Two University at Buffalo surgical residency programs have been put on probation and a third closed, a rare rebuke to how the university trains doctors.
The Accreditation Council on Graduate Medical Education cited the general surgery and pediatric surgery residency programs earlier this year. The university in June also closed for the time being its dermatology program after the council placed that program on probation.
Less than 1 percent of the nation’s 9,022 medical residency programs are on probation.
The accreditation council does not disclose the reasons for its decisions. UB and hospital officials say that the programs experienced different problems and say they are taking action to resolve them.
The plan for their turnaround counts, in part, on a cultural change that a new $375 million medical school can encourage when it opens on the Buffalo Niagara Medical Campus, university officials say. The new school is expected to be completed in 2016.
“The probations have in common that change is coming,” said Dr. Roseanne Berger, senior associate dean for graduate medical education at the School of Medicine and Biomedical Sciences. “There is a new emphasis on quality, safety, teamwork and communication skills.”
Despite troubles at the two surgical programs, Berger said the overall shape of the medical school’s 60 medical residencies remains good.
This year, 50 percent more of graduating medical students chose to stay in Buffalo for their specialty training compared with last year.
“That is a vote of confidence,” Berger said.
What’s more, all of the general surgery residents last year passed board exams to become certified as surgeons.
But issues with the three programs raise concerns.
The probations could have a broader effect on UB’s medical training.
Doctors and medical school graduates may harbor doubts about joining a program on probation. Roswell Park Cancer Institute, concerned about attracting high-caliber candidates, partnered with the University of Rochester to train residents in the sub-specialty of complex surgical oncology.
Also, federal money for residents’ salaries and other program costs comes after council approval.
University officials see the new medical school on the Buffalo Niagara Medical Campus as a decisive way to make long-term improvements in the on-the-job training program that turns medical school graduates into specialists.
“We want to transform to a culture in which people see themselves as part of something bigger on the medical campus and not just their hospital,” said Dr. Michael Cain, vice president for health sciences at UB.
With 60 medical residency programs, UB ranks seventh among the 56 institutions in New York State that sponsor residency programs. This year’s actions by the council follow UB’s closure of training programs in rehabilitation medicine in 2010 and radiology in 2006. A residency in the specialty of ear, nose and throat medicine closed in 2002 but later restarted.
Most medical schools have their own teaching hospital with a medical staff affiliated with their university. But about one-third of medical schools, like UB, rely on local hospitals whose staffs include full-time UB physicians and private doctors who also teach.
Without a hospital of its own, UB arranges with local hospitals and their physicians to train residents in dozens of specialties – everything from anesthesiology to urology.
Known as residents, the school’s 780 future medical specialists serve as a major provider of patient care for teaching hospitals and a key pipeline for supplying new specialists in Western New York.
In some cases, like the training of trauma experts at Erie County Medical Center, the arrangements can work well.
But on the downside, doctors and their trainees often identify more with their hospitals than with the medical school’s educational priorities, officials say.
Over the years, without a hospital of its own, UB’s different specialty programs became based at different hospitals, including ECMC, Roswell Park, Veterans Hospital and Kaleida Health facilities. The hospitals, which get paid by the government to train new specialists, provide the patients and medical settings for the programs.
“UB has always struggled with identity because of the geographic division of the residency programs,” said Dr. Margaret Paroski, chief medical officer and executive vice president at Kaleida Health.
Now, she and others see a chance to alter that relationship.
Kaleida Health in 2012 moved Millard Fillmore Hospital’s services into the new Gates Vascular Institute next to Buffalo General Medical Center. This year, Kaleida Health plans to start construction of a new children’s hospital on the medical campus. Roswell Park is already there.
The thinking goes that consolidation on the medical campus will reduce the geographic spread of the programs, foster greater communication among doctors and create the atmosphere of an academic medical campus with a strong research component and physicians representing the full breadth of medical specialties.
Officials also envision efficiencies, including proximity of research labs, easier access to meetings, and more effective coverage by residents of patients, especially at night.
Construction on the new medical school is scheduled to start in September.
“We don’t want to be a city with just a community hospital reputation. We want to be known for having the capacity to provide complex care. Having the school and more hospitals on the medical campus helps us maintain that,” Paroski said.
University officials express confidence the general surgery program will regain council approval by spring 2014.
This large, essential residency program with 54 residents did not have enough faculty doing research and failed to comply with a 2003 council directive to limit the work week for residents to 80 hours.
Residents also complained about aspects of their experience, citing poor communication with supervising doctors as one shortfall.
Dr. Jeff Carter, a sixth-year resident, cited a clash of expectations between a new generation of residents learning under new rules and attitudes and the supervising physicians who trained under different circumstances.
“Residents feel like they have too much supervision and want more autonomy and more of a role in patient care,” said Carter, who otherwise described the training as “excellent.”
“Probation forced an evaluation of ourselves, and a lot of positive changes came out of it,” he said.
The limit on hours arose from studies that linked resident fatigue to medical errors and injuries. But the limit means less time to learn and fewer patients encountered who provide educational value for a resident’s specialty.
“We’re good at teaching surgical skills. But we have to think more about how to train effectively as a team and with better communication,” said Dr. Gregory Cherr, the new program director.
Residency programs are turning to other ways to train, including high-tech simulators to teach surgical skills. Cherr said the consolidation on the medical campus will provide larger and more convenient simulation labs.
The pediatric surgery residency program ran into issues, too: violations of duty hour limits and not enough variety of cases to adequately train two residents, Paroski said. Also, the chief of pediatric surgery at Women & Children’s took a different job. Among the changes for that program: One resident will be in the program and a new chief of pediatric surgery will be recruited.
In the dermatology program, four physicians – with affiliations at Roswell Park, Veterans Hospital and Women & Children’s Hospital – resigned last year after a new director arrived and made changes.
The four did much of the teaching.
“There was a new chairman, and he desired to move in a new direction. The core group that was there disagreed with how he was governing the department,” said Dr. Victor Filadora, chief of Roswell Park’s Department of Perioperative Medicine and associate dean of graduate medical education at UB.
Efforts are under way to recruit new teaching physicians and regain accreditation in time for a new class of residents next year, Berger said.
Among other issues, the program that had been run with Roswell Park lacked enough research in general dermatology, UB officials said. There also were differences of opinion on how to manage the program with nine residents.
UB has submitted an application for a restructured program that is under review.
The loss of the program caused problems elsewhere, including Veterans Hospital.
Two dermatologists there left to set up a private practice, forcing the facility to find alternative services for patients until new doctors can be recruited. Without residents to teach, the job in the hospital was not as meaningful and the workload was bigger, officials said.
“For doctors, the residency made the experience of working here more interesting,” said Evangeline Conley, the hospital spokeswoman.