Northwestern University Feinberg School of Medicine

Proposal:Strategic Expansion of theAcme Residency Program

This slide set summarizes the educational rationale for a strategic expansion of the Northwestern McGaw Acme residency program.

A financial analysis of this proposal is submitted separately for consideration.

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Program Overview1. PGY 1-4 program

2. RRC-approval for 48 residents

3. Full accreditation on last site visit in 2008; Next site visit 2018

4. Among the most selective training programs in the nation

5. Highly successful program outcomes benchmarked to top tier in nation

6. Diverse clinical training sites include:NMH, NLFH, Lurie Children’s, Stroger,

70% of graduates pursue academic careers

7. 6th oldest program in the nation

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Objectives1. To create a new research training pathway

2. To improve the clinical experience of PGY-3 and PGY-4 Acme residents by increasing the size of the clinical care teams that they supervise

3. To provide a cost-effective expansion of physician services

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Rationale for NewAcme Research Training Pathway

• The majority of NU Acme graduates pursue a career in academic medicine.

NU Program: 70%

National Average : 15%

• To be competitive for faculty openings at the top US medical schools, graduates routinely consider an additional two years of fellowship and/or masters-level research training. This extra training comes at considerable financial cost and delay in permanent employment.

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Rationale for NewAcme Research Training Pathway

• Several PGY 1-4 Acme training programs at top research medical centers have the capability to decelerate clinical training and create a 5-year pathway that provides substantive research training, coursework, and mentorship.

• Yale University enters the 2014 Match with the first of these research training pathways.

• Medical students with aspirations for research careers will preferentially seek these research training pathways as programmatic opportunities expand around the nation.

• Northwestern has the faculty and institutional resources necessary to successfully implement a research training pathway, ensuring that we remain competitive among national peer institutions.

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Proposed Design for NewAcme Research Training Pathway

• 5-Year program

PGY 1 & PGY 2: same curriculum as main Acme programPGY 3 / 4 / 5: senior clinical rotations spread across final three

years

• Two residents per class would follow separate research training pathway curriculum.

• Separate NRMP match positions, separate rank list from main Acme program.

• Final three years would include:

Decelerated clinical curriculum from main Acme program in PGY 3-5 Graduate degree program (e.g., MSCI) Acme research mentorship via weekly works-in-progress and

didactics

Proposed Design for NewAcme Research Training Pathway

Goal:

Graduates capable of competitive grant applications for extramural funding

Outcome measures:

(1) job placement immediately after residency

(2) % graduates with extramural funding within five years post-residency

ProposedResearch TrainingPathwayPGY 1/2/3/4/5

2013-14 0

2014-15 2

2015-16 2/2

2016-17 2/2/2

2017-18 2/2/2/2

2018-19 2/2/2/2/2

Objectives1. To create a new research training pathway

2. To improve the clinical experience of PGY-3 and PGY-4 Acme residents by increasing the size of the clinical care teams that they supervise

3. To provide a cost-effective expansion of physician services in NMH

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Background on Senior Resident Training• The senior supervisory role in NMH is the most highly-valued clinical

training experience in the residency.

• The RRC-Acme mandates graded responsibility for residents as they progress through their training. There are two dominant models for resident training:

(a) patients are cared for by a single resident; residents see only their primary patients; graded responsibility is measured only in small increases in averaged patients per hour each post-graduate year;

(b) patients are cared for by a junior resident and a senior supervisory resident; senior residents see

all patients on a given team, with supervisory and teaching expectations similar to an attending – ** this is the model currently used for training at Northwestern Memorial.10

Background on Senior Resident Training

• Our team training model is critical to our national reputation among employers and prospective candidates.

• NU Acme residents are viewed as highly efficient and capable of meaningful supervision of students, juniors, and mid-level providers.

• Due to the design of our team training model, our residents care for approximately 40-50% more patients during their overall training than the average Acme resident.

• They are expertly prepared to assume faculty roles at the busiest departments.

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Immediate Need to Enhance Senior Resident Clinical Experience

• Unfortunately, several factors have led to significant changes to our care teams over the last several years. Most notably, there has been a progressive decrease in resident supply from other departments, increased volume, and revised program requirements that necessitate additional non-Acme rotations for our residents.

• Increased volume and decreases in resident supply have led to numerous iterations of ‘attending-only’ or ‘attending/mid-level provider’ teams, at the expense of equitable case distribution among the remaining resident care teams. Surprisingly, these teams have been less efficient and more costly.

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Immediate Need to Enhance Senior Resident Clinical Experience

• Senior residents have fewer opportunities to supervise -- our team training educational model is at risk.

• A strategic expansion will optimize the program size in order to maintain our critically important team training model.

• Expansion will allow for improved clinical hours for our residents, who have significant expectations for scholarship at our program.

• Additional resident FTEs will eliminate our dependence on “extra call for pay” (internal moonlighting) in NMH.

• This represents an immediate program need.

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Immediate Need to Enhance Senior Resident Clinical Experience

• A comparison of Northwestern McGaw Acme to local and national peer institutions is offered on the following two slides, using a benchmark of the ratio of annual patient volume to Acme resident FTE.

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ChicagoAcme Training Programs

Patients / Year(Main teaching sites only)

Program Size(# residents)

National Benchmark:Patients / Resident FTE

University of Chicago

77,000(Adult + Pediatric)

45(approved for 48)

1,711(1,604 at full complement)

Presence Resurrection

76,000(Resurrection + St. Francis)

39 1,948

Stroger / Cook County **

135,000(Adult + Pediatric)

68(approved for 80)

1,985(1,687 at full complement)

Advocate Christ 105,000(Adult + Pediatric)

42 2,500

NORTHWESTERN ** 150,000: NMH + Lurie 48 3,125

University of Illinois at Chicago

200,000 combined(equal coverage of UIC, Mercy, Masonic, Lutheran)

60 3,333

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Comparison of current Northwestern McGaw Acme program size with Chicago-area Acme programs

** Denotes PGY 1-4 Acme format

Peer InstitutionAcme Training Programs

Patients / Year(Main teaching sites only)

Program Size(# residents)

National Benchmark:Patients / Resident FTE

Johns Hopkins ** 65,000 48 1,354

Penn ** 65,000 44 1,477

George Washington ** 75,000 44 1,704

Denver Health ** 140,000 68 2,058

UCSF ** 105,000 48 2,187

Brown / RI Hospital ** 105,000 48 2,187Emory 160,000 66 2,424

UT Southwestern 140,000 59 2,456

UT Houston 135,000 54 2,500

USC ** 175,000 68 2,573

Mass General/Brigham ** 160,000 60 2,666

Washington University ** 160,000 56 2,785

Michigan ** 175,000 56 3,125 (Applying for complement increase)NORTHWESTERN ** 150,000 48 Permanent 3,125 (Applying for complement increase)

Yale ** 191,000 52 3,673 (Applying for complement increase)

Comparison of current Northwestern McGaw Acme program size with highly-competitive Acme programs at national peer institutions

** Denotes PGY 1-4 Acme format

Objectives1. To create a new research training pathway

2. To improve the clinical experience of PGY-3 and PGY-4 Acme residents by increasing the size of the clinical care teams that they supervise in NMH

3. To provide a cost-effective expansion of physician services in the NMH

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Cost-effective expansion of physician services in NMH

A financial analysis of this proposal to expand the Acme residency program is submitted separately for consideration.

Summary thAcmees: Increasing faculty size in order to improve efficiency is not cost-

effective. There is an opportunity to increase the number of patients seen by

attendings through an expanded use of mid-level providers (MLP) and/or resident physicians.

Our experience with MLPs in NMH, combined with our analysis of the projected cost of additional MLPs vs. residents, favors a strategic expansion of the residency program.

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ConsiderationsCurrent FTE Support

Total FTE : 52

Permanent Positions: 48

Northwestern MAcmeorial37.5

Northwestern Lake Forest 2.0Lurie Children’s

5.5

TAcmeporary Positions: 4

Northwestern MAcmeorial 3expires 3/1/14

Northwestern Lake Forest 1expires 6/30/17

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Considerations Every increase in 1 resident per class = 4.0 additional FTE funding

To proportionally increase the number of residents assigned to NMH, additional FTE positions must be funded in a 3:1 ratio (at least 3 NMH-funded FTEs for every 1 non-NMH FTE)

Some minimal expansion is required at Lurie, and NLFH in order to meet the RRC-Acme program requirement that Acme residents care for at least 20% pediatric patients among their total case experience during training

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Proposal Summary• Strategic expansion from 48 to 74 resident FTEs over 10 year period

Increase from 12 to 16 per class in main Acme program

(16 residents x 4 years = 64 resident FTEs)

2 residents per class in 5-year Acme Research Training Pathway

(2 residents x 5 years = 10 resident FTEs)

Full complAcmeent of 74 resident FTEs by 2023

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Summary Proposal

PGY 1 PGY 2 PGY 3 PGY 4 ResearchPathwayPGY 1/2/3/4/5

TotalComplement

2013-14 13 11 + 1 temp

12 12+ 3 temp

0 52(48 + 4 temp)

2014-15 13 13 11 + 1 temp

12 2 52(51 + 1 temp)

2015-16 13 13 13 11 + 1 temp

2/2 55(54 + 1 temp)

2016-17 14 13 13 13 2/2/2 592017-18 14 14 13 13 2/2/2/2 62

2018-19 15 14 14 13 2/2/2/2/2 66

2019-20 16 15 14 14 2/2/2/2/2 692020-21 16 16 15 14 2/2/2/2/2 71

2021-22 16 16 16 15 2/2/2/2/2 73

2022-23 16 16 16 16 2/2/2/2/2 74

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New FTE per year Total Resident FTE Proposed sourceof new funding

Comment

2013-14 1 Temp 52(48 + 4 temp)

NLFH approved FTE through 6/2017

1 temp position already funded; 3 other temp positions expire 3/2014

2014-15 3 52(51 + 1 temp)

NMH 3 Convert NMH 3 temporary FTEs to permanent

2015-16 3 55(54 + 1 temp)

NMH 2

2016-17 4 59 NMH 2NLFH 1

Convert LF 1 temporary FTE to permanent

2017-18 3 62 NMH 1 NLFH 1Lurie 1

Dept. of Acme self-study to assess continued need for expansion

2018-19 4 66 NMH 4 Research Pathway reaches full complement (2/year)

2019-20 3 69 NMH 3 Lurie 1

2020-21 2 71 NMH 1Lurie 1

2021-22 2 73 NMH 1Lurie 1

2022-23 1 74 NMH 1 Full complement

Proposed FTE support

TimelineMon, Nov 4 McGaw GMEC meeting agenda closes

Due: Application for permanent complement increase in WebADS

Due: Letter of intent to fund proposed additional FTEs

Fri, Nov 8 McGaw GMEC MeetingFor consideration: GMEC approval

Fri, Dec 13 RRC-Acme February meeting agenda closesFor consideration: Dean approval, DIO approval of

WebADS application

Fri, Jan 31 Deadline for Quota IncreaseQuota increase deadline precedes RRC-Acme

meeting, therefore we are unable to increase quota via 2014 Match

Fri, Feb 21 RRC-Acme MeetingFor consideration: RRC-Acme approval

Tues, Mar 18 NRMP SOAPPotential mechanism to increase incoming class

size, dependent on quality of unmatched Acme candidates (i.e., unmatched Feinberg students)

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