In July, the University of Michigan General Surgery Residency program will welcome an expanded class of residents for the first time in 30 years. The program has increased its class size from six to seven residents — which, though it might seem like a small change, will have a sizable impact on surgery education and patient care at the U-M.
“It’s a big accomplishment because of all the factors and regulation involved in these decisions,” says Paul Gauger, M.D., the William J. Fry Professor of Surgery and Program Director for Surgery. “Most hospitals are “over-cap,” where any incremental growth to a graduate medical education program is funded by the hospital without being subsidized by Medicare or Medicaid funding. So there ends up being a big financial and educational analysis around growth because every additional learner impacts other learners and the financial bottom line. Even if you have the money to fund growth, the program might not be educationally ideal at a certain size.”
Gauger, who also leads the Norman W. Thompson Fellowship in Endocrine Surgery, says there was a strong sense among the program and department leadership that the class size needed to expand based on clear and continuing growth in clinical activity. Over the last decade, there has been about a 49 percent increase in clinical surgical faculty and a 31 percent increase in surgical cases. At the same time the number of surgical specialty trainees only grew about 14 percent and none of that growth was in the general surgery program.
“So you can see a gap there in terms of expanding clinical activity and limited growth in the educational enterprise,” Gauger says.
A potential problem related to that gap was unmet educational opportunity. U-M surgery residents were getting outstanding operative opportunity, far above minimum threshold. But there was room to add other learners into that mix, to share some of that volume and benefit from the program, which has been rated by Doximity, Inc. as No. 1 in the Midwest, No. 1 amongst all large public universities and No. 3 nationally.
“We wanted to pursue an increase in the resident workforce as a more impactful solution for assisting with cases in the operating room and capitalizing on educational opportunities,” Gauger says. “There are other things we could have done, such as hiring more mid-level providers in the operating room in a non-educational role or hiring more advanced trainees. But those things would potentially affect the quality of the residency program by taking away opportunities. So we felt that investing in the residency program was the most important thing to do.”
The process to expand the class size involved a rigorous analysis in case volume, who was covering those cases, and whether the current class size of residents was getting to clinic often enough for outpatient learning experiences. The results revealed a need for a bigger residency with a little bit more flexibility so learners were better matched with opportunities in the operating room. Once that idea was approved within the department, the educational request was approved at the institutional level. This was followed by a year-and-a-half process of securing the commitment for increased funding from the hospital as well as getting final approval from the Residency Review Committee, or RRC, and the Accredited Council for Graduate Medical Education, or ACGME. As part of that final step, the ACGME completed a full site visit in March 2015, and the program was fully accredited with no citations. After that, the agency approved the program’s request for the seven residents per year moving forward.
“This will improve our fellow and faculty pipeline into the department so we can keep the best residents on faculty and have them spend their careers here,” Gauger says. “Having a larger class size will potentially give us more flexibility to come up with more creative educational opportunities and further enhance our educational reputation and ability to reach more people.”
Gauger adds that, because U-M attracts such high-quality resident applicants who are central to the care our patients receive, the less that that workforce is strained and spread between many different areas, the better and more coordinated that care will be.
The educational environment will improve in other important ways. As further evidence of the quality of that workforce, five surgery residents recently won 2016 Bronze Beeper Awards. These awards are given annually by the Galens Medical Society, the largest and longest-standing medical student service organization at the Medical School. Third- and fourth-year medical students award Bronze Beepers to only 12 residents throughout the Medical School who they consider to be the very best resident teachers. U-M has more than 1,000 residents and fellows, and the fact that five surgery residents were recognized is a great accomplishment for the program. The surgery resident winners included: Arielle Kanters, Roy Lirov, Charles Mouch, Matthew Ralls, and Farokh Demehri. In fact, Kanters went on to win the Gold Beeper Award as the very finest of resident teachers.
“These are the residents that made the biggest difference in teaching students how to take care of patients,” Gauger says. “Surgery shines every year because we make education such a focus. Also I think as a department, we have very clear outreach and support of our medical students. We engage our medical students in surgery very well in a number of ways and try to integrate them as part of the team that’s taking care of patients.”