transition from UMI to GME is incredibly predictable. 99% of our students go into residency and we kind of act surprised, at least traditionally. I think BTC's done a great job, but nationally, it's like why aren't people prepared? We can be much more intentional. Um, and we'll talk more about solutions and things that are happening, you know, locally and nationally sort of near the end of this um talk today. But there are some predictable things going on. I mean, number one, you know, the residency application process takes up so much of the the traditional fourth year. I mean, if you look at it, you map it out, there's so much opportunity for growth developmentally that kind of gets lost in the application process. Um, and that's there's, you know, there's no simple reason for that. Um, but I think it's also there's so much value that applicants, you know, medical students as they're applying for residency talk about how high or low they're going to go on their rank list. And the advice I've been given for a good 10 years now as I sort of seen so many students go through it is like you know your top three is sort of an arbitrary designation. You know what programs will you be happy at overall? Which programs will you may not be as happy at? Should you even rank places you're not going to be as happy at? Um but a lot of it's how do you go through those transitions? So you know Jed brought them up so well. I mean they're moving to a different place. um you know if they don't stay at the medical school they trained at there's a lot of transitions workflows very differently from place to place. I mean, I've gone through three different jobs in my career. Um, you know, and I when I first got here, I remember very clearly, get me into the operating room, then I'm fine. Once I'm in an O, I can do, but getting to the O, the processes, the steps, you're learning a different language. Um, what people call things, some people call it a code blue, some people call it something different. Um, you may be using a totally different electronic health record. Um, and the EHR transition, we're seeing that right now. It's, you know, July, first week of July. So our new residents who did not use Epic, they're a step behind of the students who were, you know, somewhat fast on Epic when they were a medical student. So there's so much that they're not ready for. I think a lot of that has just been the intentionality. Yes, we have orientation. People are here for a week or two weeks, but that's drinking through a fire hose. I think you have a lot more time. and really what are the essential things and we'll talk more about developmentally things that are going to change quickly versus not quickly and some of the foundational things that we can talk about um but I think there's like I said there's a lot of predictable things and we talk more about copa and some other things um we'll we'll address with that next slide Jed if I can just share a comment there Arthur in many ways the the breakdown Arthur's commented on it already but in GME all these microtrans transitions. I mean, for me, my own personal experience, one of the hardest transitions I ever went through was internal medicine residency from R1 to R2. Um, to go from pre-rounding and caring for five patients on an impatient medicine service up to seven because it's half the list, you're at 14 patients, you go to an R2 role, and now you're overseeing two interns, one, two, or three students, and a patient list that's up to 14 deep. Um, and there's not a lot of programs from an R R1 to an R2 transition that I experience. It just kind of it just happened by osmosis. You transition into that role. But boy, was that a a big shift for me emotionally, psychologically, professionally. So, there's all these transitions that are happening as you unpack all these these different component. Even the chief medicine or the chief resident Arthur designed and led a chief resident boot camp has done it now, I think, for a couple years. But even in that several weeks ago, the incoming chiefs are going through their own transition, which is a unique situation to be in. I don't know, Arthur, if you want to comment there. No, no, I mean that's totally true. I mean, you know, I'm thinking about just my my intern year. I mean, OB residents. Um, my first two months were on internal medicine. I took care of men. That's not what I signed up for, number one. Um, then I go to the ICU and I'm taking care of cardiac patients and surgical critical care patients. Very helpful. wasn't until October I did my first OB rotation and the and the response like why are you so far behind well because you set up a curriculum where I didn't do any obstetrics probably since I don't know August of my fourth year of residenc fourth year medical school. So I mean so that's that's part of the intentionality and part of how you design things but I think yeah I mean there's so many transitions I mean you know you'll see it you know I family medicine's a great one family medicine probably touches every single service in this hospital and their training and how they have to be adaptable there there is a different ad adaptation when you know in some residencies and others but there's always something and I think those new roles are you know that transition you know we talk a lot about July 1 we have new first years we have new second years and new third years and new fifth years, new seventh year residents who are trying to figure out what their roles are because those roles become very sudden now you hope their skill set is gradually met to that point where they can take it over. But when you're the one responsible um and that's really true when you talk about the transition to being an attending you know when you realize you're the one like that that's a that's a you know we prepare them for that but it's nothing quite like you know when you're the one and I'll share a story when we go to the next slide. Um ready for the next slide Jen. Yeah transition to practice. So um you know we're all experts in transition to practice all those that are practicing physicians. Um once again I think these are predictable transitions. Um, you know, I I think very much about, you know, I I feel like I was incredibly well trained in residency. We learned, you know, so much being around 10,000 deliveries a year and at a big academic health center. But I remember really clearly I was a resident with one of my former residents who's now attending a few years out in practice. He's putting forceps on a patient doing um actually something called a scanzone. It's a we don't see much of anymore. It's a it's a rotational force delivery. And he puts on the force goes, "Where's Dr. Ernie? He has to check my placement." who's one of our attendings like uh you're the attending now Alex he's like oh he kind of looks up says a little prayer does a perfect delivery you was well trained but I think he recognized you know the largest of the moment that he is the one that's ultimately responsible now as he attending and that that assuming that truly ultimate responsibility um can be pretty daunting and you can't really think about it too much um I think we recognize that that's a known transition again once again these are predictable things we recognize that you're still learning in practice that's why it's called practice and I won't be ashamed to say like you know once again I think I was well trained as a surgeon high volume did lots of cases but it probably wasn't until my second or third year in practice I was doing a pretty challenging vaginal hysterctomy but everything opened up like I saw the planes in a different way and I saw the spaces and like okay now I really feel like I understand what's going on and that was two years out in practice and that's true for everybody I don't think I'm different than anybody else you know as a proceduralist or a non-proceduralist there's a lot to learn still and I think um the support systems are probably lacking you know, we just, you know, we spend a lot of time out orientation, you know, from, you know, in medical school and residency, even in fellowship when you go into practice, no one's really orienting you. You know, hopefully you have good partners, you have nurses and other people that are showing to you, but I think in most places is not super intentional. Um, I think the other thing about transition to practice is, you know, residency, I think everyone recognizes, it's probably very hard to change your residency very much. like is pretty much a curriculum that you go through. Um, but I think there's a lot of hope when people go into practice. Now I can have the job I want and now I can have the flexibility I really desire. And I think that promise of career flexibility, especially early on, is kind of hollow for many people. You know, it's really hard when you have loans and you're trying to, you know, if you're trying to maintain a g a broad generalist practice, how do you do that and try to find that work life balance? So, I think there's that, you know, that certain sort of disappointment like it was going to be different and it's not different right away. And I think it can be different. It's probably not your first job where it's different. Um, or probably not your first years or your first job, but I think there's some of that transition like it's it's supposed to be different. And you see, I spent probably too much time looking at physician pages on Facebook saying, you know, I'm two, three years out of my residency and this is not what I expected. Well, the question is what did you expect and why did you expect it? Um, but I think, you know, we have to recognize that there's a lot going on in people's lives and how they're balancing that and what their expectations are may have varied. Um, and then I think just much like residency, um, I think many residency graduates are unprepared for all aspects of their practice. I'll just give one example. Um when I was in Asheville um you know we're trying to find a rural primary care workforce and we find people that have that rural desire um but based on where they're trained even they were trained you know for a rural practice not all rural practices are the same. So um we'd have people who would like sign up were really excited about being in rural practice realize you know I just don't know enough inpatient pediatrics or I have to resuscitate newborns and I didn't do a lot of that in residency. So and each job is a little bit different you know especially in primary care. So no, we have found that when we intentionally did a f a rural fellowship and we bought back 10 to 20% of their time and let them learn what they needed for their specific practice, that was an incredible satisfier for that new new graduate um and for the hospital system. And I think it it it sort of reinforced to me it's just so important to recognize that just because you learn a lot in residency doesn't mean it's going to all work out in the same way in practice and you may need different skills. um and how those get developed either intentionally or unintentionally are really really important. Um and then how do you fix that and why is that? So um next slide I'll just sort of give you one of my wise. I think the transition of practice has probably changed because of how physicians are employed. And this is data from um Avalair Health, but you see the same thing with AMA um American Medical Association data that the percentage of physicians that are employed by a health system has increased greatly over time and I think that has an incredible impact. I think in the traditional model, my uncle was a traditional private practice OB. When he started practice, his partner was highly vested in his outcomes. It was a business of two or three people and how they looked and how they acted and how they were perceived was incredibly important. So his senior partner had so much invested in him and gave him a lot of time. They scrub together on cases. They were always sort of helping each other. Um and I think it looks a little bit different in an employee practice model. Um not because people aren't as invested. I think it's just the scale. It's just really hard if you like if you're practice of two or three people. It's a very different sort of uh interaction when you're in a practice of 30 people or 50 people or 100 people and that requires a different intentionality. We can do it. It's how do you do that? Do you know do we do a job where new attending they get a buddy like who's that sort of not a mentor but a coach who coaches someone you know this is how things work at currillion or you know pick your favorite health system. Um so I think you know I think things that were just sort of this happened and happen innately um don't always happen innately when you change the basis and the model of care you're providing um and who hires you is a big part of that. So once again I think there are ways of overcoming that but I think one of the reasons that got lost is because the intentionality has to be done to scale. Um and that's very different than when it was just a one-on-one or a small private practice. Chad, anything you want to add before we hit the next section? Yeah, just one comment. It doesn't 100% overlap with these comments here around uh the the the private practice model, but in medical schools, the the Kaiser Permanente School of Medicine, the Genesis story is very similar to what Arthur just described. Um the school launched um I believe in 2020 was its first metriculating class of medical students, graduating its first class of students in May of 2024. just last year. I have to double check myself, but I think they just graduated their class just last year. But when they talk about the origin story of the school of medicine, it came from the health system saying what the US undergraduate medical education programs are are sending us, if you will, the skills, the mindset doesn't totally match what we need in our health care system. So the transition is more choppy for us. So why don't we start our a new medical school that is directly aligned with our needs. Hopefully many will will come through our medical school, enter Kaiser Permanente system, and that transition will be better, more efficient. They they used in their um some of their early talks, they used the numbers of um which is published $250,000 to almost $1 million to to replace a physician that is leaving practice. costs so x amount of dollars depending upon the specialty but it's not insignificant. So they're saying well our attrition rates are high it's impacting our bottom line but it's also impacting our outcomes. So we want to develop the skills as we see align with our health system needs. So it's just interesting Arthur to hear your private practice model to the story that from what I have heard from the Kaiser Permanente launch. Yeah. No I think that's very accurate. Now the dean at Kaiser Permanente is a friend of mine actually he's an OBGYn and you know that's what he was excited about joining them as their dean is like you know how do I how do we do this you know and how do we really prepare the workforce and the way we see our workforce and Kaiser has a very different approach because you know they're they're also a major you know healthc care employer um and they have a different lens and that lens is actually really helpful so um so 100% so that's intentionality again and they just did it to scale they I'm just acknowledging the comments. LB, we're coming there. I think I we're going to comment on in a slide. Dr. Schlupner um Dr. Musk's comment I think will come up in one of the slides coming up as well. Um yeah, maybe the next slide. I hope so. Good segue. So, we're not the first to talk about the the concept. I mean, this has been around um in the literature, but in Medad uh for quite some time, well over 10 years. and it culminated several years ago in the coalition for physician accountability the tome report. So these are multiple groups coming together. This isn't just ACGME or doubleam AMC. I think I don't have it memorized Arthur 10 or 14 different national bodies coming together CME AMA um LCME MBME to say let's collaborate on some eerent arm action strategies for improving transition particularly the um to GME transition and these are the 12 recommendations um that that they came up with. Um I'll let you um digest some of these but and this is four or five years ago. So I think we have used this internally more than once even in our strategic planning process. A lot of these recommendations got channeled into um as as fodder for our work groups but developing a shared competency. We have the new uh foundational competencies um for um that came from the doubleamc which moved us along a little bit. Um but there's the harmonized milestones for example uh many med schools are using um these unified frameworks to help with that transition moving USML beyond numeric scores improving transparency really thinking about the learner perspective particularly in four and five around costs Arthur's going to comment on that in a second um and six expanding opportunities for advising and coaching when you look at the literature on advising and coaching particularly coaching the past 10 years that has risen significantly um in addition beyond the the literature also the programs that are actually happening in the medical schools because of the acknowledgement of not only competency based med but also the transition points to help learners through those vulnerable um areas. DEI was a big piece here in 2021. Clearly, we're in a in a different landscape at least from the national norms and pressures that are upon us. um reforming away rotations to make more uh equity um so e everybody can have the opportunity to be doing away rotations adjusting funding and fostering collaboration. So we're highlighting this as as work that's gone on nationally that um in many ways have been informing and should inform many of the things that we're doing as we think about the transitions. Anything there Arthur because I know you've been immersed in this. No I think the next slide will sort of talk about that. I think it's a great kind of set up and I mean you know this is the operationalizing of it. So I was really lucky when I was um in my role with APCO as president um at the time that we had as a specialty as OBGYn had um one of the AMA grants that we called it the right resident right program ready day one and a lot of it is taking the copa recommendations and operationalizing it and you know the objective ones at the top and I would say those were sort of the simpler things to do um you know OBG1 has standards as far as when applications reviewed when interviews go out when interviews end how do we communicate with applicants so we take away some of the the anxiety. Um not I can't say we got rid of it. I think we limited it and minimized it. Um we spent a lot of time with about holistic review and how we look at applications try to get away just from scores and try to find a more broad-based way of evaluating applicants. Um you know we did program signaling fairly early on. Um we were talking about an early result acceptance program and early match that didn't really work out but we talked a lot a lot a lot about that. But I think the really cool part of the RR grant, which is the one that's still kind of being more adopted around the OB world and definitely other specialists have come to OB asking about what we're doing um is the is this intern readiness um and this curriculum is how from the time you match in your program, how do you get connected with your other co-residents? How do you get connected with the program? And how do you have a really good assessment of your strengths and weaknesses? And one thing we're trying to trying to operationalize in that other than the coaching programs and and being that intentional um is can we retake our standardized letter of evaluation are slow and that that's done typically in September of the fourth year and redo it right before they come to med come to residency as a reassessment of where are your relative strengths, where are your relative weaknesses, how can we help you, what are you going to need right away? um and really make that slow which is you know by design part of the application process by that be like a living breathing document because it's competency based as really clear um educational anchors is that a way to help program directors understand that everyone has weaknesses you know no one's intern ready because no one's intern ready um but how close can you be to intern ready um and like coaching has been really helpful for that our resident learning communities in OB have been very important that other specialies have done this. But I think once again, it's kind of what I'm seeing in the chat is how do you be intentional and and that doesn't happen accidentally. I think a lot of a lot of GM is like, well, you know, you'll learn it because everyone learns it. Well, many people learn it, but you also can learn it quicker and better um and maybe with less anxiety if you're more intentional. Anything to add, Jen? Yeah, the the parallel to this one example could be NYU as well. NYU, a smaller medical school. um not only offers but it it's a requirement for it's their program is three years they they have an additional fourth year for those who want to do other degrees or experiences but one of the things they're proud of is their retention from to GME that their numbers are remarkably high um anecdotally the numbers nationally I think 20%ish 20 to 25% Arthur may have different um um references here of those that train in the space enter the residency programs of that same space. I think our numbers are in in a similar alignment with those national numbers. NYU is is pushing 40 45%. So when your numbers are higher of your um and to Gme transition in the same place, you can then think about um these strategic coaching models where the learner is staying in this transition from from phase three the post clerkship curriculum working directly with the GE programs potentially before they match but or at the time of match so that when they enter that intern day one ready day one in Arthur's model here they've already been coached by the the coaches and the faculty in the same location. Um, which from a learner perspective, I think personally if I was in that type of environment, that that would make sense to me. I'm knowing the faculty, I know the program I'm going into and they're they're helping me transition already to hit the ground running. Um, it's just interesting to think through models such as that. Really hard to pull off. How generalizable is that is another question. Yeah, I think NY is a great example. you know, as a three-year medical school, they have to take their own applicants because it's hard to go through the match. Um, so I think a lot of it is, I mean, I'm not sure which, you know, which the chicken, which is the egg in that standpoint, but I think it does allow them to have that, you know, that more prescribed transition because a they're already there, their relationships, but also we kind of know a lot of people are staying, so let's get them better ready day one. So, it's a really interesting way to look at it and especially like NYU Long Island, which has always been a three-year school and they don't have a lot of GME programs. So, a lot of people can't stay. Um, so I think, you know, we're learning a lot from those people's experiences. We're down the home stretch, everybody. Great comment. Thanks, David, for putting the number in that in that box. So, Arthur, why don't you kick us off, take us down the home stretch? Yeah, home stretch. So, you know, why does medical struggle with learners transitions? Um, you know, I think that the chat has actually brought it up incredibly well and probably reinforce it is that we undersupport transitions and we're not intentional enough. Um, I think there are a lot of ways we can be intentional and even simple things. I think it answers one of the questions about, you know, how do you deal with the variation of experience when when students come in to residence. We did this in Cincinnati when I was at the University of Cincinnati and the GME office. What we did is when every you know I asked all the program directors what are the basic skills that residents need to be successful day one they said putting in an IV this is like late 90s or early 2000s putting an IV being able to steril cloud and club simple suturing um some basic tasks and you know day three of orientation we had them go the basic tasks and just make sure you know were they proficient were they not proficient and if they weren't proficient great we could tell the program director hey so and so seem to be struggling on this you know, something you might want to add before they start. I mean, that was just a real basic type of assessment. That was more technical skills based because it was easier to assess than some of the more, you know, higher level interviewing skills. But I think you can definitely, you know, if you wanted to, you could come with a list of things and how do we know you can do it before you start? I think about, you know, the Cincinnati emergency medicine program. The first month of residency, they don't see patients. They're simming. They're they're doing OSKYs. They're doing all these things to get everybody on the same playing field um as they can before they release them out of the patient care setting. And I think it allowed the the incoming resident to feel like I feel a little bit better about everything. I got to know people. They got to know the nurses. You know, they were doing things in team- based approaches. I think that was just like a really intentional way of getting someone ready for, you know, a four-year emergency medicine residency in a pretty intense inner city setting. Um, you know, I think training occurs less in subsequent settings when where physicians will practice, especially when you know when you train people in academic health centers. They want to stay in academic health centers and that's what they know. So, it's very hard to go into rural practice or go to a suburban practice or go into the Indian health service. My wife went to the military. Military medicine is very different um than non-military medicine as far as this this transitions that they have in the military. So once again, we try to train them the best we can, but I think we can do a better job of, you know, especially with electives and different things of getting people experiences where they need um would be great. Um, you know, we'll show we'll show some data in a second. People learn competencies at different times. We assume everyone's linear and some people bring different skill sets to the table based on past experiences, based on innate skills. Um, and everybody comes in the same. We don't expect them to come in the same. Um but you know of all the different core competencies I would hope their professionalism is pretty well established by the time they hit first year residency hopefully their communication skills are pretty well developed. Medical knowledge may not be you know you know if you were a nurse you know if you're a neurosurgery intern you may have done six weeks of neurosurgery total you're probably not going to know the vastness of neurosurgery that's fine we'll teach you that. You know we'll teach I'll teach you how to do a C-section. you know, that's my job, you know, is is helping people learn the theory and put it into practice. So, I think we have to realize that competency happens at different times, but it's definitely very clear at the beginning. Um, you know, makes me think of um think I'm the author, but one of the authors realized that if you look at hockey players that play for the Canadian national team, most of them are born in February, January, February, and March. Like, why is that? is because when they were little kids, you know, and the turnover date, you know, for each level is January. Like the kids that are six years old are a little bit bigger. If you're born in January, you're much bigger than you're born in December. They were identified early, given lots of coaching, and they were given every advantage to succeed. And if you happen to be born in December, you know, maybe when you were 8 12 years old, you grew a lot, but the coaching and all the support was gone. So, I think you realize that that's always makes you realize that people go at different rates. And here's another example. This is from Tom Nazca who was the head of the ACGME when competencies and milestones came out. And he he and I keep this slide. I mean, he probably doesn't even know he did it. This is probably the mid200s, but this is sort of recognizing there's a development and you can move this development into the space, but not everyone's going to develop competencies at the same rate. Um, and that's okay. Um, people bring in different skill sets, different experiences. Some are going to be innately different. systems based practice might be very hard to learn until you're really into it and you're really experiencing it. But then if you were a social worker or a care manager and if you did that in your gap year, you're probably really good at it. Um probably better than I am. Um I think one more slide and we'll let Jed, you know, here's another example of milestones. This is sort of a blessing and a curse. This is from the ACGE. This is national data, not not Virginia Tech, not Curillian. Um but you can see when we look how we evaluate is a little bit limited and this is a little suspicious like why is everyone meeting all their milestones at at the at the same year differently and I don't think that's true. I think our assessment methods especially in GME are probably very imperfect as we're looking at different specialties trying to really do competency based medical education. They're struggling because we don't have the assessment tools. Um especially want to do high risk because you know we're going to start doing variable time length of residency based on achieving competency. We're not there yet. This is sort of an example of that. This is sort of the antithesis of well we know how they're doing. Yeah. this seem this seems like wow you're a third year you're a level three you're a fourth year you're a level four or maybe this is how people are developing but I suspect um probably not the case um so I think there's still an opportunity for us how do we give feedback how do we assess and how do we help people along that continuum you know if you don't meet with your interns a couple of times in the first four months you probably aren't helping them very much you know a six-month evaluation for an intern is probably four months too late um to really sit down with them and see how they're doing um Jed Yeah, great comments there. LB's comment in the box. Arthur just highlighted time variable training, which I think we'll be able to get to um coming up. We're almost almost complete. This is a study that that we had done a couple years ago that comes at it from the other angle of what Arthur was just describing. Um this was a a multi-institution study in collaboration with the ACGME. We wanted to see those schools that are doing robust health system science education versus those schools that do not articulate a very robust HSS health system science education. How well do those graduates do in their residency program on those milestones in systems based practice and practice based learning and improvement? is essentially is if you you have the intervention in you and me and you're teaching all these in theory they should be further along on those milestones as they transition into the intern year. There's as everybody probably knows the holy grail really is connecting education to a patient level outcome which is so remarkably hard to do particularly for undergraduate medical education but then looking at interventions and the impact on skill development in GME has not been done that much. So this was one of the first foray into saying how can we actually it was a it was a beast to actually get the data from the ACGME um to make it happen. Fortunately some higherups were able to to make this happen. Um when you look at ACE here in the column, they're they're the schools that had um robust health system science education and the control or those schools that did not. So then you're looking at the percent difference in meeting those milestones SPIS based practice practice based learning and improvement across these specific specialties. And you can see that for the most part there was no identification of change or growth. um a schools versus not. The six boxes or five boxes I have in yellow were those that were statistically significant. So in OBGYN systems based practice one and two there was a statistically significant difference and trend towards uh those schools that that exposed the students to health system science but the numbers were very small. I think that was the key takeaway. One we were able to develop a process where we assessed me into GME which was a win. Um, but there weren't a lot of differences. They probably were not educationally meaningful. And it leaves a lot to unpack. Are the assessments reliable? Are they valid? Um, is that the right time difference? Is it assessing the right skills? Is the meme teaching and learning aligned with what those milestones are? Is there alignment? Because you could be doing a great job, but maybe you're act the assessment would be on a different milestone that actually doesn't exist. Um, and it raises questions how we can enhance education. So I use this as an example of this transition might be hard from from an education standpoint. It's also remarkably hard as Arthur already highlighted from an assessment standpoint. How do you know the things we're doing in me link really well with with the GME space? some of the transitions and ideally improvements or attenuation of the challenges in the transition really come down to identity. Um Arthur's commenting on professionalism, maybe medical knowledge. We can we can make up for that in some ways in certain areas. But the identity this is the cruis cruis model at the bottom of of the Miller's pyramid model of knows knows how shows and does. It's has been around for for decades. But this the modified amended Miller's pyramid is the cruis model where is and the identity lives at that peak. So all the knowledge and all the competencies and skills that one has it's enveloped in this identity that comes up at the peak. And for us at Virginia Tech Krillian, it's it's our three identities that work synergistically with the patient center physician. But these skills that are more ubiquitous, LB's comment in the box about leadership skills and health system science and Arthur's comment about professionalism, these more the harmonized milestones. This is a focus for us med to be thinking about how do we ensure these transitions no matter which specialty. It's not about the technical skills alone. It's also about these more crosscutting skills and the identity to help our learners transition into um the whatever lies ahead on the timeline for them and their growth. Yeah, Jen, I think it speaks a lot to you know it's having that expertise you know and think of the GME level. I mean GME is you know is structured very differently. it's really focused around a model of providing care and education um at the same time but you know provision of care is kind of the focus and I think as you're looking at all these things about intentionality um you know I'm thinking about a job that I did not take um where they want to be a division director for a general division of 36 physicians many that were very junior and they were going to give me half a day a week to do it like I can't meet with them like if you know I was just doing the math like I was going to spend one hour with each of them that's 34 hours I have half a Hey, it's going to take me a year just to talk to them. So, like they weren't investing in what they wanted. So, I think it's had that you you know, how do you invest and how do you be intentional? It's a great discussion um of of you know, I think we know what we can do, but I think you have to change the systems of care a little bit because, you know, a division director could be a really good person. Some division directors have a lot of people in them and they all have varying needs and they may not be the best people to coach. I mean, you know, we've been, you know, I I applaud the medical school known transition of, you know, starting medical school the PMI program. Let's give each of them each of the medical students a coach to help them not talk about, you know, not an adviser, not a mentor, but a coach. How do we help them go through this transition? Um, you know, we do it in residency in a different way, but I think we can be more intentional. I think we have a lot of opportunity um into into attending hood into practice of how do you take these things um you know and I think we try to do some things like you know the GME core curriculum we have kind of we highlight three topics every year an educational topic a health system science topic and a leadership topic um once again that's educational that's not so much the coaching but at least it's that awareness and that's of the importance of it you're trying to model some of that but I think you know getting to the nitty-gritty level of what's happening at the bedside what's happening in departments, you know, that's that's where systems matter. Um, and it's adapting those systems. And I think all these ideas that people are posting of, you know, how do you do it? Um, you know, these are things we have to hear so we can sort of like how do we do that? Why can't we do that? Why do some places do it? And we're still on that journey. Um, to me, that's really important. So, I appreciate these comments. And hopefully, as I look, you know, this final slide is just the evolution of the white coat. And you know, jokingly, I look at my white coat in the corner. It is nicely pressed, has only been used once at a white coat ceremony. I don't wear a white coat. I'm an OB. That's all I have to say. You don't want your be wearing white coats during the course of their work. Um, but I mean, there's a meaning of the white coat and the white coat still has incredible importance and significance. Um, but it definitely is used very differently depending on where you are. So, I mean, yes or no, Arthur, do you still have your med school white coat? Uh, I probably don't, but I do have my residency blue coat because we have blue coats in residency and I have white coats from a Cincinnati job and my my Asheville job. I've kept them. I think a lot of them also were used for smocks for my daughter when she was younger. It's great for painting. Old white coats are really good for kids either for dress up or artwork. That's all we have everybody. Paul, please we see your hand up. Oh, yeah. Thank you. Um, yeah, I just wanted to make a couple of points. you guys uh touched on these um but especially for internship fellowship and junior attending um it really is a conglomeration of of events and experiences that takes one through this journey to being a competent expert physician. But one thing is structural. So many programs for instance during July and August for the interns will structure their team. So a senior resident is leading that team and certain attendees who are particularly good at mentoring and guiding are on those particular teams as things go forward. And the other thing is you know the notion of internship, residency and fellowship really as an apprenticeship and you touched on this in terms of private practice but it's true in academia as well. The old see one do one teach one is sort of true and I think most of our interns and residents although they come in at different stages the physicians who are leading the teams and doing the procedures and instructing those particular interns and residents firsthand along with the nurses and all the interprofessional things are incredibly critical. So it's it's not just a lecture on this or a course on this or prepping in this way. It's really who your mentors are. Most of us can remember those mentors from the earlier years and throughout our lives. So what your talk has highlighted for me especially is the importance of mentorship and guidance and viewing these experiences especially again in the GME world and junior junior attending world as as having an important apprentice apprentichip aspect. Thank you. No thanks Paul. I mean there's so many good points in that and I think you know the one struggle I've had you know sort of in a leadership position is when does someone need a coach versus a mentor they're actually very different right and I think identifying which is the right relationship to have and who's that right person have a relationship you know I would say I became a better coach after I went into addiction and I realized it's the same as do motivational interviewing talk less smile more um helps a lot but I think that's a different skill set so I think it's also when you identify the need getting the right person to be that person and not flipping roles too often because it's easy to sort of slip into this is how I was taught and I had you know these mentors who were you know had great wisdom that never applied to me. Um but you know they they had the best of intentions. I I I'll also say I'm almost talking about the hands-on, you know, doctor or nurse who says to the intern who wants to give a patient 80 mill equivalents of potassium chloride over 10 minutes. You can't do that and then explain why you can't do that. So much of it is just hands-on. Yeah, great point. Yeah, Paul, it's a reminder, at least for me, not to make assumptions. I mean, you think an M2 students here, well, they know the routine. They're they're good to go. They just spent a whole year with us, but let's not make assumptions about that. Like, they're going through their own transition and stretch just like an intern coming in or an R2. Dr. Schlupner, do you want to comment because I know your comments in the box here related to mentorship during these transitions, similar to to Dr. Skolnick's comments. Or we can go to Farrell. Farrell's got his hand up. We'll go to Frell for now. I've left Charlie speechless. I think um I hope you guys can hear me. The uh my question is sort of in regards to you know one of the comments uh that Jed made uh was related to uh programs that have higher rates of students who are staying there for their GME program and the opportunities for longitudinal coaching there. But I was wondering if you can comment on some of the um you know potential barriers surrounding uh sort of that feed forward type of feedback um and what that you know what that puts those individuals at risk in terms of bias, stigma, um privacy. H so how do how do those schools overcome those types of barriers and are there other ways to implement that for students who are moving to other institutions? Yeah, I mean Frell for the you know what we're trying to do in OB we're going to make it you know and this takes a lot of bravery but it's going to be sort of internled. I'm going to sh I'm going to share where I think I need improvement. Now, that's takes that hits a lot of coaching and a high level of psychological safety. So, but I mean, Furpa doesn't really apply to GME. It may or may not depending on the on the instance. So, there's something there's some legal issues, but I think I think there's always a concern that we're going to brand somebody. Oh, they're the one who struggles with not tying or they're the one who gets nervous in front of patients. Um, I think most times you figure that out in the end. So, I'd rather, you know, I'd rather address it on the front end than on the back end in most cases. But I think how that happens and the actual mechanism is a little tricky because there's a balance there because you don't want to pigeon hole people at the same time you want people to you know identify opportunities for growth and be brave enough to say I need help in this area like you know that would be I mean that's the ideal um how to do it is a little tricky 100% especially brand new intern trying to talk about these are my deepest darkest concerns to the program director or faculty that sounds great in theory but I I think in practice that'll be very difficult it might be more to cheer the senior residents or other people. But it's you bring up some great points. Yeah. And it also happens phase one to phase two. What do we do from the pre-clerkship curriculum into the clerkship? Should we feed forward? I mean, Frell's been in those discussions, too, but I don't think there's a clear answer. Yeah. I just I'm just curious. Um so um so are there um so is Arthur is that something that you're going to be implementing like right at the beginning of internship year and if so do they really have the experiential context to know what they don't know yet? I mean that's the plan. I mean, I think every transition you learn and it's always a constant assessment, right? And if you're looking about how do you take data to improve your outcomes, you only have the data you have, right? This is what I'm worried about moving in. This is where my relative strengths lie. Um, you know, the learning curve, especially first year of residency, is so high, right? Um, you know, it's hard to know. Um, but I think it's it's a start of a conversation of sort of an intentionality that doesn't currently exist. It'll be probably imperfect. I mean, it will be imperfect. I I don't think we've got everyone on board yet. Uh I think we have a lot of people leadership nationally know like this makes sense. Um but you know the devil's in the details for sure. Dr. Rubio please. I was thinking that the good lecture by the way you know very good important points but on on the people that transition from med school to residency the good thing is that we have them here right so we can actually coach them and mentor them or whatever you feel is best for each person. But one of my concerns on the uh fellowship side is getting people ready for practice afterwards. And and that's where we are not going to have as much control because we don't have anything afterwards, right? But we want to make sure they're going to succeed. And you're correct. There's about 20% private practices right now. Most everybody else is employed now. But there's also a difference between being employed in corporate for-profit medicine than being employed in an academic center. So I would say that we still have likely a majority of people that really work more for profit kind of private practice like model which is quite different than the way we train people. So I think it's very important that that we maybe develop some task forces or or groups within sections and practices that ideally have people that have worked in private practice before or or or the sort of for-profit model that maybe can guide through the years you know all our fellows to do that because the turnover is huge. I mean it's still there about 30 plus% of people will change jobs within a couple of years and definitely it's not just bad for the people hiring them but it's bad for them because they're getting very disappointed. They're having wrong expectations of volume of patients, you know, that affect their quality of life and work life balance of wrong expectations of salaries, wrong expectations of benefits, you know, of what does it mean to work with a group of smaller people where for instance now everything you do impacts everybody else and you're not just one piece of a puzzle, you know, of a gigantic universe where it may not matter as much and I don't think in that sense we have done a good job of uh setting up ways for our teams to be able to help folks get to that. And some of them come to me sometimes even worrying about billing. What am I going to do when I graduate, you know, with my billing because if my billing is not to par, my salary going to get cut down. So, I think it'd be nice to to look forward to how can we implement mechanisms to address better their needs after they graduate from us. No, great point. I mean, you know, how structures change. When I was a resident, I would say I probably did 70% of my surgeries with private practice attendings and the private practice attendings actually as part of their relationship actually covered our outpatient clinic. So, there was a constant dialogue with people who are actually in real practice, whatever that meant. But I think that gets lost when you don't have those people anymore, right? So, there is this, you know, lovely intentionality of what could happen, but now as a dynamic chain, how do we replace that? I think once again I think it's how do we focus on it and how do we identify it and how each of us do it a little bit differently because you're right that fellowship transition you know in a subsp specialty might be different than going into family medicine in a general practice or to be in general practice so you really need that that content expertise as well as the the bigger picture stuff but Dr. sloper, please. I know you've been waiting. I know. Yeah, you get to hear us out of this one. Can you hear me? Yes, sir. Good. I There was a problem with the mic. I I really want to say I think this discussion has been great and I I've been involved with mentoring both faculty and students. I was reflecting back on what happened with me and there were no formal programs, but I generally sought out. So I think one of the things we have to rely upon and teach the students residents to seek a mentor, someone who provides advice. The last comment that I'll make because I don't want to prolong this for any of us, the June 26 New England Journal had the first of a series of articles that dealt with medical education. And I was I read that article and I it's Chad Deont and I have had some discussions back and forth. um uh in by email about it. But I I really think that that article sets the tone for the need for me and GME to start to talk and get together. uh whether that occurs just at the individual programs level like Korean clinic with BTC or wherever it is. I just think that is important because we have challenges ahead of us right now and our profession depends upon succeeding. Enough said. Thank you. Thank you for leading this discussion as well. Thank you all for leading a fabulous discussion there. Um clearly there are multiple points of transition beyond the um obvious even um that that we need to think about as faculty members. Um if anybody I I clearly realize we're two minutes past. If anybody wants to stay on for a couple of minutes has any additional questions you can either um email Arthur and Jed and or stay on for a few minutes and ask yourself. So otherwise, enjoy the rest of your day and thank you for being here.