|T H E N I H C A T A L Y S T||N O V E M B E R D E C E M B E R 2002|
GRADUATE MEDICAL EDUCATION AT NIH
GME Colleagues: Frederick Ognibene and Brenda Hanning
There are 7,838 accredited graduate medical education programs (GME) in the United States and 95,990 active residents and fellows in these residencies and subspecialty fellowships. NIH is home to 16 of those programs and about 160 of those residents and fellows. (Another five programs are jointly sponsored by NIH and other institutions; see chart below).
NIH may be a small part of a very big GME picture, but it is a vital and growing part that is distinct in its focus on training physician-investigators. It is also subject to the same stringent and changing criteria for accreditation as the rest, although some aspects of training in clinical research cannot be captured so handily in standards meant to measure the quality of training for clinical practice.
GME at NIH is "unique," says Brenda Hanning, acting director of the NIH Office of Education, in that there are many more fellowship than residency slots (see chart), a reflection of the patient caseload at NIH. "We are ideally suited for subspecialty training because we dont treat the bread-and-butter population," observes Hanning, who for the past three-and-a-half years has co-chaired a revitalized NIH GME Committee with Frederick Ognibene, director of the NIH critical-care medicine fellowship program at the Clinical Center.
The core requirements related to curriculum and patient contact are similar to other programs around the country, Ognibene notes, "but we have a more fertile, richer research environment in addition to the clinical exposure." Applicants to NIH programs are "self-selected," presumably having been attracted to the emphasis on the research component of the training during recruitment, he says, noting that most NIH fellowships are two to three years with an additional block of time to train to become an independent investigator.
|NIH Accredited Training Programs|
|Anatomic Pathology *||Lance Liotta, NCI|
|Dermatology (3rd year only)||Mark Udey, NCI|
|Psychiatry (4th year only)||Donald Rosenstein, NIMH|
Frederick Ognibene, CC
|Monica Skarulis, NIDDK|
|Cynthia Dunbar, NHLBI|
|John Bennett, NIAID|
|Barry Gause, NCI|
|Gregory Dennis, NIAMS|
|Allergy/Immunology||Dean Metcalfe, NIAID|
|Blood Banking and Transfusion Medicine||Cathy Conry-Cantilena, CC|
|Clinical and Laboratory Immunology||Thomas Fleisher, CC|
|Cytopathology||Andrea Abati, NCI|
|Hematopathology||Elaine Jaffe, NCI|
|Medical Genetics||Maximilian Muenke, NHGRI|
|Pediatric Endocrinology||Constantine Stratakis, NICHD|
|*Anatomic pathology is the only one of the 16 ACGME-accredited fellowship programs at NIH that is a full-fledged residency program conferring board eligibility in one of the recognized medical specialties. Two other programsin dermatology and psychiatryextend residency credits earned elsewhere. The other 13 are subspecialty fellowships open to those who have already completed their core residencies.|
Outreach and Selection
Although the existence of GME at NIH is less well-known around the country than Hanning would like"We still bump into physicians at meetings who are surprised that NIH has a hospital"applicant numbers are "healthy." Ognibenes program, for instance, draws about 150 applicants for the four available slots each year. "We typically narrow it down to 15 interviews; we look at the academic record in its entirety and clinical and research faculty recommendationsand then the interview is very important. What are the persons long-term goals? We take our role of training the next generation of physician-scientists very seriously," says Ognibene. (See the profile of one critical care fellow, "Where the Action Is.")
Taking the Helm: James Thompson, new GME executive director
As testimony to the growing GME emphasis at NIHand the growing programs, both in numbers of slots and potential new subject areasa principal wish of Hannings was granted last spring with the approval of a new position for a GME executive director.
James Thompsonwhose experiences as head of the American Psychiatric Associations education programs, residency review committee member, and GME provider at a university preceded his NIH appointmentarrived here in August.
One of his main charges is to oversee expanded and targeted outreach to that pool of physicians who would be most drawn toward residency and subspecialty training at NIH.
His other main charge is to oversee the development of evaluation measures that document the degree of success NIH programs have in meeting ACGME (Accreditation Council for Graduate Medical Education) criteria for GME accreditation.
and Competent Measures
ACGME conducts institutional GME reviews at least every five years; in addition, each individual GME program within an institution undergoes periodic reviews. Hanning was elated when NIHs last review in May recently earned a "favorable action," with the next review planned for five years hence. "Thats as good as it gets," she says of ACGMEs list of possible ratings.
As individual NIH programs come up for accreditation review from now on, however, each will have to present evidence that it is meeting six new ACGME "competency" requirements that took effect in July. The six areas are:
Patient care (clinical and patient management skills)
Interpersonal skills and communication
Hanning and Ognibene estimate that programs will have about four years leeway to fashion and implement assessment measures that satisfy the ACGME mandate.
"Are these six competencies being taught? How can they be assessed? We are relying on the individual programs to develop their own tools for some of theseeach program has its own core skills in medical knowledge and patient care, for instance," says Ognibene. "Other competencies, like communication and professionalism, transcend all programs."
For these, the GME Committee (including Thompson, Hanning, Ognibene, all the other program directors, two fellows representatives, and others) is working collectively to devise central measures.
"Were adapting a 360-degree feedback tool to see how ones self-perception compares with others perceptions of the quality of each residents and fellows interactionsat the bedside with patients and with other members of the health-care team," Hanning says. "Self-evaluations will be held to the mirror of evaluations by the program director, the teaching faculty, fellow residents, and other members of the team."
Competency in "practice-based learning"which encompasses practicing evidence-based medicine grounded in an understanding of how to use the medical literature and how to interpret studies and meta-analysesis a challenge to assess, Ognibene says.
And "systems-based practice," adds Hanning, "is an interesting one. In the outside market, systems-based would refer to such things as how hospital reimbursement works, third-party payers, insurance, finances. We dont have that at NIH, but weve created a tool to fulfill this requirement that were very excited about. Its systems-based practice in the context of NIH clinical trials. It hasnt been tested yet, but it would include things like attending John Gallins IPPCR (Introduction to the Principles and Practice of Clinical Research) course, participating in developing an IRB protocol, enrolling in a jointly sponsored NIH masters degree program in clinical research. Weve developed a template from which to choose a number of options to achieve mastery in systems-based practice NIH style. We think its a great model."
Asked whether the new evaluation requirements might be a distraction from actual training, Thompson observed that "we have to make sure that it does not interfere with the training itself." Its not the "extremely high quality of training that would change," he said, "just the documenting of it."
"This concern with verifying competency has burgeoned throughout the house of medicine over the last 10 or so years," he added. "We would like NIH to be a model for the country in documenting quality. And I suspect many of our scientistsno strangers to documentationwould welcome that challenge."
According to Aaron Auerbach, one of the two trainee representatives on the GME Committee and an anatomic pathology resident in Lance Liottas lab, his program director is one of those people who "says we have to figure out how to do this right."
"Its a work in progress, but I dont think the changes are going to be tough for us to makementoring and review have always been part of the process," observes Auerbach, now in his third year of residency (see "One Phone Call Launched a Career.").
By his third year in medical school (at Rutgers in Piscataway, N.J.), Aaron Auerbach knew he wanted to go into a diagnostic fieldperhaps pathology, perhaps radiology, but the pull to pathology proved stronger. For personal reasons, he also wanted to spend as much of his fourth year in the Washington, D.C., area as possible.
"I also had an interest in researchand what better place could there be than NIH?" Auerbach says, recalling the impetus for his after-hours phone call to the NCI Laboratory of Pathology one evening to leave a message requesting information on the possibility of a rotation during his senior year of medical school. Instead of the answering machine, however, lab chief Lance Liotta, who "happened to be working late that night," picked up the phone. "He asked me what my research interests were, what I wanted to do in the futureand then he said, absolutelyand the next day it was all set up, and I spent the month of October of my senior year in medical school doing clinical research in Lance Liottas department. I was the only medical student. I didnt know anything, and then I was swept into the science, and I knew that this was where I wanted to do my residency."
During his months stint, he did surgical pathology and research on genetic syndromes, specifically the Birt-Hogg-Dube (BHD) syndromework that he continued as a resident and prepared for presentation at this years Research Festival and the upcoming U.S. and Canadian Anatomic Pathology Society meeting. He and his colleagues reported on previously undescribed colonic lesions in BHD patients.
Auerbach suspended all other residency-selection activities and applied for the NIH anatomic pathology residency program, which does not participate in the national residency matching program. He learned in November that he had been accepted. The following June (of the year 2000), he graduated from Rutgers with his M.D. degree and a concurrent M.P.H. in health-care administration from the graduate school and returned to the Laboratory of Pathology.
Now chief resident, Auerbach cannot praise the program highly enough. "My experience has been excellent; the protocols are interesting, the research possibilities endless. My mentor (Maria Merino) has been great, and I love what I do. The residents here are not viewed as labor for others but are treated as intellectual equals whose input is appreciated and used. I came in a medical student, and Im leaving a pathologist."
Headed for the Armed Forces Institute of Pathology, Auerbach plans to specialize in GI and liver pathology and to conduct research on medications to reverse hepatitis-associated fibrosis. (According to the website, 143 residents graduated from the program between 1955 and 2001, with approximately 41 percent moving on to nongovernment academic pathology, 40 percent to government positions in academic pathology, 18 percent to community pathology practice, and under 1 percent to industry.)
"NIH is different from anywhere else," Auerbach says. "Not needing to earn X amount of dollars for my laboratory through grants has allowed me the freedom to shape electives and research projectsto create my careeraround those things that I want to do while at the same time meeting American Board of Pathology requirements." There is, of course, the pressure to publisha not-unwelcome pressure that has helped fuel his submission for publication of studies on ovarian cancer metastatic to the mediastinum, Cytokeratin 7 and 20 staining of hepatocellular carcinomas, and solitary fibrous tumor involving the pituitary fossa.
During the last year of her internal medicine residency at the University of Texas Health Science Center, San Antonio, Denise Gonazales spent one day at NIH. She was one of a highly select group tapped by the National Hispanic Medical Association (NHMA) to compete for a slot in one of NIHs 16 accredited fellowship programs, and she was here for interviews.
Gonzales had not known that these programs existed; it was the chairman of medicine in San Antonio, a former NIH fellow himself and her attending physician during her second year of residency, who had nominated her for an NHMA-sponsored NIH program. Looking through the information on each of the NIH fellowships, she had homed in on critical care medicine. "There was no question. That was the one I wanted," she recounts.
Critical care, Gonzales says, appealed to both of the two strong forces that had propelled her in two directions during her medical school training: surgery because she loved its "pace and demands" and internal medicine because she loved its "intellectual challenges." Her experience in the ICU during her San Antonio residency suggested that it was in the ICU environment that an internist could feel her adrenaline pumping.
And it was that one long day spent at NIHin February 2000that convinced her that the Critical Care Department in the NIH Clinical Center was where the action should be for her.
That day started at 7:30 a.m., observing rounds. "I saw a fellow presenting patients to four or five other fellows and about 15 attendingsand those attendings had recognizable faces and names, like Tony Fauci, and they were firing off all these questions. And I asked myself, Can I do this? Can I answer these questions every morning about why I did what to the patients of these world-famous experts?"
After rounds, the day was spent interviewing with "every single member of the Critical Care Department." Not only the excitement of being at NIH"where great studies are designed and performed and reviewed"but the unparalleled freedom to pursue her own interests pushed away any other possible fellowship choice. "Whatever I wanted, I was told, they could find the funds, the space, the time, the supervision. The physical, financial, and intellectual resources were all hereacross the board."
With four other fellows, Gonzales started her four-year NIH fellowship in July 2001two years as an "intensivist" or "criticalist" in training, providing care for critically ill patients, and two years conducting research in critical care.
She spent her first fellowship year caring for patients on protocols at NIH who required critical care, interspersed with rotations through the surgical, medical, coronary, and pediatric ICUs at the Washington Hospital Center, the National Naval Medical Center, and Childrens National Medical Centeraltogether five months at NIH and seven months elsewhere.
"Ive been very pleased with my training. In my rotations through one of the hospitals, I saw that other fellows from other programs arent getting such broad exposuremost other programs dont place their fellows in formal surgical ICUs." As for her critical care experience at NIH, she finds it hard to describe. "Challenging is not an adequate term. These are patients who have failed conventional therapy and a certain level of experimental therapy. They are here for highly experimental therapy, and if they have reached the ICU . . . ."
Now in her second fellowship year, Gonzales is at the Johns Hopkins Medical Institutions fulfilling the requirements of the pulmonary care component of her dual subspecialty training. The last two years of the fellowship will be spent doing research in the Critical Care Department heremost likely in the area of DNA arrays to identify markers for sepsis. "Anthony Suffredini, a senior investigator here, is doing array analysis in sepsis models, searching for ways to identify the ARDS [acute respiratory distress syndrome] patients who may survive septic shock, who may respond to immunomodulatory drugs or activated protein C."
Beyond that, Gonzalez envisions independent research in the area of noninvasive monitoring of critically ill patientssomething that would marry her intensivist training with her interests and skills in biomedical engineering (just one month before entering medical school in 1994, she had completed a three-year Master of Science in Biomedical Engineering program at Boston University, where she had designed a chip resembling the cochlear implant but utilizing a different computer platform).
"If I were ever to use my engineering training, it really should be in an ICU setting," she says, pointing to the desirability of being able to assess hemodynamic status without transport or central lines, without the risk of infection, bleeding, and lung collapse.
In the long-term, Gonzales sees herself in academic medicine, blending clinical care responsibilities with teaching and clinical research. "I could not imagine myself in private practice anywhere. I enjoy working in a research environment."
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