ACGME President and Chief Executive Officer Thomas J. Nasca, MD, MACP called on nearly 4,000 members of the graduate medical education (GME) community not only to teach medicine to heal the body, but also to teach how medicine can heal society.
“Today I’m going to try to challenge you not to just have a sense of relief that we’re hopefully seeing the end to the pandemic and going back to what we used to do,” Dr. Nasca said during his President’s Plenary address at the 2023 Annual Educational Conference in Nashville, Tennessee, “I’m going to ask you to do more.”
His talk explored the connection between undergraduate medical education (UME) and GME; revisited the three pandemics he discussed in his 2022 President’s Plenary; and offered a path forward from the COVID-19 pandemic to help residents and fellows strengthen their identities as physicians.
UME to GME
The explosion in medical school graduates in recent years has been followed by a dramatic expansion—a 40 percent increase over two decades—of GME programs and positions, Dr. Nasca said. (Note: The ACGME does not set the overall number of residency or fellowship positions in the US.) Even with that increase, the GME growth rate is slower than that of UME, he said. This has led to a more competitive environment, with fewer slots for more applications from both American medical school graduates and graduates of medical schools outside the US.
“Twenty years ago, the bottleneck to becoming a physician was entry in medical school,” Dr. Nasca said. “Today, it is entry into residency.” With this shift, he noted, it is more important than ever that those in UME and GME work together to address this bottleneck by doing it right, well, and fairly.
The Three Pandemics
Dr. Nasca also revisited the three pandemics he discussed in his 2022 address, offering new perspective on how GME can and must help residents and fellows address them.
“[Residents and fellows] need to be prepared for the challenges of tomorrow along with the knowledge and skills of today,” Dr. Nasca said. One significant challenge, he noted, continues to be the national opioid epidemic.
Since its peak in 2012, Dr. Nasca said the number of opioid prescriptions has fallen significantly, providing a significant positive impact in the US. Still, he noted, one in five opioid-related deaths is tied to prescribed opioids.
"We still have work to do,” he said, in understanding and treating substance use disorders, and shared insights on the ACGME’s work to help educate and train residents and fellows about this issue.
Discussing what he has dubbed the second pandemic—the “5 Is” of inequality, intolerance, incivility, incoherence, and inhumanity—Dr. Nasca highlighted inequities regarding hunger, food instability, and incorporating nutritional understanding into residency and fellowship programs, noting that the nutritional aspects that were important for him to know as a nephrologist were learned on the job, not in residency. He also discussed the effects of gun violence on the medical community, whether it be mass shootings, general homicides, or completion of suicide using guns, and the role the medical community can play in addressing this national crisis.
Dr. Nasca also discussed the ACGME’s involvement with decarbonization and mitigating its effects on climate change, including reducing waste, the establishment of the ACGME’s internal “Green Team,” and continuing to focus on developing innovative solutions. He noted the ACGME’s emissions come from commuting and flights to and from meetings and conferences, and promised to update the community on the organization’s efforts and continued commitment to reducing its environmental impact.
Resident Frustration, Identity Formation
A large cohort of learners—medical students who became residents, residents who became fellows, and residents and fellows who became independent physicians—had their medical education marked by the uncertainty, frustration, and fear of the COVID-19 pandemic.
“Their identity has been molded by this environment,” Dr. Nasca said.
To emphasize the impact of traumatic episodes on the identity formation of physicians, he shared his own memory of what he described as the worst day of his life as a physician. On Christmas in 1975, he pronounced 11 people dead. Reflecting on the lasting impression of that day, he noted that those practicing during the pandemic faced days much worse than that. The GME community, he said, has an imperative to acknowledge the resentment and stress borne from that experience and to reconnect learners to the reason they entered medicine in the first place: to help patients.
“It’s up to us to channel and nurture their altruism and commitment – they stood the line and are standing the line,” he said. “We need to honor that.”
While acknowledging there is comfort in returning to the daily business of teaching residents and fellows, Dr. Nasca asked the audience to take the physical and emotional exhaustion of the last three years and channel it into excitement for what’s ahead.
“The future of health care and physician education are in the balance, so I ask you to take these issues on each day,” he said. “You can make a difference.”
View the recording of the 2023 President’s Plenary in Learn at ACGME.