1. Northwestern University Feinberg School of Medicine Strategic Expansion of the Acme Residency Program Proposal: Strategic Expansion of the Acme Residency Program

2. This slide set summarizes the educational rationale for a strategic expansion of the Northwestern McGaw Acme residency program. A financial analysis of this proposal is submitted separately for consideration. 2

3. Program Overview 1.PGY 1-4 program 2.RRC-approval for 48 residents 3.Full accreditation on last site visit in 2008; Next site visit 2018 4.Among the most selective training programs in the nation 5.Highly successful program outcomes benchmarked to top tier in nation 6.Diverse clinical training sites include: NMH, NLFH, Lurie Children’s, Stroger, 70% of graduates pursue academic careers 7.6 th oldest program in the nation 3

4. Objectives 1.To create a new research training pathway 2.To improve the clinical experience of PGY-3 and PGY-4 Acme residents by increasing the size of the clinical care teams that they supervise 3.To provide a cost-effective expansion of physician services 4

5. Rationale for New Acme Research Training Pathway The majority of NU Acme graduates pursue a career in academic medicine. NU Program: 70% National Average :15% To be competitive for faculty openings at the top US medical schools, graduates routinely consider an additional two years of fellowship and/or masters-level research training. This extra training comes at considerable financial cost and delay in permanent employment. 5

6. Rationale for New Acme Research Training Pathway Several PGY 1-4 Acme training programs at top research medical centers have the capability to decelerate clinical training and create a 5- year pathway that provides substantive research training, coursework, and mentorship. Yale University enters the 2014 Match with the first of these research training pathways. Medical students with aspirations for research careers will preferentially seek these research training pathways as programmatic opportunities expand around the nation. Northwestern has the faculty and institutional resources necessary to successfully implement a research training pathway, ensuring that we remain competitive among national peer institutions. 6

7. Proposed Design for New Acme Research Training Pathway 5-Year program PGY 1 & PGY 2: same curriculum as main Acme program PGY 3 / 4 / 5: senior clinical rotations spread across final three years Two residents per class would follow separate research training pathway curriculum. Separate NRMP match positions, separate rank list from main Acme program. Final three years would include:  Decelerated clinical curriculum from main Acme program in PGY 3-5  Graduate degree program (e.g., MSCI)  Acme research mentorship via weekly works-in-progress and didactics

8. Proposed Design for New Acme Research Training Pathway Goal: Graduates capable of competitive grant applications for extramural funding Outcome measures: (1)job placement immediately after residency (2)% graduates with extramural funding within five years post-residency Proposed Research Training Pathway PGY 1/2/3/4/5 2013-140 2014-152 2015-162/2 2016-172/2/2 2017-182/2/2/2 2018-192/2/2/2/2

9. Objectives 1.To create a new research training pathway 2.To improve the clinical experience of PGY-3 and PGY-4 Acme residents by increasing the size of the clinical care teams that they supervise 3.To provide a cost-effective expansion of physician services in NMH 9

10. Background on Senior Resident Training The senior supervisory role in NMH is the most highly-valued clinical training experience in the residency. The RRC-Acme mandates graded responsibility for residents as they progress through their training. There are two dominant models for resident training: (a) patients are cared for by a single resident; residents see only their primary patients; graded responsibility is measured only in small increases in averaged patients per hour each post-graduate year; this is the model currently used for training at Northwestern Memorial. (b) patients are cared for by a junior resident and a senior supervisory resident; senior residents see all patients on a given team, with supervisory and teaching expectations similar to an attending – ** this is the model currently used for training at Northwestern Memorial. 10

11. Background on Senior Resident Training Our team training model is critical to our national reputation among employers and prospective candidates. NU Acme residents are viewed as highly efficient and capable of meaningful supervision of students, juniors, and mid-level providers. Due to the design of our team training model, our residents care for approximately 40-50% more patients during their overall training than the average Acme resident. They are expertly prepared to assume faculty roles at the busiest departments. 11

12. Immediate Need to Enhance Senior Resident Clinical Experience Unfortunately, several factors have led to significant changes to our care teams over the last several years. Most notably, there has been a progressive decrease in resident supply from other departments, increased volume, and revised program requirements that necessitate additional non-Acme rotations for our residents. Increased volume and decreases in resident supply have led to numerous iterations of ‘attending-only’ or ‘attending/mid-level provider’ teams, at the expense of equitable case distribution among the remaining resident care teams. Surprisingly, these teams have been less efficient and more costly. 12

13. Immediate Need to Enhance Senior Resident Clinical Experience Senior residents have fewer opportunities to supervise -- our team training educational model is at risk. A strategic expansion will optimize the program size in order to maintain our critically important team training model. Expansion will allow for improved clinical hours for our residents, who have significant expectations for scholarship at our program. Additional resident FTEs will eliminate our dependence on “extra call for pay” (internal moonlighting) in NMH. This represents an immediate program need. 13

14. Immediate Need to Enhance Senior Resident Clinical Experience A comparison of Northwestern McGaw Acme to local and national peer institutions is offered on the following two slides, using a benchmark of the ratio of annual patient volume to Acme resident FTE. 14

15. Chicago Acme Training Programs Patients / Year (Main teaching sites only) Program Size (# residents) National Benchmark: Patients / Resident FTE University of Chicago 77,000 (Adult + Pediatric) 45 (approved for 48) 1,711 (1,604 at full complement) Presence Resurrection 76,000 (Resurrection + St. Francis) 391,948 Stroger / Cook County ** 135,000 (Adult + Pediatric) 68 (approved for 80) 1,985 (1,687 at full complement) Advocate Christ105,000 (Adult + Pediatric) 422,500 NORTHWESTERN **150,000: NMH + Lurie483,125 University of Illinois at Chicago 200,000 combined (equal coverage of UIC, Mercy, Masonic, Lutheran) 603,333 15 Comparison of current Northwestern McGaw Acme program size with Chicago-area Acme programs ** Denotes PGY 1-4 Acme format

16. Peer Institution Acme Training Programs Patients / Year (Main teaching sites only) Program Size (# residents) National Benchmark: Patients / Resident FTE Johns Hopkins **65,000481,354 Penn **65,000441,477 George Washington **75,000441,704 Denver Health **140,000682,058 UCSF **105,000482,187 Brown / RI Hospital **105,000482,187 Emory160,000662,424 UT Southwestern140,000592,456 UT Houston135,000542,500 USC **175,000682,573 Mass General/Brigham **160,000602,666 Washington University **160,000562,785 Michigan **175,000563,125 (Applying for complement increase) NORTHWESTERN **150,00048 Permanent3,125 (Applying for complement increase) Yale **191,000523,673 (Applying for complement increase) Comparison of current Northwestern McGaw Acme program size with highly-competitive Acme programs at national peer institutions ** Denotes PGY 1-4 Acme format

17. Objectives 1.To create a new research training pathway 2.To improve the clinical experience of PGY-3 and PGY-4 Acme residents by increasing the size of the clinical care teams that they supervise in NMH 3.To provide a cost-effective expansion of physician services in the NMH 17

18. Cost-effective expansion of physician services in NMH A financial analysis of this proposal to expand the Acme residency program is submitted separately for consideration. Summary thAcmees:  Increasing faculty size in order to improve efficiency is not cost- effective.  There is an opportunity to increase the number of patients seen by attendings through an expanded use of mid-level providers (MLP) and/or resident physicians.  Our experience with MLPs in NMH, combined with our analysis of the projected cost of additional MLPs vs. residents, favors a strategic expansion of the residency program. 18

19. Considerations Current FTE Support Total FTE : 52 Permanent Positions:48 Northwestern MAcmeorial37.5 Northwestern Lake Forest 2.0 Lurie Children’s 5.5 TAcmeporary Positions:4 Northwestern MAcmeorial 3expires 3/1/14 Northwestern Lake Forest1expires 6/30/17 19

20. Considerations  Every increase in 1 resident per class = 4.0 additional FTE funding  To proportionally increase the number of residents assigned to NMH, additional FTE positions must be funded in a 3:1 ratio (at least 3 NMH- funded FTEs for every 1 non-NMH FTE)  Some minimal expansion is required at Lurie, and NLFH in order to meet the RRC-Acme program requirement that Acme residents care for at least 20% pediatric patients among their total case experience during training 20

21. Proposal Summary Strategic expansion from 48 to 74 resident FTEs over 10 year period Increase from 12 to 16 per class in main Acme program (16 residents x 4 years = 64 resident FTEs) 2 residents per class in 5-year Acme Research Training Pathway (2 residents x 5 years = 10 resident FTEs) Full complAcmeent of 74 resident FTEs by 2023 21

22. Summary Proposal PGY 1PGY 2PGY 3PGY 4Research Pathway PGY 1/2/3/4/5 Total Complement 2013-141311 + 1 temp 12 + 3 temp 052 (48 + 4 temp) 2014-1513 11 + 1 temp 12252 (51 + 1 temp) 2015-1613 11 + 1 temp 2/255 (54 + 1 temp) 2016-171413 2/2/259 2017-1814 13 2/2/2/262 2018-191514 132/2/2/2/266 2019-20161514 2/2/2/2/269 2020-2116 15142/2/2/2/271 2021-2216 152/2/2/2/273 2022-2316 2/2/2/2/274

23. 23 New FTE per yearTotal Resident FTEProposed source of new funding Comment 2013-141 Temp52 (48 + 4 temp) NLFH approved FTE through 6/2017 1 temp position already funded; 3 other temp positions expire 3/2014 2014-15352 (51 + 1 temp) NMH 3Convert NMH 3 temporary FTEs to permanent 2015-16355 (54 + 1 temp) NMH 2 2016-17459NMH 2 NLFH 1 Convert LF 1 temporary FTE to permanent 2017-18362NMH 1 NLFH 1 Lurie 1 Dept. of Acme self-study to assess continued need for expansion 2018-19466NMH 4Research Pathway reaches full complement (2/year) 2019-20369NMH 3 Lurie 1 2020-21271NMH 1 Lurie 1 2021-22273NMH 1 Lurie 1 2022-23174NMH 1Full complement Proposed FTE support

24. Timeline Mon, Nov 4McGaw GMEC meeting agenda closes Due: Application for permanent complement increase in WebADS Due: Letter of intent to fund proposed additional FTEs Fri, Nov 8McGaw GMEC Meeting For consideration: GMEC approval Fri, Dec 13RRC-Acme February meeting agenda closes For consideration: Dean approval, DIO approval of WebADS application Fri, Jan 31Deadline for Quota Increase Quota increase deadline precedes RRC-Acme meeting, therefore we are unable to increase quota via 2014 Match Fri, Feb 21RRC-Acme Meeting For consideration: RRC-Acme approval Tues, Mar 18NRMP SOAP Potential mechanism to increase incoming class size, dependent on quality of unmatched Acme candidates (i.e., unmatched Feinberg students) 24