Graduate medical education is critical to the training of physicians. Residencies are where most new medical school graduates train for the specialties they have chosen.
By the time a residency is completed, a physician should be ready to practice without supervision and lead a team in taking care of patients. It isn’t easy — 80-hour weeks are often the norm — but often a residency is the last step in making their career dream come true. For some, the road doesn’t end there. Because of the complexity of some areas of medicine, additional graduate medical education (GME) in the form of fellowships is required.
At the UNLV School of Medicine, Dr. Kate Martin, associate dean of graduate medical education, currently oversees 20 post-graduate training programs with 321 residents/fellows. The overall program is accredited by the Accreditation Council for Graduate Medical Education (ACGME). Dr. Martin and her staff do everything from helping keep residents/fellows healthy to dealing with funding mechanisms for post-graduate education.
She previously served as a family medicine residency program director and director of community engagement in the school. A graduate of the UNR School of Medicine, where she also completed her family medicine residency, Martin went on to complete a teaching and learning fellowship with the USC Keck School of Medicine and as well as a National Institute for Program Director Development fellowship with the Association of Family Medicine Residency Directors.
A 2002 UNLV summa cum laude graduate who earned her bachelor’s degree in biology, Martin was UNLV's 2016 Honors College Alumna of the Year.
Today, she says because of her staff’s two-year team effort, two more fellowships were added by the ACGME in 2019 — one in pediatric emergency medicine and another in geriatrics. “This means we can recruit new fellows to start in July 2020,” she said. “We are also currently applying for accreditation to start a fellowship program in forensic psychiatry and adult endocrinology.”
How important are new fellowships to the people of Southern Nevada? According to a recent report by the Nevada Health Workforce, they are critical, given that many physicians stay to practice where they finish their GME training. The authors wrote:
One key finding of this report is that 35 of the 43 physicians pursuing additional training (81.4%) are leaving the state for fellowship and subspecialty training that does not exist or is in short supply in Nevada. This finding suggests that the development of fellowship programs in Nevada holds the potential for increasing the number and percent of GME graduates who ultimately remain in Nevada to begin practice.
At present, about 50 percent of those who complete residencies/fellowships in Southern Nevada stay here.
Martin pointed out that during her tenure the ob/gyn, psychiatry, critical care medicine, and critical care surgery GME programs have expanded as the result of funding provided by Nevada governor’s office of science, innovation and technology.
Here, Martin expands on the importance of graduate medical education.
Discuss the impact of GME.
GME is the next step after someone graduates medical school in order to become a practicing physician. Without it, you can't prescribe medications or treat patients. You need to complete a residency/additional training to obtain a medical license and be able to practice.
GME programs average three to five years in length, but sometimes are much longer, depending on the specialty and additional fellowship training pursued. For example, a cardiologist spends three years doing an internal medicine residency, then another three years in a cardiology fellowship, then possibly another one to two years in a second fellowship to become an interventional cardiologist who performs angiograms to open blocked arteries when someone is having a heart attack.
Sponsoring institutions that participate in GME, such as UNLV’s School of Medicine, have a mission, according to the ACGME, to improve the health of the public, specifically to reduce health disparities. People from socioeconomically disadvantaged groups should have the opportunity to live long and healthy lives like everyone else. GME helps level that playing field through the vulnerable populations it reaches, elevating their quality of care, while training the next generation of physicians.
Why is it difficult to get new residencies and fellowships?
Starting a new residency or fellowship program requires funding, lead time, and community support. University Medical Center (UMC) is our primary teaching hospital, serving as the home base for nearly all of our GME programs. UMC is the largest financial supporter. GME funding is complex. Although UMC receives partial financial assistance from the Centers for Medicare and Medicaid Services (CMS), the hospital makes up the difference to pay resident and fellow salaries and benefits. We have recently increased our involvement with the Veterans Administration Health System and the U.S. Air Force to sponsor some resident and fellow positions, and we also receive support from several other community partners.
With the right funding, we could grow graduate medical education in Southern Nevada on a larger scale and bring even more specialties to the area — with the goal that these new doctors would remain to practice in our community.
I should also point out that, in order to get there, it takes at least two years, as this requires a team of people to come together and submit an application to the ACGME. Faculty are needed in the chosen specialty to lead the program, including a program director, and additional physicians to teach the residents, along with administrative support for the program. These are the minimum ACGME requirements, so that is where we start from. The possibilities are really only limited by our passion to meet the community’s health care needs.
How do residents/fellows "study" in a residency/fellowship? How are they "graded"?
Residents take and study for yearly in-training exams throughout residency to prepare for the test they will take at the end of their training in order to become board-certified in their chosen specialty — for instance internal medicine, pediatrics, psychiatry. (The in-training exam is a practice version of the board certification exam, so they study regularly for this. They also take licensure-related exams, called Step exams, to complete a series, i.e. Step 1, 2 and 3, which they start in medical school. Step 3 is the last step and that is taken during residency, so that is another exam that they study for, in addition to their clinical work.)
Residents and fellows are evaluated throughout the year based on the following six core competencies determined by the ACGME:
- patient care
- medical knowledge
- practice-based learning and improvement
- interpersonal and communication skills
- systems-based practice
The evaluation system uses milestones that the residents and fellows must achieve in order to get to the next level and be promoted within their program, and ultimately graduate. All of this relies on feedback from their attending physician faculty, staff members, patients, and peers.
How are new residents and fellows are chosen?
Most new residents and fellows are selected through the National Resident Matching Program. (Some fellowship programs do not participate in this, but nearly all residency programs and most fellowship programs do.) Medical students submit their applications in the fall of their fourth year of medical school, travel for interviews typically in the fall/winter months, then submit a rank list of where they would like to go. Programs submit a rank list of the applicants they want to recruit. The results are released in mid-March on Match Day, when everyone finds out where they are going to be for residency on July 1. On Match Day, the GME office goes to work to start on-boarding the next class of new residents and fellows.
How many more residences would you like to see in Las Vegas?
I would like to see every specialty and subspecialty of adult and pediatric medicine offered in our GME programs in Southern Nevada. Our community has grown to deserve (and should demand) this level of care and medical expertise.
How many residencies do new doctors apply for?
It depends on the program, but the application numbers have gone up in recent years due to increased competition. Fourth-year medical students typically apply to at least several programs (ranging from four to eight), but some can apply for many more.
How are doctors chosen to be the "faculty" for each residency/fellowship?
The ACGME specifies that faculty must be board-certified (or have equivalent qualifications) in their specialty or subspecialty field, so they are held to that standard for competency. The residency and fellowship program faculty have a passion for teaching, often years of experience in an academic setting, but all have some alignment with our mission of education, research, and clinical service in a GME setting.
We often hear that residents/fellows work many hours? How many hours can they work?
Per ACGME requirements, residents may work no more than 80 hours per week with one day off in seven, averaged over a four-week period. The GME office and residency/fellowship programs monitor work hours closely and make schedule adjustments to stay in compliance.
Has your team heard from medical students who wish there were more residencies/fellowships here?
Yes, and so we are working on bringing more fellowships online and are already expanding our current programs in psychiatry, ob/gyn, critical care medicine, and critical care surgery.
How does your team support residents/fellows?
The GME team provides support through their individual roles. In addition, the GME office serves as a safe space for residents and fellows to bring concerns and have issues addressed that may be going on within their programs or the institution at-large. Our office also provides assistance with processing of loan deferment requests, acts as a liaison with HR, sponsors several subcommittees on topics important to the residents/fellows, such as well-being, space/learning environment, and policy creation/review.
We also carry out the Graduate Medical Education Committee (GMEC) meetings, which bring the core residency program directors, program coordinators, and residents together to discuss important accreditation, program, and institutional issues every other month. The GME office hosts an annual resident/fellow research day, a chief resident retreat (for the new/incoming senior-level residents), and institution-wide orientations for new residents and fellows each year. We have an annual program director retreat for the faculty as well. The GME office also funds residents and fellows to travel around the country to present their research at national conferences.