Joseph E. Kerschner, MD
Medical education is intrinsically connected to our state and nation’s health. Currently, as we consider the education of our nation’s physicians, we must include a discussion on student well-being, transition from medical school to residency, and the number of residency positions available to train the next generation of physicians – which are important areas and in need of improvement.
Here in Wisconsin, we are privileged to have two outstanding schools of medicine: the Medical College of Wisconsin (MCW) and the University of Wisconsin School of Medicine and Public Health (UWSMPH). These two institutions train the vast majority of physicians who practice in hospitals, clinics, health systems, medical groups, and private practice throughout the state. The fact that Wisconsin is consistently ranked at or near the top among the national leaders in overall quality of health care is a testament to the excellence of medical education in our state.¹
However, we know that we have a crisis in health care – both within Wisconsin and elsewhere – as it relates to the well-being of our students, residents, and ultimately the physician workforce. More than 50% of US physicians report significant symptoms of burnout, which can have serious, wide-ranging consequences, from reduced job performance and high turnover rates to medical error and clinician suicide. Recent reports note that the prevalence of physician burnout has reached critical levels.²
Clinician well-being is essential for safe, high-quality patient care. Supporting clinician well-being requires sustained attention and action at organizational, state, and national levels. The Association of American Medical Colleges (AAMC) supports a culture in academic medicine that values the well-being of learners, faculty, and staff, including a robust well-being website for medical students.³ In my national role as the recently elected chair of the board of the AAMC, among other endeavors, I am helping to facilitate ongoing discussions related to how medical students can best transition to the role of resident physician.
We know that one of the most important items impacting student well-being is the pressure that exists in single “high-stakes“ examinations such as the US Medical Licensure Examination (USMLE) process (especially Step 1), which is governed through the Federation of State Medical Boards and the National Board of Medical Examiners. The AAMC is helping to convene conversations related to the Step examination processes. I have participated in numerous national conversations on this topic looking to develop possible solutions regarding how the Step 1 exam is currently utilized as a tool to evaluate medical student performance and as part of the residency Matching process. These conversations are particularly important given that this examination has demonstrated limited ability in meaningfully correlating with a physician‘s level of quality in future clinical practice. I remain optimistic that solutions to consider in this area will be forthcoming in the near future.⁴
At MCW, although we have distance to travel to enhance our overall well-being for faculty, staff, and students, we continue to prioritize initiatives to enhance wellness. The mission of our Wellness Program is to create and maintain a workplace environment that encourages a healthy lifestyle and individual wellness for all members of the MCW family. We offer a Well-Being Index designed to evaluate fatigue, depression, burnout, anxiety/stress, and mental/physical quality of life, as well as resources to address each of these areas. We offer an Employee Assistance Program that provides free, immediate, and confidential support with work, health, and life challenges. We offer classes, tools, and resources to help individuals create and maintain a healthy lifestyle and have incorporated the topic of wellness into our routine communications. We also provide a wellness champion for each department in the institution.
Additionally, specifically for students and residents, we offer behavioral health services and provide a single-source, all-inclusive website that contains information on services provided, common concerns, hours for appointments, general and emergency contacts, behavioral health clinic providers, information on mental health resources in the Milwaukee metro area, a Stress and Depression Questionnaire, FAQs, and more.
Speaking of the Residency Match, there is also substantive work being done nationally to examine the possibility of moving toward a system in which the Match would occur more than once a year. This would enable more flexible academic programs at medical schools to accommodate specific student needs – both educationally or personally. A more flexible Match system would allow more individualized academic progression; this has been identified as another potential enhancement in medical education to support student well-being.
In addition to the above, enhancing opportunities in the Match for those students completing their degrees would alleviate some concerns related to the recent expansion of medical students being trained in the United States. During this period of growth, comparatively fewer new residency positions were created.⁵ Equally important to providing more opportunities to US-trained medical students is the fact that the country and Wisconsin are facing a very large physician shortage and expansion of Graduate Medical Education (GME) positions is necessary to alleviate this difficulty for the future. (In my Dean’s Corner, which was published in Volume 118, No. 2 of the WMJ, I discussed important work being done to help alleviate the projected physician shortage) Although there have been some federal initiatives to grow GME positions nationally, most notably through the Department of Veterans Affairs, these initiatives will fall far short of what is needed nationally to prevent the physician shortage – which has been well-documented for well over a decade. Fundamentally, the “cap” on GME positions supported through the Centers for Medicare & Medicaid Services (CMS) – which has been held in place since 1997 – needs to be revised so that institutions such as MCW and UWSMPH have access to additional federal dollars to expand their GME programs.
There are additional solutions to federal sponsorship of GME programs, and at MCW, we have made progress in adding new residency positions, including two new four-year psychiatry residency programs attached to our regional medical school campuses (seven residents in total per year), 18 FTE GME positions through our partners at the Clement J. Zablocki VA Medical Center, a new three-year family medicine residency program that is training six residents per year at Froedtert Community Memorial Hospital in Menomonee Falls, and a planned new three-year family medicine residency in Green Bay in conjunction with Prevea Health and Hospital Sisters Health System to train four residents per year.⁶
By 2020, Wisconsin will have 133 more Wisconsin physician residents in the pipeline to practice in Wisconsin thanks to the GME matching grant legislation that was passed with the help of the Wisconsin Hospital Association (WHA) and bipartisan support in the Wisconsin legislature in 2013. Initial results are encouraging, and the state has improved its state rank from 25th to 18th for the number of GME residency spots compared to medical school enrollments, according to the WHA’s Wisconsin 2018 Health Care Workforce Report.7
We are grateful to the elected officials in Wisconsin who have supported state funds for these programs. We will look to this support in the future as we work with UWSMPH to develop additional GME programs in underserved areas for the future.
- Wahlberg D. Wisconsin has best health care quality in the nation, federal agency says. Wisconsin State Journal. August 23, 2017. https://madison.com/wsj/news/local/health-med-fit/wisconsin-has-best-health-care-quality-in-the-nation-federal/article_d194bcd9-5c4b-5b74-a42e-000a2d20ce5b.html. Accessed December 1, 2019.
- Jha A, Iliff A, Chaoui A, Defosez S, Bombaugh M, Miller Y, for the Massachusetts Medical Society, Massachusetts, Health and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute. A crisis in health care: A call to action on physician burnout. Waltham, MA: Massachusetts Medical Society. https://cdn1.sph.harvard.edu/wp-content/uploads/sites/21/2019/01/PhysicianBurnoutReport2018FINAL.pdf. Published January 30, 2019. Accessed December 2, 2019.
- Medical Student Well-Being. Association of American Medical Colleges website. https://students-residents.aamc.org/attending-medical-school/medical-school-survival-tips/medical-student-well-being/. Accessed December 1, 2019.
- Cooper K, Brownell S. Who perceives they are smarter? Exploring the influence of student characteristics on student academic self-concept in physiology. Adv Physiol Educ. 2018;42(2):200-208. doi:10.1152/advan.00085.2017
- Averting physician shortage now depends on more slots for residency training [press release]. Washington, DC: Association of American Medical Colleges; July 25, 2019. https://www.aamc.org/news-insights/press-releases/us-medical-school-enrollment-surpasses-expansion-goal. Accessed December 2, 2019.
- Kerschner J. Helping to alleviate the projected physician shortage. WMJ. 2019;118(20):103-104.
- Wisconsin 2018 Health Care Workforce Report. Madison, WI: Wisconsin Hospital Association. https://www.wha.org/WisconsinHospitalAssociation/media/WHA-Reports/2018_Workforce_Report.pdf. Published December 13, 2018. Accessed December 2, 2019.