Out of Adversity - Transforming Graduate Medical Education
Dr. Holly J. Humphrey, president of the Josiah Macy Jr. Foundation and the former Ralph W. Gerard Professor of Medicine and Dean for Medical Education at the University of Chicago, began the Marvin R. Dunn Keynote Address at the 2022 ACGME Annual Educational Conference with humble and heartfelt notes of appreciation and acknowledgement. She paid tribute to all those who have worked so hard during the COVID-19 pandemic, thanking those who serve in leadership roles, especially chief residents and offering sincere condolences to those lost to COVID-19. In short, she recognized that the past two years has been a time unlike anything we have ever experienced.
But the fault lines for adversity didn’t begin with the pandemic. Dr. Humphrey contrasted the brilliant scientific advances made recently in our society with a widening trust gap regarding science among much of the public. She noted that the fault lines for adversity also include inequity for patients, inequity for learners, a culture of incivility, stressors leading to burnout, and the phenomenon of “presenteeism,” in which individuals feel compelled to show up for work at all costs to themselves and those around them.
She noted that inequity for patients derives from social determinants of health: educational access and quality; health access and quality; economic stability; social and community context; neighborhood; and built environment.
As social determinants of health affect patients, social determinants of medical education lead to inequity for learners as well. Dr. Humphrey acknowledged that for decades, the US has been unable to diversify the profession of medicine to match the diversity in the country’s population. Enrollment of black men in medicine has actually declined, she emphasized. Citing statistics pointing to the profession of medicine as elitist, she asked a pointed question to those in graduate medical education (GME): “Do you think that students who enter our profession from the lower quintiles feel as if they belong in our learning environments?” She challenged the audience to think about specific ways to address the social determinants medical learners face.
Dr. Humphrey observed that the pandemic, when added to racism, exhaustion, and mental health concerns, has only increased the chasms for learners, adding that the ways in which learners are being treated at times is almost incomprehensible.
Another important stressor is the fact that some health care workers have seen potentially more death during the pandemic than they would normally see in the course of their entire careers. “Have we dealt with that grief, and are we prepared for the next pandemic of PTSD?” she asked.
Out of this adversity, Dr. Humphrey described a vision to transform GME. She challenged listeners to re-orient medical education using a socio-cultural axis, noting that structural determinants of health must be foundational. She urged everyone to work to expand public health curricula and experience, and to bring rigor to the framework and assessment of managing uncertainty. To accomplish this, she recommended:
- Co-create learning experiences, noting that adult learners learn best under conditions of “high challenge, high support.”
- Adopt competency-based and interprofessional education.
- Eliminate the detrimental effects of the social determinants of medical education.
- Nurture professional identity formation, personal well-being, and belonging.
- Eliminate racism and inequities in all policies, procedures, and practices.
Finally, she proposed building connections in the community, with patients, in the clinical learning environment, in future learners, and through the use of technology.
Dr. Humphrey stated that this connection-building should occur through a deliberate focus on the health of the population, not just the patient in front of us in a particular moment. Following the lead of the specialties of emergency medicine and family medicine, she emphasized that meaningful engagement with the community can flourish through genuine connections with patients.
This focus is equally important within the clinical learning environment, Dr. Humphrey said, noting the ACGME’s progress in this arena through the Clinical Learning Environment Review Program. She emphasized that it is essential that the chasm related to social determinants of resident education be closed. “Holistic admissions strategies require holistic retention strategies,” she said, including for those who are differently-abled.
She encouraged the institution of a systems approach to well-being, focusing on time away and work-life balance, salary, and benefits (Dr. Humphrey acknowledged this problem is a significant challenge for lower-income learners), as well as a culture of support, mental health resources (she suggested an opt-out system rather than an opt-in system), and addressing discriminatory licensure and credentialing practices.
A silver lining of the pandemic, Dr. Humphrey noted, is the discovery that connections can be made with an assist from technology. She gave examples of success in telehealth, didactic sessions, and virtual interviewing. Technology solutions are more efficient and can help with work-life balance, she said.
Dr. Humphrey closed her address with a major announcement. The Josiah Macy Jr. Foundation has instituted a new awards program, Catalyzing Transformation in GME, offering six awards of $50,000 each to help programs identify the characteristics of exemplary learning environments for the education of master adaptive learners, where all who work or receive care feel they belong. She ended with a final call to action:
“Let’s transform GME together.”