Even prior to the onset of the COVID-19 pandemic, healthcare staffing shortages were a primary concern amongst many hospitals. The impact is widespread, particularly on a hospital’s core missions, such as health outcomes, as well as GME learning environments for teaching hospitals. The quality of care and services a hospital provides is ultimately reliant on the expertise and longevity of its faculty and healthcare staff. Beyond patient health, staffing shortages bleed through to the education of our future physicians, via the loss of a continuous educational experience.
Below, Germane Solutions will explore how the shortages can impact the lives of your GME residents/fellows and faculty, programs, and steps to take to mitigate these turnover factors, provided by the ACGME and industry best practices.
Causes of Staffing Shortages
Similar to the broad nature wherein these shortages impact hospitals, its cause is not single-fold; however, well-being is a core metric used in the discourse of staffing shortages: a recent study on healthcare staff retention found nine domains influencing staff turnover, primarily led by workplace culture, management and leadership, education, and support at work.[i] During the height of the pandemic, burnout was undeniable - especially among nurses, emergency department techs, and other front-line workers: some staff were made to work increased shift hours, with nurses often seeing staff-to-patient ratios doubled or tripled beyond standards. With a dramatic influx of patients flooding the healthcare system, existing staff is stretched too thin without a proportionate hiring of new staff.
Hiring new staff seems like an obvious fix but is not always accessible for program leadership. In January of this year, a study found that training program closures (as a result of the COVID-19 pandemic) have also played into long-term medical staffing shortages.[ii] This can, in turn, have long-term effects on hiring staff via a shortage of fully-trained new graduates. Rural, non-dense hospitals may face a profound lack of new graduates that are specialty-specific for onboarding replacement staff.
Even when hospitals have applicants to choose from, they may find difficulty in hiring due to a poor working environment that has not been attempted to be improved. And, if key individuals involved in hiring faculty/fellows vacate their positions, such as a program director, organizational structure will be damaged.
Effects on GME Residents/Fellows
The above studies both report workplace wellness as a primary factor in turnover, and this sentiment is not forgotten from the accrediting body of GME programs, the ACGME, as the well-being of GME trainees and faculty is emphasized throughout common and specialty-specific program requirements, which highlight that “[f]aculty members are a foundational element of graduate medical education . . . [they] provide an important bridge allowing residents to grow and become practice-ready.”[iii] When the relationship between faculty and trainee is damaged, it is well recognized that the education received is not optimal.
While the well-being of faculty directly impacts the education and care they provide within a program and hospital, the loss of faculty is felt broadly and significantly throughout hospital systems as well as in the lack of a continuative education this causes within GME programs. This is especially apparent in program leadership roles, where it is actively encouraged (and a significant detriment to programs if not achieved) to maintain the same program director throughout the initial years of a program. Similarly, a shortage of nurses impacts their educational assistance in GME daily programming and leaves holes to fill, by the nature of their duties. If residents lose key leaders and educators, gaps may arise in their training—and their education is, at minimum, directly or indirectly delayed until new, quality staff is acclimated to their position.
Staffing Shortages and ACGME Requirements
The ACGME provides current mandates universal to all programs, as well as those particular to each specialty depending on their unique demands. Shortages may be problematic for maintaining accreditation requirements, positive survey results, and ultimately avoiding adverse actions from the ACGME.
For example, each program must maintain a program director, program coordinator, and a grouping of core and other faculty. The number of the aforementioned positions required for a program is usually tied to the number of residents within a program; such is the case for Emergency Medicine, where there must be a minimum of one core faculty member for every three residents in the program. Similarly in several specialties, residents must demonstrate competence in performing as the primary surgeon for numerous specialized procedures; staffing shortages will negatively affect a program in fulfilling these requirements, if specialized faculty are not accessible due to loss of faculty and/or challenges within recruitment. Programs most affected by these specialty-specific shortages would include smaller, rural, or community-based programs where the specialty is rarer and/or specialized faculty may be unwilling to teach.
Action Steps to Create Lasting Change in GME Programs
In short, the sources of concern for medical staff can be, at least in part, improved or corrected by proficient administration and program leadership. Broadly, creating and maintaining a positive, healthy GME workplace culture can lead to higher retention of faculty and residents alike; and the base of this culture is directly impacted by the actions of leadership. With this being said, the ACGME requires programs to achieve the following (for both residents/fellows and faculty), in order to maintain a positive culture and enhance meaning in experiences provided by the program:
Protecting time with patients
Minimizing non-physician obligations
Providing administrative support
Promoting progressive autonomy and flexibility, including appropriate absence lengths
Enhancing professional relationships
Attention to scheduling and work intensity
Evaluating workplace safety of residents and faculty members
In order to achieve the above or to communicate pertinent changes to all healthcare staff involved, Germane Solutions has observed positive shifts to GME program culture through Town Hall events on GME or with other focuses, which facilitates the open communication and transparency required to discuss challenges and receive feedback from faculty and residents. Within this time, members must have the opportunity to share issues as they arise, wherein administration can take necessary action. It is extremely important that GME programs implement direct and lasting adjustments to show faculty, residents, and the ACGME that programs are willing to improve conditions and address concerns in order to promote staff retention and wellness.
A culture that encourages regular wellness checks and work-life balance without the expectation of reciprocity reflects the ideal clinical learning environment model. Constructive behaviors are necessary to make lasting change and prepares residents with skills that they will carry to their own autonomous medical practice after graduation. Equally as important as their enforcement, all of these policies must be implemented without fear of negative
[i] Marufu, T. C., Collins, A., Vargas, L., Gillespie, L., & Almghairbi, D. (2021). Factors influencing retention among hospital nurses: systematic review. British journal of nursing (Mark Allen Publishing), 30(5), 302–308. https://doi.org/10.12968/bjon.2021.30.5.302 [ii] Halstead, D. C., & Sautter, R. L. (2023). A Literature Review on How We Can Address Medical Laboratory Scientist Staffing Shortages. Laboratory medicine, 54(1), e31–e36. https://doi.org/10.1093/labmed/lmac090 [iii] Accreditation Council for Graduate Medical Education. (2022, July 1). ACGME Common Program Requirements (Residency). ACGME.org. Retrieved from https://www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2022v3.pdf.