COUNCIL OF TRANSITIONAL YEAR PROGRAM DIRECTORSCHAIR: DAPHNE NORWOOD, MD MPH FACPOVERVIEW FOR CTYPD ANNUAL MEETING/AHME INSTITUTE MAY 2015

The State of the Transitional Year:Present and Future

Potential Benefits of TY Programs• Attracts medical students with high grades, high USMLE/COMLEX

scores. • Can serve to attract physicians with subspecialty training such as

dermatology, ophthalmology, PM+R, neurology, anesthesia and radiology, rad on back to an area without those residencies.

• One year program with milestones to guide competency and a dedicated program director to achieve those goals.

• 28 weeks of fundamental clinical skills, with ambulatory and Emergency Room experience.

• Customizable to the needs of residents with different career goals. • Potential QI with smart residents who have a view across the silos of

various residency programs/departments. 3

Transitional Year Residency Program Demographics1,179 residents entered GME training in 108 Transitional Year Programs

70% male/30% female

83% US LCME grads (974), 10% US Osteopathic (113), 8% IMG (92)

12% Positions (147) were in 9 Military ACGME TY Programs.

33 DO’s matched into civilian TY programs in the Match in 2014. (NRMP)

(does not include military or SOAP numbers)

Appears that a higher percentage of military TY residents might be DO compared to civilian TY residents.

GME Data Resource Book 2013-2014, ACGME

The State of the Transitional Year:Data Sources and Limitations•ACGME, GME Source Book 2013-2014 and ACGME Specific Program Data includes all civilian and military TY programs but does not include summative data for other prelim PGY-1

•ERAS Cross Specialty Applicant Data, 2011-2014. AAMC. Not available for ophthalmology.

•NRMP, Advance Data Tables for 2015 Residency Match, includes data on TY programs, TY tracks, preliminary programs but not on military programs or ophthalmology

•Next Programs – the Advanced and Physician (R) Matches (NRMP and SFMatch)

•TYPD Data: JGME TYPD Survey, 2012 and TYPD ACGME Data

•AOA (American Osteopathic Association) and ACGME website on future accreditation and OGME-3 “traditional rotating internship year”

NRMP – Transitional Year (Does not include Military)

Match Summary 2015

101 Transitional Year programs in the Match

842 TY PGY-1 positions is about 20% of Preliminary PGY1 TY (842), IM (1928), Surgery (1296), Pediatrics (36), OBGYN (21)

Total applicants 2,977 (Total U.S. 2,219 = 74.5%)

Matched Positions 790 (US 685)

Total Ranked TY positions by Applicants 18,736 (US 15,726)

Transitional Year Trends NRMP

7

2010 980 119 -28 -22011 952 117 -11 -72012 941 110 -4 02013 937 110 -69 -22014 868 108 -26 -72015 842 101

Offered Positions Civilian Programs in Match

0

500

1000

1500

2000

Transitional Year IM- Prelim Surgery- Prelim Pediatrics- Prelim

2011 2012 2013 2014 2015

+28

+117

-110

Preliminary Positions Offered in NRMP, 2011-2015

-17

Net Change in these Prelim Positions in the Match =+18. Not all available positions may have been in match prior to 2013, due to “All-In” policy.

Who matched in positions? NRMP 2015 (pre-SOAP)

9

0

500

1000

1500

2000

2011 2012 2013 2014 2015 2011 2012 2013 2014 2015

US Allopathic SeniorsOther (DO, IMG, Past Grads)Unfilled Postions

Transitional Preliminary Surgery

2011 2012 2013 2014 2015

Preliminary Medicine

0

1500

3000

4500

6000

Transitional Year IM-Prelim Surgery-Prelim Pediatrics-Prelim

Positions US Allopathic Seniors All Applicants

2.6:1

1.7:1

2.6:1

3.5:1

2.7:1

1.5:1

4.7:1

Applicants Submitting Ranks:Offered Position Ratios, NRMP 2015

0.75:1

0

15000

30000

45000

60000

Transitional Year IM-Prelim Surgery-Prelim Pediatrics-Prelim

US Allopathic Senior ApplicantUS Senior RanksAll ApplicantsAll Ranks

Ranked Programs/Applicant Ratios, NRMP 2015 (total ranks by applicants/# applicants in NRMP)

7:16:1

13:1

11:1

3:13:1

5:1 3:1

ERAS Applicants 2012-2014

12

0

1000

2000

3000

4000

5000

6000

7000

TY Also IM-P Also Surg-P Also Anesthes Also Rad Also Derm

2011 2012 2013 2014

Source: AAMC: ERAS Cross Specialty Applicant Data

*Since ERAS feeds military match, it ishard to accurately say “how many applicantsper program on average each program sees listed”for Transitional Year.

Transitional Year Program Voluntary Withdrawal ACGME 2010-2015 (15)

Academic Years 2013/2014-2014/2015 Albert Einstein Healthcare Network Program Arrowhead Regional Medical Center Program

Albert Einstein College of Medicine/Montefiore (New Rochelle) New York Hospital Medical Center of Queens/Cornell University Medical College Aultman Hospital/NEOMED Program Legacy Emanuel Hospital and Health Center Marshfield Clinic-St Joseph's Hospital Program

Academic Years 2010/2011-2012/2013 Flushing Hospital Medical Center Program

Mayo Clinic College of Medicine (Jacksonville) Program

Conemaugh Memorial Medical Center Program University of Texas Health Science Center at Houston

Carilion Clinic-Virginia Tech Carilion School of Medicine

Atlantic Health Program Voluntary Withdrawal 06/30/2011

Maimonides Medical Center Program

Allegheny Health Network Medical Education Consortium (WPH)

Texas Tech University Health Sciences Center Paul L Foster School of Medicine

New Transitional Year Programs ACGME 2010-2015 (6) and Beyond

Academic Years 2015/2016

Stony Brook Medicine/Mather Hospital Program

Kaweah Delta Health Care District (KDHCD)

Lincoln Medical and Mental Health Center

Oakwood Heritage Hospital Program

St Mary Mercy Hospital Program

University of Puerto Rico School of Medicine

Anticipated New Programs 5 programs + (“word of mouth”)

Possible other growth from ACGME / AOA accreditation merger AOA= American Osteopathic Association

“DO Traditional Rotating Year” (>70 programs) Have until 2020 to submit application and gain “pre-accreditation” but may have a diminishing number of places to send people to as their pre-accreditation lags behind their sponsoring institutions and programs getting pre-accreditation

Transitional Year Accreditation

98% with Full Accreditation

2% with Warning

0 on Probation

Mean Number of Residents – 10.9, Range 0-30, ACGME Minimum 4

ACGME Website, GME Source Book 2013-2014

Transitional Year Outcomes

Completion Rate 98.9% (13 did not complete – 1.1%) Dismissed : 2

Transferred: 7

Withdrew: 4

Outcome data for other preliminary year (IM, Surgery, Pediatrics) is not available from ACGME Source Book but is requested from ACGME.

ACGME Website, GME Source Book 2013-2014

“Advanced” Programs are the major “Consumers” of TY Residents

An Advanced Programs has positions that begin 1 year after the end of medical school and require a clinical base year.

A medical student would participate in the NRMP in 2 matches (preliminary/TY) and advanced program or in NRMP (prelim) and SFMatch (ophthalmology)or Military Match.

Ophthalmology has a separate match, SFMatch.

Advanced Positions Offered 2011-2015NRMP Match and SFMatch*

0

183

367

550

733

917

1100

Radiology Anesthesia Ophthalmology* Dermatology Neurology PM+R Radiation Oncology2011 2012 2013 2014 2015

-57

+41

+6

-26 -5

b +21

In the 7 major advanced program types, there was only a net loss of 1 position between 2011-2015.

+19

Other Advanced Positions in the NRMP Match2011 2012 2013 2014 2015

Child Neurology 1 0 47 37 28 24

Emergency Medicine 19 0 0 0 0

Neuro-developmental Disabilities 2

0 7 7 5 5

Plastic Surgery 38 20 11 6 0Preventive Medicine 1 1 3 2 2

Psychiatry 4 3 2 2 1Psychiatry-Neurology 1 0 1 0 1

Radiology- Nuclear Medicine

0 0 0 1 1

Nuclear Medicine 6 4 5 4 3

1- Not TY eligible; requires Peds/FM/IM 2-Not TY Eligible, requires Peds Gray= No advanced programs

Anesthesia ACGME Program Requirements (effective 7/1/2014)

20

Duration and Scope of Education Length of Program

A minimum of 48 months of graduate medical education is necessary to train a physician in the field of anesthesiology. Thirty-six months of the education must be in clinical anesthesia. The Review Committee and the Accreditation Council for Graduate Medical Education (ACGME) accredit programs only in those institutions that possess the educational resources to provide three years of clinical anesthesia education. The capability to provide the Clinical Base Year within the same institution is desirable but not required for accreditation. (Core)

0

200

400

600

800

1000

1200

Radiology Categorical

Radiology Advanced

Anesthesiology Categorical

Anesthesiology Advanced

2011 2012 2013 2014 2015

+19 +255

-57

-10

NRMP Positions in Match, 2011-2015

If your TY resident does not achieve an “advanced” position… There are Physician (R) Positions which are PGY-2 Match Spots for applicants in or with graduate medical education already.

Unlike advanced positions, which lag a year, Physician (R) Positions are available for PGY-1 residents (such as TY residents) to apply for a match spot during their PGY-1 year and start at the end of their PGY-1 year.

There were almost no spots in Physician (R) PGY-2 match in 2011. In 2015, there were 221 spots available for matching. Most of these were in fields potentially filled with TY residents (182).

Physician (R) Positions in NRMP Match2011-2015

(There is no R2 Match for Ophthalmology)

0

25

50

75

100

Radiology Anesthesia Dermatology Neurology PM+R Radiation Oncology

2011 2012 2013 2014 2015

One Accreditation - ACGME Many types of TY programs! The theme of CTYPD workshops, therefore, this year, is:

Competency from Beginning to End of PGY-1 Year.

But what are the necessary competencies for a TY intern? Milestones! Look to CTYPD website changes to include best practices. Ability to adjust and comment on ACGME Milestones 2.0 coming soon!

Transitional Year Demographics – Sponsors (ACGME) All ACGME sponsored TY programs must have 2 sponsors – some have up to four.

Most common sponsors are: Internal Medicine, Family Medicine, Emergency Medicine, Surgery, Radiology, Anesthesia, Pediatrics

25% of time of the curriculum should be spent in one of of the sponsoring programs.

Defining the TY Residency (NRMP) About 16 Transitional Year Residencies (2010-14) have “tracks”. TY Programs have from 0-5 Tracks but most do not list a track. Anesthesia 6 Radiology 8 Neuro 3 Institution 2 Radiation Oncology 1 Derm 1

* Multiple tracks may exist at one institution. Some listed tracks do not appear to have positions assigned.

ACGME Program Data For Military Programs(**Unconfirmed estimates from 2014 ACGME Specific Program Data)

2014: 147 Transitional Year residents in 9 Institutional Sites Other preliminary Surgery and Medicine slots exist - count is not clear.

Approximately 106 Advanced Residencies requiring clinical base year. (Radiology-39, Anesthesia-35, Dermatology-18, Opthalmology-16, Rad Onc-2,

Neurology-2)

Preliminary year residents may do their preliminary year either within the military or outside the military.

Differences in Military TY Programs•A significant number of graduates need to be prepared to be medical officers, deferring additional medical training.

•Most military anesthesia and radiology Programs are Advanced (not Categorical).

•Higher turnover of TY program directors (6/9 are new since 2013) – but most are sub-specialty trained.

•Many TY PD’s are not in the specialty of their TY program’s main sponsor.

•ERAS used, but separate military match not at same time as NRMP.

DO Medical Graduates and ACGME In 2013, 17,937 DO’s in postgraduate medical training.

By 2020, accreditation must be through ACGME.

29

AOA8,210

ACGME9,727

54%

46%

Other4,222

Primary Care3,978

51%

49%

ACGME and AOA Merger AOA will be part of BoD for ACGME

Each RC will have members that are nominated by the AOA (0 to > 3 reps)

The number varies by specialty:

0 for Radiation Oncology

1 for Anesthesiology, Radiology, Neurology, Dermatology, Ophthalmology

3 for Transitional Year.

Webinar about merger w.r.t. Transitional Year was April 29, 2015 and will be available at ACGME website soon.

30

Traditional Rotating Internship (TRI) AOA Accredited

OGME-3 (Traditional Rotating Internship Year or TRI) may be considered for ACGME accreditation from 7/1/2015-2020.

As of July 1, 2014, ACGME residencies can not accept non-ACGME certified preliminary years. Previously, a waiver was accepted.

Four states have required a TRI for State Board DO licensure: Florida, Michigan Pennsylvania and Oklahoma. To bypass this requirement, resident physicians must apply for a resolution 42 waiver. Most can get this.

Pathway for Osteopathic Transitional Year Internship to become ACGME recognized• Must be sponsored by an institution which is either ACGME-accredited OR in pre-

accreditation status (paperwork submitted between July 1, 2015 and July 1, 2020)

• Must ALSO be sponsored by at least two core specialty programs (IM, Fam Med, EM, General Surgery, Pediatrics or OB-GYN) which are ACGME accredited OR have pre-accreditation status.

• At least one of those programs must be sponsored by the same Sponsoring Institution as the TY program. The other may be in a participating site.

• If the sponsoring institution and the sponsoring programs have submitted applications by July 1, 2015, they have “pre-accreditation status” and the concomitant AOA accredited internship program can also submit application and have “pre-accreditation status”.

• These internship programs will remain in “pre-accreditation” status until the sponsor programs are ACGME accredited and there is compliance with all current ACGME PR’s. There may be an AOA co-PD and AOA-certified faculty, but not solo AOA PD.

32

2015 ACGME

Transitional Year Key Points • Transitional Year residencies have very high numbers of high quality

applicants and ranks per position as compared to other preliminary positions.

• TY outcomes are excellent - high success rate with completion of residency and no programs on probation.

• Over the past 5 years, although some advanced program numbers are shifting, the need for preliminary positions has remained steady and may be growing in certain fields.

• There has been a drop in Transitional Year program numbers and positions, but shifting to other preliminary type positions may not necessarily match applicant or advanced program desires and needs

• With 2014 ACGME policy for advanced positions requiring ACGME preliminary year, more DO’s may apply for TY spots.

• There may be a significant number of existing DO programs applying to be TY in the next 5 years and a growing number of new programs.

Transitional Year Key Points • Sub-groups of Transitional Year residencies may have unique

characteristics (programs with specific tracks, military programs).

• An understanding and transparency of the demographics of these sub-group TY Programs may aid in assisting applicants in finding a good preliminary program fit.

• A better understanding of the goals and feedback of medical students, graduates and next programs should likely guide accreditation criteria. CTYPD should advocate in this regard.

• CTYPD is well-placed be a conduit of information about TY Programs to applicant, next programs and institutional administrators.

REFERENCES

1.Accreditation Council for Graduate Medical Education (ACGME). Public Programs and Sponsoring Institution Searchable Database. www.acgme.org/ads/Public. Accessed 3/24/2015.

2.Accreditation Council for Graduate Medical Education (ACGME). Data Resource Book 2009-2010. www.acgme.org/ads/Public.

3.American Osteopathic Association. http://www.osteopathic.org/inside-aoa/Education/postdoctoral-training/Pages/recognition-of-pgy1-year.aspx. Accessed 3/24/2015.

4.Craig SR, Smith HL, Short MW. Results from a Transitional Year Program Director Survey. JGME. March 2012, pp.28-33.

5.Institute of Medicine, National Acady of Sciences. Graduate Medical Education That Meets the Nation’s Health Needs. July 2014.

6.The Journal of the American Osteopathic Association, Vol. 104, pp 304-315.

7.National Residency Matching Program (NRMP). Program Results, 2010-2014. http://www.nrmp.org/match-data/main-residency-match-data/.

CTYPD Meeting May 19-20, 2016

MARRIOTT HARBOR BEACH FORT LAUDERDALE, FLORIDA

ASSOCIATION OF HOSPITAL MEDICAL EDUCATION60TH ANNIVERSARY

CTYPD Goals 2015-2016 - Feedback on Milestones and discuss Milestones 2.0

- Accreditation Feedback

- Gather best practices and enhance TY community with better website.

- Establish a more responsive Program Directors component to policies and notification of our members.

Website: Nikhil Goyal and Daphne Norwood

37

Looking to the Future–

• Creating a forum to show the value of the TY year. • Highlight Successes. • Identify Goals

•Website •Surveys, Purpose and Timeline

•Validate TY PD time, pay, position, needs for information

•Define what TY programs do best. •Assess Next Program Needs – Resident Skills and Information

•Assess Applicant and Resident Needs

TY Program Director Demographics•69% were male.

•Mean years as PD – 7.7.

•39% of TYPD were director or program director of another program.

•64% shared a program coordinator.

•72% were satisfied or very satisfied with time for duties,

•86% were satisfied or very satisfied with institutional support.

•58% were satisfied or very satisfied with salary support (12% dissatisfied)

•98% were satisfied or very satisfied with serving as TYPD.

Craig et al. TY Survey JGME,2012

TYPD Demographics 2013 •TY PD mean hours/week in key activities (34 hours, with 13.5 hours administrative) * Internal Med (45 hours, with 22 hours administrative) Family Med (39.5 hours, with 21 hours administrative) Surgery (57 hours, with 19 hours administrative)

•Program Director Tenure – Median 5 years, Mean 7.1 years •2013-2014 TY Programs with PD Change: 10 (at or below average) •TY Core Faculty #’s (Range 1-34, Mean 9.9 Faculty)

QUESTION: Are these survey driven estimates of time spent for TY PD’s indicative of their TOTAL key activity and administrative time or combined with their other PD duties? Is it meaningful or possible to separate these activities?

GME Source Book, 2013-2014, ACGME

COUNCIL MEETING THOUGHTS Transitional Year residency spots continue to shrink… as program directors who believe in the value of TY residency, what can we do?

41

One Year Residency is High Stakes

42

State Boards Allowing Licensure

After Only 1 year of Training (US Graduates)Alabama (ACGME only) Arizona Arkansas California Colorado Delaware Florida Georgia Hawaii Idaho Indiana Iowa Kansas Louisiana Maine Osteopathic

Maryland Michigan Osteopathic Minnesota Mississippi Missouri Nebraska New Mexico Osteopathic New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Osteopathic Puerto Rico

South Carolina Tennessee Texas Vermont Virginia Washington Osteopathic Washington DC West Virginia Wisconsin

Federation of State Medical Boards Web Site, Accessed 5/2015 http://www.fsmb.org/policy/public-resources/state_specific

State Boards Requiring More Than 1 Year

Training Before Licensure(US Grads)Alaska (2 years) Connecticut (2 years) Illinois (24 months) Kentucky (2 years) Maine Medical (3 years ACGME) Massachusetts Michigan Medical Board (2 years) Montana Nevada (2 years if signed agreement to practice in NV) New Hampshire (2 years) New Jersey (2 years in same field with contract for 3rd) New Mexico Medical Board (2 years) Pennsylvania Medical Board (2 years)

Rhode Island (2 years) South Dakota (Completion of Program) Utah (2 years) Washington Medical Board (2 years) Wyoming (2 years)

Federation of State Medical Boards Web Site, Accessed 5/2015 http://www.fsmb.org/policy/public-resources/state_specific

State Boards Allowing Unlimited Attempts/Unlimited Time at COMLEX Certifying Exam Passage Before Licensure

Alabama Arizona California Connecticut Florida Georgia Hawaii Idaho Maine Michigan Mississippi Nevada New Mexico New York Pennsylvania

Tennessee Washington Washington DC West Virginia

Federation of State Medical Boards Web Site, Accessed 5/2015 http://www.fsmb.org/policy/public-resources/state_specific

State Boards Allowing Unlimited Attempts/Unlimited Time at USLME Step 3 Certifying Exam Passage Before Licensure

Florida Pennsylvania

Federation of State Medical Boards Web Site, Accessed 5/2015 http://www.fsmb.org/policy/public-resources/state_specific

Resolution 42 It is a “hardship resolution” enacted in 2000, allowing Do graduates to apply to the AOA during or after completing a non-AOA internship or residency. They must demonstrate a significant hardship due to “unusual or exceptional circumstances”. This includes physical, mental, legal restrictions or service in a federally designated health shortage area or in a specialty for which no AOA programs exist.

The vast majority of these applicants are granted the waiver.

In the initial few years, over 98% of applicants were granted a waiver

Letters to the Editor, August 2004

The Journal of the American Osteopathic Association, Vol. 104, pp 304-315.

47

Root cause analysis Why the loss of TY programs and positions programs?

48

Overhead CostACGME Cost about $4200/yearPD salary/benefits

Advanced Programs Changing to Categoricaland absorbing slots

Putting limitedGME dollars into other programs

AccreditationHassle?

CTYPD Meeting May 19-20, 2016

MARRIOTT HARBOR BEACH FORT LAUDERDALE, FLORIDA

ASSOCIATION OF HOSPITAL MEDICAL EDUCATION60TH ANNIVERSARY