Integrated Training Programs Offer Future Physicians ‘Unbelievable Breadth and Depth’ of Experiences

“Being able to train at both Massachusetts General Hospital and the Brigham — the best of the best in emergency medicine — was a key feature of what initially attracted me to the program,” he said. “I have an even deeper appreciation for it now, having experienced it. I really like how it’s exposed me to the full breadth of emergency care, with the Brigham being more of a classic quaternary center and Massachusetts General Hospital being more of a catchment hospital for urban, underserved areas.”

The Emergency Medicine residency is one of more than 60 integrated residencies and fellowships across Mass General Brigham, amounting to about 20% of the system’s graduate medical education (GME) programs.

Like HAEMR, many programs have a long and successful legacy of having trainees learn and practice at multiple hospitals — a journey more GME programs are embarking on as Mass General Brigham transforms into a fully integrated health system. Most recently, the Massachusetts General Hospital and Brigham and Women’s Hospital Orthopedics Sports Medicine fellowships earned approval from the Accreditation Council for Graduate Medical Education to combine into an integrated program.

By exposing residents and fellows to different settings of care, integrated programs provide “an unbelievable breadth and depth” of educational experiences and opportunities for mentorship, explained John Patrick T. Co, MD, MPH, MBA, vice president of Education for Mass General Brigham.

“Each of our institutions, on their own, already has impressive educational opportunities within their specialties. When you think about combining those not just across Massachusetts General Hospital and Brigham and Women’s Hospital but also our community and specialty hospitals, it’s hard to imagine a place that offers trainees more than that,” Co said. “Building joint programs requires careful thought and effort, but we have to keep in mind that the whole is greater than the sum of its parts.”

When more is more

In fact, that goal was one of the founding principles behind the combined Addiction Psychiatry Fellowship, which formed in 1999 as a collaboration between McLean, Massachusetts General Hospital and Brigham and Women’s Hospital, explained Roger D. Weiss, MD, director of the program and chief of McLean’s Division of Alcohol, Drugs and Addiction.

“When we started the fellowship program, none of the three hospitals individually had all of the elements of addiction education we wanted to offer. We needed to combine our efforts to create a complementary experience,” Weiss said. “Of course, the hospitals have changed over time, but this arrangement has worked so well that we’ve felt it’s one of those ‘if it’s not broken, don’t fix it’ situations. The fellows give great reviews of all the different rotations. It’s been a very successful formula.”

The one-year fellowship prepares addiction psychiatrists to practice in diverse settings and care for a wide variety of patient populations. At McLean, that includes rotations in the hospital’s inpatient units as well as its LEADER program, which provides specialized mental health and addiction treatment for police, active military and other first responders. Fellows also train in outpatient care through Massachusetts General Hospital’s Chelsea Healthcare Center and West End Clinic, the Brigham’s Dushku-Palandjian Bridge Clinic and McLean’s outpatient clinic. They learn to perform addiction consultations at Brigham and Women’s Hospital and deliver methadone treatment at North Charles Foundation, a Cambridge-based addiction treatment center that partners with the program.

“Seeing patients in different contexts helps fellows identify the kind of setting they want to work in when they complete the program. They also see how providers in different places handle similar situations, sometimes a little differently,” Weiss said. “Moreover, all of these hospitals have differing patient populations in every sense. It offers the opportunity to see much more heterogenous populations.”

For Addiction Psychiatry fellow Emily Kager, MD, the breadth of clinical experiences is what first attracted her to the program and remains its greatest strength. The rotation schedules are structured such that fellows can follow their patients longitudinally throughout the year.

“It’s busy, and we’re in a lot of places, but honestly, I love it. You can tell a lot of thought has gone into the way they’ve structured the fellowship,” Kager said. “I’m applying for attending jobs now, and it does make me feel so much more confident interviewing because I have a firm grasp on the role of an addiction psychiatrist in all these different settings.”

Similarly, Emergency Medicine residents receive a far more robust education training at both Massachusetts General Hospital and the Brigham than they would at just one of those hospitals, said Daniel J. Egan, MD, program director of HAEMR and vice chair of Education for Mass General Brigham Emergency Medicine.

“It’s a very different experience to work in a department that sees 120,000 patients per year versus 60,000. Part of our job as emergency physicians is to think about flow, resource optimization and physical space, and those are very different conversations when you have twice as many patients,” Egan said. “A lot of our clinical pathways are becoming similar through departmental integration, but there are subtle differences between the practice environments. For example, at Massachusetts General Hospital, we have palliative care embedded in the Emergency Department, whereas at the Brigham, that’s more on the emergency physician, which is a good skill set to have. Getting to know these nuances makes you adaptable to practicing in any environment.”

Creating a cohesive experience

Combining existing programs is a more complex undertaking than starting a new one in that model, GME leaders acknowledged. But the benefits make the effort well worthwhile, they added.

“For many programs, this is a big change, and that can be unsettling. But when you think about it, it is also a great opportunity to rethink what would comprise the optimal program experience by leveraging all of our resources across the system,” Co said. “To do that, we need representatives from across the system at the table and aligned on a common purpose — to design the best trainee experience — and that process has value in itself.”

In addition to providing a more comprehensive educational experience for trainees, an integrated model benefits programs as well, as they no longer compete for the same applicants. Faculty, staff and patients also benefit from the presence of trainees with more diverse experiences.

“Speaking as someone who works at McLean, the advantage of having fellows who have, for example, just come off of six months of addiction consultations at the Brigham, is that they bring a fresh perspective,” Weiss said. “They’ve learned things at those other places they couldn’t learn at McLean, so they might say the Brigham does something this way, and we evaluate whether it’d work here. Sometimes it doesn’t because we don’t have the same setup as a general hospital, but sometimes it works out well and helps us improve care.”

The very thing that makes integrated programs valuable, however, also creates a challenge: When trainees divide their time between different hospitals, it can be difficult to cultivate a unified experience.

Having common systems, guidelines and protocols are a big part of the solution. But just as important is the culture around integration throughout the rest of the department, education leaders said.

“The more work you put into bringing your faculty and administrative groups together — ensuring that you have people from ‘both sides of town’ at the table — the more people start to feel we’re all one and striving for the same thing,” Egan said.

In HAEMR, the hosting of weekly didactics alternates between Brigham and Women’s Hospital and Massachusetts General Hospital. Faculty from both institutions participate in resident retreats, as well as interviews for prospective residents.

For Morris, the Emergency Medicine chief resident, he doesn’t see his training as divided in any fashion. “It feels like one cohesive experience at two sites, rather than two separate experiences,” he said.