Graduate Medical Education: Is There Value Beyond What Meets the Eye?

Graduate medical education (GME) programs are intertwined in the mission and vison of all academic centers and many community medical centers, because they provide significant value across many fronts. The better we understand the value of GME programs, the better we can understand how to collaborate with education leaders to design strategic plans that maximize benefit to the institution.

Traditionally, GME programs have been relied upon to enhance general service line staffing as well as staffing in niche subspecialty areas. The resulting cost reduction, improved patient outcomes, and staffing during emergency settings such as the recent pandemic are also well-recognized benefits. GME programs also provide value beyond what is traditionally recognized—an unconventional value that directly affects institutions. These programs increase faculty retention and create an alumni network, which, in turn, reduce the cost of turnover. The programs also contribute to both the personal brand of faculty members and also the brand of the entire organization through publishing of research and other content on social media platforms. Finally, GME programs contribute significantly to diversity, equity, and inclusion (DEI) by increasing the number of physicians who represent our patient populations. Programs serve the community through service efforts, advocacy, and mentorship initiatives.

Conventional Value

Let us begin by assessing the conventional benefit of GME programs, with a special focus on community health systems:

1. They afford the opportunity for service line expansion, which is necessary because the number of patients relative to healthcare providers is rising, particularly in wake of the COVID-19 pandemic and subsequent provider burnout. For example, in primary care, the increased number of advanced practice providers (APPs) has not been sufficient to address this supply-and-demand dilemma.(1)

2. In the community setting GME programs provide a reliable pool of re-deployable healthcare providers in public health emergencies. In teaching institutions, the physician workforce is largely composed of GME trainees who serve as the cornerstone of healthcare systems’ ability to address such emergencies, as was the case in the COVID-19 pandemic.(2)

3. The presence of trainees (i.e., residents, fellows, and medical students) enhances staffing of services in specialties that face difficulty in recruiting applicants. Trainees also cover undesirable shifts, such as weekends and nights.

4. GME programs are likely to reduce the overall cost of care. Although some studies assert that there are added costs in time and other productivity metrics associated with trainees (i.e., residents and fellows), this is likely true only in the initial period of training. When considering the broader benefit to the hospital and community, GME programs appear to be worth the initial cost. Employing APPs, compared with residents, increases the cost to the institution with minimal effect on patient outcomes, ultimately resulting in a net financial loss.(3,4) This cost reduction benefit is especially helpful for community programs, which are more reliant on revenue from primary and secondary level care, as opposed to academic programs, which have various funding sources, including research grants.(5) Additionally, increased scholarly activity and quality improvement projects improve patient outcomes and enhance revenue.

5. GME programs offer improvement on multiple levels. For example, mortality rates at 7, 30, and 90 days in more than 21 million Medicare admissions (for 15 medical and 6 surgical conditions) were shown to be lower in teaching hospitals compared with non-teaching hospitals, with a linear inverse relationship between volume and mortality.(6,7) These results were replicated in studies that looked at admissions to specific specialties and diseases, such as general surgery, vascular surgery, acute myocardial infarction, heart failure, and pneumonia.(8) Patient safety also is enhanced through education, as in the case of morbidity and mortality conferences. Thus, the investment in teaching returns excellent value for resources utilized.

6. GME programs contribute to the perpetuation and growth of the existing culture in the home institution. Given the “imprinting” phenomenon, whereby trainees’ clinical environment influences their behaviors and practice patterns for decades after the completion of their training, these downstream effects contribute to a more seamless transition into practice when faculty are retained at their home institution.(9) Therefore, costs related to orientation and cultural barriers are minimized.(10)

Unconventional Value

Next, let us examine the unconventional value that GME programs offer from a faculty and alumni, branding, social responsibility, and DEI perspective.

Faculty and Alumni

Hospitals with GME programs benefit from increased faculty retention, reduction of burnout, and creation of a broad alumni network. Programs that are continuously improved to meet the needs of their trainees directly increase the likelihood that residents will be retained for fellowship, and thereafter as faculty. Trainees who stay with a program following training are more likely to give back to that program. Furthermore, post-graduate trainees commonly remain committed to the communities they served during residency and fellowship, and they work to fulfill the needs of these particular communities.(11) Thus, the community derives invaluable direct benefits from the graduate medical programs. However, there are also substantial indirect benefits: for example, the positive impact of trainees’ spouses and families on the communities in which they live. This positive effect extends outside of medicine, influencing the local economy, academics, and many other related factors.(12) Thus, trainees’ commitment to their communities helps establish pipelines through which recruiting and retention take place.

Early efforts to incorporate trainees into quality improvement projects and other academic endeavors foster an environment of invested learning.

The environment of academic medicine created by GME programs also reduces burnout. With less reported burnout and a resulting lower turnover rate, new staff members are readier and more willing to contribute to their training institutions, in ways such as a greater affinity for contributions to quality improvement initiatives and more seamless transitions into meaningful leadership roles.(11) Early efforts to incorporate trainees into quality improvement projects and other academic endeavors foster an environment of invested learning, which leads to retention.(11)

This engagement during training makes physicians more likely to desire to stay and to invest in growing the programs from which they graduated. As a result, an alumni network is established within the program and serves as an unspoken perpetual recruitment method. Potential trainees and staff members observe retention and see a positive place in which to work and grow in their careers. Witnessing a positive work environment has a significant impact during training, because it encourages trainees to stay and further contributes to the development of an alumni network.(13) In academic medicine, graduates of programs represent their training institutions at conferences locally, regionally, nationally, and internationally, weaving an alumni lattice for expanded recruitment efforts. This fosters opportunities for career advancement and educational growth, strengthening the alumni connection, and, in turn, contributing to career satisfaction and retention. Utilizing one’s alumni association allows for networking, career services and counseling, access to institution publications, mentorship, and exclusive job opportunities.(14) An alumni network therefore creates a positive culture for medical trainees, influences them to stay at their home institution, and inspires them to lead.(11)

Branding

All leaders seek to improve the brand name of their organizations. The presence of GME in a hospital system plays a significant role in branding throughout the system. Branding can take several forms, but a key element is exuding positive imagery on both the personal and organizational levels. Positive personal and organizational branding can potentially lead to increases in staff recruitment and retention as well as patient perception.

The personal branding that potential or actual thought leaders create is very valuable to the system, and manifests in several ways. Today it is most often quantified in the social media arena. For example, if faculty members have a social media following under their professional accounts (e.g., X [formerly Twitter], LinkedIn, Facebook), they can share the work they are doing for the institution on these platforms. Sharing the ongoing research production of their departments helps improve the brand of both the faculty members themselves and the institution. In fact, the sharing of academic work on social media and the subsequent crowd engagement that it produces is now a viable area of consideration for academic promotion.(15) This is a “win-win” for the institution: the faculty members are improving their academic CVs while the department (and by proxy, the institution) is also refining its branding.

The organizational branding that comes with GME is valuable to the system.

Furthermore, the organizational branding that comes with GME is valuable to the system. Within each academic specialty or subspecialty there is an opportunity for the showing and growing of the individual program’s brand. Each residency program and fellowship program can create and maintain a public-facing social media profile.(16) Using this social media profile, a program can highlight its trainees, faculty, research, social events, and more. By creating a profile and curating the content portrayed there, each program can show the culture of their people and the organization. Outsiders looking at the profile may be searching for a place to train, a place to work, or a place to choose for their own healthcare needs. Having a social media profile that is interactive, educational, and informative could potentially assist with recruitment for the program and the organization.(17) Furthermore, as the technologically facile millennials and Generation Z patients enter the market, active social media profiles can help with increasing hospital market share in these age groups. Another innovative value to be leveraged within this branding effort is the internal development of trainees to represent their own programs on their own outward facing social media profiles. Mentoring trainees to build their brand actively, as well as the brand of their program and organizations, instills dynamic leadership skills while simultaneously benefiting the entire organization.(18)

Social Responsibility

The GME system is, essentially, an implicit social contract, one that the public subsidizes in order to produce physicians who meet society’s needs. Much of what is included under the conventional value of GME falls under the umbrella of social value, such as the areas of service after completion of training, providing value-based care, and reducing overall healthcare cost.(19)

It can be argued, however, that the unconventional societal value of GME programs has increased exponentially in recent years, particularly in wake of the COVID-19 pandemic. As hospital systems were facing increasing staffing shortages in virtually all employee service lines, GME trainees remained a foundation that hospital systems could rely on. Across the country, GME programs responded to the COVID-19 pandemic in various ways, including mobilizing procedural teams, communication skills training (e.g., goals-of-care conversations), and protocol development (e.g., proning checklists). Most notably, trainees across the country were redeployed to staff medical teams in overwhelmed acute care settings. One might argue that these are all conventional benefits of GME programs. However, in some institutions, trainees went beyond. They were additionally involved in training other healthcare providers during the pandemic and helping faculty with pandemic preparedness initiatives.

Outside of COVID-19, GME programs also have been involved in different outlets of community service. In a recent program director (PD) survey, more than 80% of PDs stated that community service was moderately to extremely important to their residency programs. Such services included involvement with free or underserved clinics, advocacy, mentorship, and educational outreach.(20) This is in addition to program-driven blood donation drives and other initiatives that are more difficult to account for. It is clear that GME programs have numerous pivotal unconventional social contributions that are not yet well quantified.

Diversity, Equity, and Inclusion

In 2019, the Accreditation Council for Graduate Medical Education introduced diversity accreditation standards as part of the common program requirements. The goal of establishing such initiatives is not only to achieve equity and justice for faculty and trainees of diverse backgrounds, but also to achieve these goals for patients and communities, with the ultimate goal of reducing healthcare disparities by training future leaders, educators, and caregivers.(21) Following this initiative, GME programs are now required to report on their recruitment and retention practices to develop greater diversity.(22) This naturally led to an uptick in establishing diversity, equity, and inclusion (DEI) initiatives across GME programs.(23)

A recent evaluation of DEI initiatives at exemplary GME programs identified different foundational strategies that are easy to establish across the country. These include incorporating DEI in program mission statements, holistic reviews during recruitment, training on mitigating implicit bias, establishing DEI committees and mentorship initiatives, and retention efforts targeting improved faculty diversity. The sidebar provides a summary of these initiatives.(23) Given that these requirements have only recently been instituted, the outcome of these DEI initiatives are not yet part of the conventional scope of GME programs. Moving forward, however, as these requirements become more enforceable, such outcomes will become a part of the conventional value of GME, with significantly positive societal and community implications.

Conclusion

The value of GME extends beyond conventional dimensions, encompassing various aspects that contribute to the impact and success of healthcare institutions. GME programs traditionally are valued for addressing healthcare service demands, enhancing staffing in challenging specialties, reducing costs, improving patient outcomes, and preserving institutional culture. However, there are additional unconventional values that deserve recognition.

GME programs serve a significant role in faculty retention and alumni network creation. By tailoring programs to enhance trainee experiences, institutions increase the likelihood of trainees staying on as faculty, ensuring institutional continuity and growth. Trainees’ commitment to their communities during training also benefits those communities economically and academically.

GME programs are a key element of branding efforts. Faculty members can share their work and research on social media, thereby improving personal and institutional brands. Residency and fellowship programs, as well as respective trainees, can establish public-facing social media profiles to highlight culture, research, and events. The profiles serve to attract new patients and competitive applicants.

Furthermore, GME programs fulfill social responsibilities and promote DEI. They provided vital support during the COVID-19 pandemic; and actively engage in community service, advocacy, and mentorship. The programs help expand hospital DEI initiatives as they actively recruit and retain diverse trainees and faculty. Consequently, programs reduce healthcare disparities and enhance patient care.

In summary, GME programs offer unconventional values far beyond their conventional benefits. Faculty retention, alumni networks, branding, social responsibility, and DEI initiatives all contribute to the success of their respective healthcare systems. Recognizing these values is crucial for healthcare institutions to thrive and provide high-quality care in an ever-evolving landscape.

References

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13. Sperico J. How alumni can help drive student enrollment and retention. The EvoLLLution: A Modern Campus Illumination. September 2021. https://evolllution.com/revenue-streams/market_opportunities/how-alumni-can-help-drive-student-enrollment-and-retention .

14. 5 Ways to Use Your Alumni Network Effectively. Ultimate Medical Academy. November 2016. www.ultimatemedical.edu/blog/5-ways-use-alumni-network-effectively/ .

15. Gambril JA, Boyd CJ, Egbaria J. The numerous benefits of social media for medicine. Comment on “Documenting social media engagement as scholarship: a new model for assessing academic accomplishment for the health professions.” J Med Internet Res. 2021;23(6):e27664. https://doi.org/10.2196/27664 .

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21. Kara A, Wright C, Funches L, et al. Serving on a graduate medical education diversity, equity, inclusion, and justice committee: lessons learned from a journey of growth and healing. Front. Public Health. 2022;10:867035.  https://doi.org/10.3389/fpubh.2022.867035 .

22. Common program requirements (residency)Accreditation Council of Graduate Medical Education. 2022. Accessed April 7, 2023.  www.acgme.org/globalassets/PFAssets/ProgramRequirements/CPRResidency_2022v2.pdf

23. Boatright D, London M, Soriano AJ, et al. Strategies and best practices to improve diversity, equity, and inclusion among US graduate medical education programs. JAMA Netw Open. 2023;6(2)e2255110. https://doi.org/10.1001/jamanetworkopen.2022.55110 .