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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Graduate Medical Education Outcomes and Metrics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25003.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Graduate Medical Education Outcomes and Metrics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25003.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Graduate Medical Education Outcomes and Metrics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25003.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Graduate Medical Education Outcomes and Metrics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25003.
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Graduate Medical Education Outcomes and Metrics PROCEEDINGS OF A WORKSHOP Payal Martin, Mariana Zindel, and Sharyl Nass, Rapporteurs Board on Health Care Services Health and Medicine Division PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 This activity was supported by the Accreditation Council for Graduate Medical Education, Alliance of Independent Academic Medical Centers, American Associa- tion of Colleges of Osteopathic Medicine, American Board of Internal Medicine, American Board of Internal Medicine Foundation, American Board of Medical Specialties, American Board of Obstetrics and Gynecology Foundation, American Board of Physical Medicine and Rehabilitation, American Osteopathic Associa- tion, The Arnold P. Gold Foundation, Association for Hospital Medical Education, Foundation for Advancement of International Medical Education and Research, The Josiah Macy Jr. Foundation, National Board of Medical Examiners, and the U.S. Department of Veterans Affairs (Office of Academic Affairs). Any opinions, ­ findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17266/25003 Additional copies of this publication are available for sale from the National A ­ cademies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2018 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medi- cine. 2018. Graduate medical education outcomes and metrics: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi. org/10.17266/25003. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of C ­ ongress, signed by President Lincoln, as a private, nongovernmental institu- tion to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the char- ter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engi­ eering, and Medicine to provide independent, objective analysis and n a ­ dvice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine ­ at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, E ­ngineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typi- cally include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and ­ pinions o contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

PLANNING COMMITTEE FOR A WORKSHOP ON GRADUATE MEDICAL EDUCATION OUTCOMES AND METRICS1 DEBRA F. WEINSTEIN (Chair), Vice President, Graduate Medical Education, Partners HealthCare System VINEET M. ARORA, Director, Graduate Medical Education Clinical Learning Environment Innovation, The University of Chicago DAVID A. ASCH, Executive Director, Penn Medicine Center for Health Care Innovation KARL Y. BILIMORIA, Associate Professor of Surgery and Medical Social Sciences, Feinberg School of Medicine, Northwestern University ROBERT A. CAIN, Assistant Dean, Office of Clinical Education, Ohio University Heritage College of Osteopathic Medicine CANDICE CHEN, Director, Division of Medicine and Dentistry, Health Resources & Services Administration MALCOLM C. L. COX, Adjunct Professor of Medicine, University of Pennsylvania DEBORAH A. DRISCOLL, Luigi Mastroianni, Jr., Professor and Chair, Hospital of the University of Pennsylvania EDWARD SALSBERG, Director, Health Workforce Studies, Health Workforce Institute, The George Washington University DOUGLAS S. SMINK, Associate Professor of Surgery, Harvard Medical School, General Surgeon, Brigham and Women’s Hospital Project Staff MARIANA ZINDEL MUNDET CRUZ, Research Assistant KELSEY GEISER, Research Associate (until April 2017) SHARYL NASS, Director, Board on Health Care Services Consultant PAYAL MARTIN, Consulting Writer 1  The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rap- porteurs and the institution. v PREPUBLICATION COPY—Uncorrected Proofs

Reviewers This Proceedings of a Workshop was reviewed in draft form by indi- viduals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical com- ments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: FRANCISCO CIGARROA, The University of Texas Health Science Center, San Antonio RACHEL KELZ, University of Pennsylvania DEBORAH POWELL, University of Minnesota Medical School ERIC SCHNEIDER, The Commonwealth Fund MEDHANIT TEKLE, Institute for Family Health Harlem Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The ­ eview of this proceedings was overseen by MOLLY COOKE, University of r C ­ alifornia, San Francisco. She was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies. vii PREPUBLICATION COPY—Uncorrected Proofs

Acknowledgments We are grateful to the members of the planning committee for the Workshop on Graduate Medical Education Outcomes and Metrics, who collaborated to ensure a workshop with informative presentations and rich discussions, and especially to Debra Weinstein, the committee chair, for her valuable contributions to the development and orchestration of this work- shop. We also thank the speakers and moderators, who generously shared their expertise and time to make the workshop a success. We are also grateful for the coalition of sponsors who supported the workshop, without whom we could not have undertaken this project. The sponsors of the Workshop on Graduate Medical Education Outcomes and Metrics included the Accreditation Council for Graduate Medical Educa- tion, Alliance of Independent Academic Medical Centers, American Asso- ciation of Colleges of Osteopathic Medicine, American Board of Internal Medicine, American Board of Internal Medicine Foundation, American Board of Medical Specialties, American Board of Obstetrics and Gynecol- ogy Foundation, American Board of Physical Medicine and Rehabilitation, American Osteopathic Association, The Arnold P. Gold Foundation, As- sociation for Hospital Medical Education, Foundation for Advancement of International Medical Education and Research, The Josiah Macy Jr. Foundation, National Board of Medical Examiners, and the U.S. Depart- ment of Veterans Affairs (Office of Academic Affairs). ix PREPUBLICATION COPY—Uncorrected Proofs

Contents WORKSHOP OVERVIEW 1 OPENING REMARKS: OPTIMIZING GME BY MEASURING OUTCOMES 2 Insights from the 2014 Consensus Report: Graduate Medical Education That Meets the Nation’s Health Needs, 3 Why Measure GME Outcomes, and What Is Needed?, 6 Why Now?, 7 GME OUTCOMES: WHAT MATTERS? 7 Discussion of Challenges to Identifying, Measuring, and Achieving Optimal Outcomes, 11 CURRENT METRICS: WHAT IS MEASURED NOW? 12 National Board of Medical Examiners (NBME) Measurements, 12 ACGME Milestone Data Measurements, 15 GME Program Metrics of the Health Resources & Services Administration, 18 Metrics of the American Board of Medical Specialties, 21 BLUE SKY: DATA IN THE FUTURE 23 Lessons from Measuring Provider Performance in Clinical Practice, 23 Linking Data Sources to Inform GME, 25 Using Clinical Data for GME, 27 GME METRICS 28 GME Graduate-Level Metrics, 28 GME Residency Program-Level Metrics, 30 xi PREPUBLICATION COPY—Uncorrected Proofs

xii CONTENTS Teaching Institution Metrics, 31 National-, Regional-, or State-Level Metrics, 32 CAN OUTCOME MEASUREMENT PROVIDE A PATH TOWARD EVIDENCE-BASED EDUCATION? 33 Answering GME Questions Using “Big Data” at NYU, 33 Outcomes-Based Education in Surgery, 37 Workforce Data and Metrics Based on Residency Program Outputs, 41 PUBLIC POLICY IMPLICATION 42 Implications of Workforce Goals, 43 Alignment Between GME Goals and Public Policy Priorities, 45 Lessons Learned from State-Based Approaches to Reforming Medicaid-Funded Graduate Medical Education, 45 PRIVACY VERSUS TRANSPARENCY 48 IMPLMENTATION 49 Achieving Buy-In and Requiring Data Reporting, 50 How Should a National Database Be Maintained and Funded?, 51 What Infrastructure Is Required?, 52 ORGANIZATIONAL REACTIONS 53 CLOSING REMARKS 55 REFERENCES 57 APPENDIXES A Statement of Task 61 B Workshop Agenda 63 PREPUBLICATION COPY—Uncorrected Proofs

Boxes and Figures BOXES 1 Overview of Suggestions Made by Individual Workshop Participants for Defining and Implementing Outcome Measures of Graduate Medical Education (GME), 4 2 Statutory Reporting Requirements for Health Resources & Services Administration Graduate Medical Education Programs, 19 3 Summary of Outcome Metrics Discussed by Workshop Breakout Groups, 29 FIGURES 1 Logic model and outcomes, 16 2 The medical education data continuum, 34 3 NYU Langone’s approach to merging and analyzing data sets to assess medical education, 36 4 Education to outcomes and value in surgery, 38 5 A framework for the assessment of graduate medical education, 39 6 Projected adult population under two different scenarios, 2015–2030, 44 xiii PREPUBLICATION COPY—Uncorrected Proofs

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Graduate medical education (GME) is critical to the career development of individual physicians, to the functioning of many teaching institutions, and to the production of our physician workforce. However, recent reports have called for substantial reform of GME. The current lack of established GME outcome measures limits our ability to assess the impact of individual graduates, the performance of residency programs and teaching institutions, and the collective contribution of GME graduates to the physician workforce.

To examine the opportunities and challenges in measuring and assessing GME outcomes, the National Academies of Sciences, Engineering, and Medicine held a workshop on October 10–11, 2017, in Washington, DC. Workshop participants discussed: meaningful and measurable outcomes of GME; possible metrics that could be used to track these GME outcomes; possible mechanisms for collecting, collating, analyzing, and reporting these data; and further work to accomplish this ambitious goal. This publication summarizes the presentations and discussions from the workshop.

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