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Page 1: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Complementary and Alternative Approaches to

Fellow Recruitment

Kevin Foley, MD

David Sandvik, MD

James Campbell, MD

Page 2: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Complementary and Alternative Approaches to

Fellow Recruitment

Kevin Foley, MDDivision Head of Geriatrics and Geriatrics Fellowship Program Director

Michigan State University

Page 3: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Disclosures

None (all presenters)

Page 4: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Learning Objective

• Review several “vital signs” reflecting the health of the specialty of geriatric medicine: the past, recent trends, and a forecast for the future.

Page 5: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

We Need More Geriatricians!

Page 6: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Comparison of Number of Certificates Awarded to Number of Active Certificates in Geriatric Medicine

(Family and Internal Medicine)

1988

1990

1992

1994

1996

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2,412

4,089

5,940

8,2798,824

9,263 9,4749,701

9,915

10,21510,530

10,85811,117

11,42311,719

12,036

12,286

12,57512,835

13,08913,365

13,610

2,412

4,089

5,940

8,2798,824

8,1438,354

7,7627,976

7,420

7,7356,875

7,084

7,1287,344

7,345

7,0296,756

6,999

7,147

6,8736,256

Cumulative Certificates Awarded Active Certificates

Source: ABIM (Lou Grosso), ABFM (Gary Jackson), and ABMS. Data used with permission and compiled by Libbie Bragg and Gregg Warshaw, University of Cincinnati. Updated 2015

Page 7: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Geriatrics Fellowship Programs 1991-2 to 2013-4 Family Medicine

Academic Year

Programs Fellows (All Years)

Fellows > 2nd Year (% of all fellows)

First Year Positions Available

Fellows in 1st Year Positions (% Filled)

Fellows Completing Program

1991-92 17 17 --- --- --- ---

1993-94 16 17 --- 21 --- 7

2000-01 23 28 3 (11%) 45 25 (56%) 29

2009-10 41 54 1 (2%) 95 53 (56%) 65

2010-11 45 64 0 95 64 (67%) 71

2011-12 44 56 0 102 56 (55%) 69

2012-13 41 65 5 (8%) 98 60 (61%) 62

2013-14 41 52 2 (5%) 94 50 (53%) 64

Source: AMA and AAMC data from National Survey of GME programs, JAMA 1992-2014. Data through 2010-11 compiled by Geriatrics Workforce Policy Studies Center.

Page 8: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Geriatrics Fellowship Programs 1991-2 to 2013-4 Internal Medicine

Academic Year

Programs Fellows (All Years)

Fellows > 2nd Year (% of all fellows)

First Year Positions Available

Fellows in 1st Year Positions (% Filled)

Fellows Completing Program

1991-92 75 181 --- --- --- ---

1993-94 82 208 --- 142 --- 111

2000-01 96 293 71 (24%) 292 222 (76%) 247

2009-10 107 242 22 (9%) 394 220 (56%) 294

2010-11 104 237 22 (9%) 393 215 (55%) 284

2011-12 105 219 24 (11%) 388 195 (50%) 273

2012-13 105 246 10 (4%) 388 236 (61%) 275

2013-14 105 267 11 (4%) 383 256 (67%) 276

Source: AMA and AAMC data from National Survey of GME programs, JAMA 1992-2014. Data through 2010-11 compiled by Geriatrics Workforce Policy Studies Center.

Page 9: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Geriatrics Fellowship Programs 1991-2 to 2013-4 Family Medicine and Internal Medicine

Academic Year

Programs Fellows (All Years)

Fellows > 2nd Year (% of all fellows)

First Year Positions Available

Fellows in 1st Year Positions (% Filled)

Fellows Completing Program

1991-92 92 198 --- --- --- ---

1993-94 98 225 --- 163 --- 118

2000-01 119 321 74 (23%) 337 247 (73%) 276

2009-10 148 296 23 (8%) 489 273 (56%) 359

2010-11 149 301 22 (7%) 488 279 (57%) 355

2011-12 149 275 24 (9%) 490 251 (51%) 342

2012-13 147 311 15 (5%) 486 296 (60%) 337

2013-14 146 319 13 (5%) 477 306 (64%) 340

Source: AMA and AAMC data from National Survey of GME programs, JAMA 1992-2014. Data through 2010-11 compiled by Geriatrics Workforce Policy Studies Center.

Page 10: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Certification and Re-Certification by Year of Original Certification

Family Medicine Internal Medicine

Year CertifiedFirst

Re-certSecond Re-cert Certified

First Re-cert

Second Re-cert

1988 752 482 (64%) 282 (38%) 1,659 830 (50%) 426 (26%)

1990 473 318 (67%) 196 (41%) 1,204 562 (47%) 246 (20%)

1992 597 375 (63%) 242 (41%) 1,254 650 (52%) 292 (23%)

1994 771 415 (54%) 234 (30%) 1,568 774 (49%) 274 (17%)

1994 was the last year candidates could sit for the certification examination without completing fellowship training

Source: Lou Grosso, ABIM & Gary Jackson, ABFM.

Data used with permission and compiled by Libbie Bragg and Gregg Warshaw, University of Cincinnati. Updated 2015

Page 11: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Certification and Re-Certification by Year of Original Certification

Family Medicine Internal MedicineYear Certified First

Re-certificationCertified First

Re-certification1996 254 123 (48%) 291 169 (58%)1998 103 52 (50%) 337 231 (69%)1999 28 19 (68%) 183 117 (64%)2000 27 22 (81%) 200 140 (70%)2001 21 18 (86%) 193 132 (68%)2002 30 24 (80%) 270 189 (70%)2003 53 40 (75%) 262 168 (64%)2004 72 42 (58%) 256 138 (54%)

Source: Lou Grosso, ABIM & Gary Jackson, ABFM.

Data used with permission and compiled by Libbie Bragg and Gregg Warshaw, University of Cincinnati. Updated 2015

Page 12: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

National Survey of Allopathic and Osteopathic Geriatrician Academic Leaders – 2010*

• 51% of medical schools reported < 9 FTE geriatrics physician faculty

• Estimated 1,549 FTE geriatrics physician faculty in 159 medical schools

• Estimated 249,910 FTE supply of primary care physicians in 2015†

• 39% of geriatrics program directors planned to relinquish leadership role by 2015

*Bragg, EJ, Warshaw GA, et al. J Am Geriatr Soc 60:1540-1545, 2012.

† HRSA. The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand, 2008.

Page 13: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Program Directorship Changes 2009-2014

Academic Year

Newly Accredited

FM/IM Programs

FM/IM Programs

with Withdrawn

Accreditation

DeltaFM/IM

Programs with at least 1 New

Program Director Change

2009-2010 9 3 +6 152010-2011 4 2 +2 62011-2012 2 1 +1 182012-2013 1 0 +1 252013-2014 2 3 -1 16

Source: ACGME Data Resource Books, 2009-2010 to 2013-2014.

Page 14: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

ARE YOU PLANNING TO BECOME CERTIFIED IN A SPECIALTY?

Specialty 2009 2010 2011 2012 2013 2014Family Medicine 6.4% 5.6% 6.3% 5.9% 6.2% 7.3%Internal Medicine

16.0% 15.3% 15.8% 16.1% 16.4% 17.3%

Overall number of responses to question regarding all specialties

9,356 11,150 10,278 10,167 11,230 12,041

Total FM + IM 2,096 2,330 2,271 2,237 2,538 2,962

AAMC, Medical Student Questionnaire, All Schools Summary Report, August 2013

Page 15: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Projection of the Number of Certified Geriatricians in 10 Years*

Obs. Year Forecast STD L95 U9519 2015 6232 0.045 5704 679420 2016 6290 0.052 5668 696121 2017 6402 0.058 5707 715922 2018 6136 0.058 5469 686223 2019 5958 0.062 5268 671324 2020 5803 0.065 5094 658125 2021 5837 0.072 5055 670426 2022 5749 0.074 4963 662427 2023 5658 0.076 4860 655028 2024 5489 0.078 4699 6373

*Auto regressive integrated moving average (ARIMA) model for time series forecasting. Analysis provided by Yuning Hao, MS, Dept. of Statistics and Probability, Michigan State University

Page 16: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Summary

Over the past 5 years

• The numbers fellows in first year positions, positions available, and fellows completing training have remained fairly constant.

• The number of fellows in the second year of training and beyond has decreased.

• Program directors have turned over at an increasing rate, possibly due to retirement.

Page 17: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Summary

• For geriatricians certified prior to the fellowship eligibility requirement, first re-certification rates are lower when compared to those after 1994.

• Second re-certification rates are very low.

• Of all geriatricians who were required to complete fellowship training, only 63% have re-certified for the first time (55% for 2004).

Page 18: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Summary

• There are now 6,256 certified geriatricians, the lowest number since 1994.

• The current influx of fellows is not enough to counterbalance the harmful effect on our ranks of low recertification rates.

• The number of certified geriatricians could fall below 6,000 by 2019.

Page 19: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Summary

If new methods of recruiting trainees into geriatrics fellowship programs are not considered, the number of geriatricians will probably continue to decline and lead to a further increase in the shortage of geriatric medicine clinicians and educators.

The alternative pathway to certification is one of those methods.

Page 20: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Recruitment of Mid-Career and Part-Time Practicing Physicians

David Sandvik, MD

University of South Dakota (USD)

Sanford School of Medicine (SSOM)

Evangelical Lutheran Good Samaritan Society

Geriatrics Fellowship Program Director

Page 21: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Objectives

1. Review evidence that mid-career and practicing physicians are interested in geriatrics training.

2. Review why training mid-career and practicing physicians is a good idea for fellowships and the specialty of geriatrics.

3. Review logistic barriers to training mid-career and practicing fellows and creative solutions.

4. Suggest new sources of geriatrics-trained physicians.

Page 22: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

USD SSOM Fellowship History

• USD SSOM is SD’s only medical school– Community school with immersion model– Four primary campuses– Eight Farm and Rural Medicine (FARM) sites– Highly developed distance education infrastructure

• Fellowship accredited in 2011• Three of the first four graduates were mid-career

physicians• No fellows were matched in the 2014 Match• Part-time track initiated for practicing physicians

Page 23: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD
Page 24: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Objectives

1. Review evidence that mid-career and practicing physicians are interested in geriatrics training.

Page 25: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Board Certification History

IOM. 2008. Retooling for an aging America: Building the health care workforce.

Page 26: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Survey of all Practicing Primary Care Physicians in Arizona:1992*

• 702 of 1011 complete responses (69%)

• 242 would consider a geriatrics fellowship (33%)– 2-year fellowship: 30% likely or very likely– 1-year fellowship: 44% likely or very likely– Mini-fellowship: 74% likely or very likely– Part-time fellowship: 87% likely or very likely

*Abyad A. Factors influencing the decision to enter a geriatrics fellowship. Educational Gerontology 2000;26:97-105.

Page 27: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

AMDA Certified Medical Director (CMD)/American Board of Post-Acute and

Long-Term Care Medicine (ABPLM)*

• Number certified since 1991: >3500• Current CMD’s: 2140• Percent recertified at least once: 73%• Mean yearly certifications 2010-2015: 165

• Partly online program the last two years• Numbers are limited by space in

face-to-face sessions

*Personal Communication: Suzanne Harris, Director AMPLM

Page 28: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

USD SSOM Recruitment History Part-time track initiated for practicing physicians

– Word-of-mouth advertising • One completed application withdrawn before starting • One rural physician without FM or IM residency

(unqualified for accredited track)

– Recruitment letter to supporting health system• Four inquiries• Two hospitalists part-time fellows• One physician boarded in two non-FM/IM specialties

(unqualified)

– One mid-career applicant accepted in Nov. 2014

– Other physicians have expressed interest

Page 29: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Evidence that Practicing physicians Will Pursue Geriatrics

1. Geriatrics Board Certification History

2. Survey of Arizona Physicians

3. AMDA’s Certified Medical Director (CMD)/American Board of Post Acute and Long Term Care (ABPLM) Numbers

4. USD SSOM Recruitment Experience

Page 30: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Motives for Practicing and Mid-Career Physicians to Pursue Geriatrics Training

• Desire to change practice style: burnout, etc.

• Desire for professional development and prestige: Confirmed in Abyad study (40%)

• Desire to improved the quality of care for older patients

Page 31: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Objectives

1. Review evidence that mid-career and practicing physicians are interested in geriatrics training.

2. Review why training mid-career and practicing physicians is a good idea for fellowships and the specialty of geriatrics.

Page 32: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Training Mid-Career and Practicing Physicians is Good for Fellowships

• Fellowship curriculum must remain highly relevant

• New pathway into geriatrics for US graduates– Many become hospitalists

– Many begin practice for financial and social reasons

• Educational debt

• Starting families

– They could consider a part-time program

Page 33: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Training Mid-Career and Practicing Physicians is Good for Geriatrics

• Part-time pathways could be built into all fellowships

• Provide improved care of older patients in existing clinical sites, since trainees continue in current practices

• Increase the visibility of the specialty of geriatrics

Page 34: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Objectives

1. Review evidence that mid-career and practicing physicians are interested in geriatrics training.

2. Review why training mid-career and practicing physicians is a good idea for fellowships and the specialty of geriatrics.

3. Review logistic barriers to training mid-career and part-time practicing fellows and solutions.

Page 35: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Logistical Barriers and Solutions to Training Practicing Fellows

• Relevance of education– Adult Learning methodology– Training is more of a collaboration– Solicit referrals from local Alzheimer’s Associations– Arrange outreach consultation days at nursing

homes to see patients on antipsychotics, etc.

• Develop novel educational experiences– Nursing home night call added for weeks when

fellows come off night call and miss a half day. Counted as less than hour-for-hour daytime learning experiences, but counted

Page 36: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Logistical Barriers and Solutions to Training Practicing Fellows

• Definition of part-time pathway: 2000 hours of approved education

• Schedules– Start training when the physician is ready– Every-other month or week?

• Location– Utilize physician’s personal practice for continuity clinics,

nursing home panels and rotations: Send a roving faculty member to attend experiences

– Develop distance learning technology seldom used in GME

– Develop distant rotations with local geriatricians (multi-campus model fellowship)

Page 37: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Objectives

1. Review evidence that mid-career and practicing physicians are interested in geriatrics training.

2. Review why training mid-career and practicing physicians is a good idea for fellowships and the specialty of geriatrics.

3. Review logistic barriers to training mid-career and part-time practicing fellows and solutions.

4. Suggest new sources of geriatrics-trained physicians.

Page 38: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Sources of Geriatric-Trained PhysiciansI

• Traditional post-residency pathway

• Mid-career and practicing physician pathway

• Start more convenient, local fellowships

– None of our past or current fellows would have moved away for a one-year fellowship, then returned

– Satellite fellowships model (Michigan)

– Multi-campus model (South Dakota)

Page 39: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Sources of Geriatric-Trained PhysiciansII

• Non-family/internal medicine-trained physicians (PM&R, Surg., Occupational Med.,etc.)– Train in a para-ACGME-accredited

pathway– “Board certification” would require

changes in board-eligibility

• Recertification of geriatricians who have allowed certification to lapse?

Page 40: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Sources of Geriatric-Trained PhysiciansIII

• Convince health systems of the value of geriatrics and geriatricians – Concentrate on services requiring geriatrician

such as patient discharges to SNF units– Systems might send their physicians for

training– Systems might provide stipends– Two of our four graduates are Directors of

Geriatric Services in health systems that had no geriatric services

Page 41: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Fellowship Part Time Alternative Pathway

James Campbell MD, MS

Fellowship Directors

May 13, 2015

Pre-Conference

National Harbor, Maryland

Page 42: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Learning Objectives

• Understand basics of why to offer

• Appreciate need for stakeholder assessment

• Understand how to do environmental assessment

• Comprehend multidimensional value assessment

• Steps to success

• Pitfalls to avoid

Page 43: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Background

• Work force– Supply

– Demand

– Total

– Geographic mismatch

– Program size mismatch

Page 44: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Assumptions

• Willingness to train is enough– What about money?

– What about time?

– What about location?

Page 45: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Assumptions

• Historical– Preconceived ideas

– New program recent history

– Worst case last 10 years

– Best case last 10 years

– Who weighs in?

Page 46: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Assumptions

• Culture– Academic

– Research

– Teaching

– Productivity

– Mission and vision statement

Page 47: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Stakeholder Assessment• Patients• Community

– Service organizations– Government

• City • Regional • State• Federal

– Philanthropic community

Page 48: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Stakeholder Assessment

• Health System– Faculty– Operations Administration– Finance Administration– Chair– Service Line Director– CMO– CEO– Board

Page 49: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Value Added Business Case• Story development• Audience • Service line alignment• Revenue levers*

– Average revenue• Price• Collections• Case mix

– Volume• New patients• Physical capacity• Operational capacity

* Weatherhead drivers of financial performance

Page 50: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Analyze on a System Perspective

• Capacity management

• Operational efficiency

• Effect on other service lines / departments

• Effect on GME

• Through-put

Page 51: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Beyond the Numbers

• Culture change– Behavior – Process

Page 52: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Change

• Certainty– Funding– Economy– Policy– Clinical practice

Page 53: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Steps to Success

• Recruitment

• Pre-approval

• Curriculum

• Accreditation

Page 54: Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

Pitfalls to Avoid

• Work with the Board of the applicant

• GME funding issues

• Billing issues

• Call

• Vacation

• Continuity clinical experiences


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