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The DO | In Training | Training Ground

Creating new OGME: LECOM initiative transforms nonteaching hospital

Given the rapidly increasing number of osteopathic medical schools and satellite campuses and the expansion of class sizes, the profession has a moral obligation to start new osteopathic graduate medical education programs, says Richard Terry, DO, the director of medical education for Arnot Health in Elmira, N.Y. Colleges of osteopathic medicine in particular need to take the lead in establishing AOA-approved residencies and fellowships, he insists, noting that this process requires investment and persistence but pays huge dividends for all stakeholders.

Richard Terry, DO, and staff

Arnot Health’s DME Richard Terry, DO (left), who champions OGME development on behalf of LECOM, confers with family medicine resident Harry Dale McHenry II, DO, and rotating intern Kevin Smith, DO. (Photo credit courtesy of Dr. Terry)

“The main challenge is changing the culture from nonteaching to teaching. But it can be done, and it’s a win-win for everyone,” says Dr. Terry, the assistant dean for regional clinical education at the Lake Erie College of Osteopathic Medicine (LECOM) in Erie, Pa.

The brand-new OGME program at Arnot welcomed its first 24 residents and one cardiology fellow in July. Training in family medicine, internal medicine and general surgery, these residents will be joined by psychiatry and diagnostic radiology residents in 2014. Arnot also has 10 traditional rotating internship positions, a program in emergency medicine that is awaiting AOA approval, and an approved but not yet initiated fellowship in endocrinology. Gastroenterology, geriatrics and critical care fellowships are also in the works.

“We will have a house staff of well above 100 DOs,” Dr. Terry says.

A year before launching the OGME program, Arnot became the hub rotation site for dozens of LECOM students completing their third-year core and fourth-year elective rotations. The students, residents and fellows train primarily at the largest of the health system’s three hospitals—Arnot Ogden Medical Center in Elmira.

New teaching hospitals must begin training students before rolling out GME, Dr. Terry notes. “You can’t have GME without having students. It’s your students that you primarily recruit from,” he explains.

Laying the foundation

The Balanced Budget Act of 1997 capped the number of Medicare-funded GME positions at existing teaching hospitals. Although positions can be shifted from one residency or fellowship to another within a hospital, the Centers for Medicare and Medicaid Services for the most part will not fund the overall expansion of an institution’s GME program, unless it is taking in trainees from a shuttered program at another hospital.

But Medicare will fund new GME programs at nonteaching (or virgin) hospitals, which currently constitute more than 90% of all hospitals.

To encourage virgin hospitals to establish OGME programs, the AOA launched its OGME Development Initiative, which provides expertise and informational resources to potential teaching institutions.

In Dr. Terry’s opinion, osteopathic medical colleges need to hire their own GME experts to create new programs, as he has set out to do.

“As a profession, we should go as many places as possible and be as aggressive and proactive as we can,” he says.

Dr. Terry first became aware of Arnot Health’s untapped GME potential when he was the DME for another health system. Although Arnot did not have established clinical training programs for medical students and residents, it did accept the occasional student on rotation. Dr. Terry had used Arnot for some of his DO students’ emergency medicine out-rotations.

In addition to providing quality health care, Arnot Health struck Dr. Terry as being especially DO-friendly.

“We already had a dozen osteopathic physicians on staff in many different specialties,” says William E. Huffner, DO, Arnot Health’s chief medical officer.

For LECOM, Dr. Terry further assessed Arnot’s advantages as a regional clinical campus. Although Elmira has only 35,000 people, the health system serves all of the county, which has a population of more than 90,000. Arnot’s three hospitals and multiple clinics and outpatient offices would ensure the breadth and volume of clinical experiences required by students and residents.

“As a profession, we should go as many places as possible and be as aggressive and proactive as we can.”
Dr. Terry

Arnot Health, in turn, had needs that a new GME program could help meet. “Arnot needed a supply chain of physicians who would stay in the area to practice,” Dr. Terry says. Graduate medical training would alleviate both short-term staffing challenges and the region’s long-term demand for more physicians.

Because physicians tend to practice close to where they train, developing GME programs in community hospitals can play an important role in addressing the burgeoning physician shortage. “There is a huge physician shortage in upstate New York,” Dr. Huffner says.

Like many mid-sized towns not connected to a major urban area, Elmira has experienced a brain drain of young aspiring physicians who leave to attend medical school and rarely return.

“You are talking to one of those kids who grew up here, left and later came back,” says Dr. Huffner, who went to med school and trained in Syracuse, N.Y., more than 80 miles away. “So I’m acutely aware of the need for GME to get medical school graduates to train and later practice in this area.”

Initial investment

Developing clinical rotations and GME requires significant financial commitment in the early stages. LECOM gave a $25,000 gift to the Arnot Ogden Medical Center Foundation, which raised approximately $200,000 to build the needed infrastructure, including new information technology systems, meeting room renovations and student housing in the community, Dr. Huffner says. LECOM is responsible for paying the salaries of Dr. Terry and a student program coordinator.

Figuring out the financial side of OGME is a major undertaking. “At the time you start your process for planning residencies, you need to simultaneously explore the funding options, work with a GME consultant to determine the reimbursement and develop a fiscal plan to move the program forward,” Dr. Terry says. “You also have to work with CMS to change your status to a teaching hospital, which usually requires nine to 12 months of advance notice.”

From the time Dr. Terry first approached Dr. Huffner, the whole process of establishing the student rotations and rolling out OGME required approximately two years and many meetings between LECOM and Arnot leaders.

Creating a teaching culture

The hardest part of creating OGME at a virgin hospital is convincing experienced attending physicians who have never taught before that they can be excellent educators.

The key to a successful transformation, according to Dr. Terry, is to find a physician champion among the hospital staff who will inspire other physicians to embrace teaching. This leader need not be an academician to begin with but must be someone with the desire to teach.

“All physicians really are teachers because we teach our patients all the time,” Dr. Terry notes. The physician champion must work to instill confidence in those doctors who say “I could never do that.”

“At Arnot, I was the only physician who had any educational experience to a significant degree,” says Dr. Terry, who is also the chief academic officer for the Lake Erie Consortium for Osteopathic Medical Training, LECOM’s osteopathic postdoctoral training institution. “But through faculty development, we’ve brought everyone else along to become educators, and they’ve proven to be outstanding.”

“It enlivens not just the attending staff but also the nurses and ancillary staff to have young people around who are interested, committed and compassionate and caring for our patients. It’s refreshing.”
Dr. Huffner

Physicians who are not used to teaching also tend to worry that it will reduce their productivity. “You need to demonstrate to them that it won’t affect their productivity in a negative way,” Dr. Terry says. “Senior residents, in fact, significantly improve attending physicians’ productivity.”

Being part of a teaching hospital also forces physicians to stay more up-to-date on clinical issues. “Teaching makes you more apt to read and look things up,” Dr. Terry says.

At Arnot, all of the OGME faculty members except for Dr. Terry are home-grown, which helps prevent the turf wars that can occur when outside clinical instructors are brought in. “If you have internal people who are interested in teaching, you can train them to become program directors,” he says.

A community hospital may not have all of the expertise needed to give trainees the desired breadth and depth of clinical instruction. But online technology can be tapped to supplement the training provided by on-site faculty.

Dr. Terry developed an online curriculum for students at Arnot that allows them to watch lectures, view other didactic materials and communicate with one another and with instructors.

Fresh perspectives

Arnot’s conversion into an academic health center has been well-received by hospital staff, according to Dr. Huffner.

“It certainly has transformed us,” he says. “In some ways, it has changed the nature of how we care for our patients. We have academic programming going on all the time now—didactic lectures, grand rounds every week. We have constant interaction between attendings and residents.

“It enlivens not just the attending staff but also the nurses and ancillary staff to have young people around who are interested, committed and compassionate and caring for our patients. It’s refreshing.”

Dr. Huffner says that patients like the changes they’ve noticed. “We’ve heard only positive comments from our patients,” he says. “The students and residents have been exceptionally professional, kind and caring. We’ve not had a single complaint from a patient.”

Patients appreciate getting more follow-up care from physicians, adds Henry Dale McHenry II, DO, who is serving a family medicine residency at Arnot. “Because of the residents, patients are able to be seen by physicians four or five times a day as opposed to once or twice,” he says.

Dr. McHenry, who served a rotation at Arnot last year, is from Elmira and expects to practice at one of the health system’s outpatient clinics when he finishes his residency. He is already building his patient base. “People in town who know me are coming to see me now that I’m starting my clinic hours,” he says.

Although it can be challenging not to have senior residents as mentors, Dr. McHenry likes being a pioneer in a new residency program. “It’s an advantage to be first because you can help mold the program the way you’d like to see it,” he says.

“It’s difficult in the sense that there is nobody ahead of you to whom you can ask questions,” says Lauren Kopicky, DO, a general surgery resident. “But it’s also exciting to be part of something new. You are defining the program, paving the way for future residents.”

Dr. Kopicky chose her residency program because of the favorable experience she had during her fourth-year general surgery elective at Arnot. “The general surgery attendings here are really great to work with,” she says.

Some osteopathic medical schools feel that it’s not their role to develop OGME, Dr. Terry observes. But LECOM, he says, has made developing OGME a priority. The school is working with other hospital systems to establish programs similar to the one at Arnot Health. “We’re growing GME from the ground up,” Dr. Terry says.

cschierhorn@osteopathic.org

One Response

  1. Sam Garloff, D.O. on Sept. 7, 2013, 8:52 a.m.

    What a great win-win-win situation. New training slots, expansion of the profession and service to the Twin Tiers.
    Congratulations to all.

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