Graduate Medical Education: Successes Despite Challenges

In a post a few days ago, Dr. J Russell Strader, in a post entitled “Why graduate medical education is failing”, described concern over graduates of residency in the current era, compared with those who trained in a different era.  He opines that many current residents feel, in his words, “woefully unprepared” for the realities of practice and have a “lack of ability to work independently”.  While his specialty of cardiology, a mix of a “procedural specialty” and a “cognitive specialty”, is slightly different from mine (primarily cognitive), I have a few thoughts about graduate medical education (GME) that paint a different picture.

 The current residents in training now did not “ask” for the duty hour restrictions.  The duty hour restrictions were placed on them, not the other way around.  Program directors themselves are in a quandary to produce competent graduates while still adhering to restrictions with which they may or may not agree.   For example, what should I do when a resident chooses of her own volition to stay over on duty hours by 25 minutes to finish discussing end-of-life concerns with a family of an ill intensive care unit patient?  I personally applaud such residents for understanding the bigger picture (for the record, a scenario such as this IS allowed by the current duty hour regulations).

Current program directors have to make the following statement on every one of their graduates and "sign off" on each resident at the time of graduation: “This graduate is competent to practice [SPECIALTY] independently without supervision.”  The current era of competency-based medical education, administrated through the Milestones initiative will likely demonstrate that some residents need longer training times while others will prove appropriate competency earlier.  The focus, of course, is to produce physicians who truly are ready to practice unsupervised, as the ACGME is accountable to the public.

The current generation of residents seem to describe a greater interest in caring for the underserved and global health initiatives than previous generations (this is purely anectodal based on applicants I have interviewed over the past 10 years).  This may be multifactorial, due to factors such as newer curricular opportunities in these areas that may not have existed many years ago.

The current residency and fellowship training programs still place great emphasis on “thinking like a doctor” and other clinical decision-making curricula, and have many novel curricular tools to evaluate residents in this regard.  

So what might we take from all of this?

First, I believe that the current generation of trainees is as dedicated as any other to the provision of outstanding patient care.  This generation has many competing demands and barriers to that care that simply did not exist 10 or more years ago, and they are handling it as best as they can.  They are not lazy!

Second, the concept of supervision, which has always existed, has nevertheless evolved over the years, necessitating more oversight by current attendings.  Attitudes such as “If I had to call the attending for help, it was a failure” might now be (and should be) a minority opinion, as the field of patient safety now demands more intensive supervision from attending physicians.

Third, the ACGME has moved towards a concept of “graded supervision”, meaning PGY1 residents should have more oversight than those 3 months from graduation.  The amount of supervision diminishes as time progresses through the training program.  This is different from the mentality of “let’s crush them during intern year so that they are REALLY ready as upper level residents” which was likely the pervasive mentality.  Of course a consequence of this may lead to some residents taking longer to feel comfortable as a supervisory PGY2 resident.

Fourth, the concept of life-long learning means that someone does not know “everything” once she/he begins practice.  It is, after all, the “practice” of medicine, and we all are always learning (even many years after training is completed).  This concept of lifelong learning can even be taught.  There is nothing wrong with newly minted clinicians thinking: “Can I run this patient care scenario past you?”  In fact, it is probably safer for patients to have another opinion when one clinician is doubtful as to diagnostic or therapeutic plans.  This is best described as “knowing when you don’t know something”.  The danger of course lies in the physician who “doesn’t know what she/he doesn’t know.”

My colleague Teresa Chan also outlined her thoughts on this same post earlier today, and provides a truly compelling argument why graduate medical education is succeeding in producing competent physicians ready to practice independently and unsupervised.  Like Dr. Chan, I am very proud of the “products” of the current GME environment, and feel that patient care has improved over the years as the graduate medical education community has evolved in not only what it teaches to residents but also how it teaches.

Advocacy in Academic Medicine

Today’s blog covers advocacy from a variety of angles, and reflects my thoughts over what I learned from the #AAMC13 meeting over the last 24 hours.

Advocacy within Social Media

The University of Utah is taking a huge presence at this meeting with its Innovations theme.  At a booth set up in the exhibit hall, they were interviewing folks coming through to provide brief reflections.  I was able to spend a few moments reflecting on what the impact that social media can have on medicine and medical education.  What a timely opportunity to focus on what so many great folks have done parlaying the importance of vaccines for communities, as well as providing truthful, succinct messages to society.  See the audio interview here.

Advocacy within Education

Daphne Koller, who started Coursera, spoke to the participants on the power of what MOOCs (Massive Online Open Courses) can do, not just for the schools or professors who host them, but for society as well.  I was moved by the stories from student learners from sub-saharan Africa and others who became more educated from their use of Coursera.  The potential ramifications of the betterment of the entire planet: wow!

Advocacy within Continuing Education

I attended a workshop on CME in which Don Moore described a tool that integrates the IHI Model for Improvement with PI CME (Performance Improvement CME) to help clinicians better understand the pieces needed to make improvement science and lifelong learning relevant to their day-to-day practice.  Some in the community have questioned how Maintenance of Certification actually “helps” them provide better care for their patients.  This session helped clarify the potential benefits of the Maintenance of Certification program.  We also heard from Mary Turco and George Blike about a concept at Dartmouth called “Value Grand Rounds”, which itself showcases improvements in the health system, but also itself has the opportunity for members of a team to see the fruits of their labor, and also drives them to want to get better.

Advocacy for Research

At the Town Hall meeting, Dr. Darrell Kirch answered questions from the audience about a variety of topics.  One comment hit home: the public is “scientifically illiterate”.  A new initiative by the AAMC entitled “Research Means Hope” focuses on how the public can better understand why research funding is so desparately needed, because the end product of research should be improved patient livelihood. 

Advocacy for Graduate Medical Education

Also at the Town Hall meeting, a question was raised about the “rate limiting step” in producing new physicians in the United States—namely, the shortage of residency positions for graduates of medical schools, who themselves have increased enrollment by 25-30% over the past few years.  Atul Grover discussed bills in Congress that aim to address the “GME crisis”: HR 1180, HR 1201, and Senate 577.  We hope that these campaigns can be successful in providing the resources for the physicians of the future, hoping to achieve the ultimate goal of improved patient outcomes in our communities.

Advocacy for Me

I was honored to have met Dr. Lewis First as well, the editor of the journal Pediatrics, and a giant in the world of pediatrics.  His own career embodies the best of academic medicine, and the best of how physicians can make a difference.

A hearty thanks go out to the AAMC on a fantastic meeting, with so many opportunities for reflection, for networking, and for the opportunity to improve the education of future physicians and leaders in health care.

Technology Meets Humanism: #AAMC13-Style

Sunday, November 3, 2013, certainly did not disappoint at the AAMC 2013 meeting in Philadelphia.  I had the opportunity to attend many great sessions.  This blog will touch on two of them.

Digital Literacy

The session on digital literacy was as engaging as any I’ve ever attended.  The speakers brought cases from real life to discuss with the participants.  Table exercises provided the substrate for meaningful interaction among people who literally met two minutes ago.  There were some quotes that hit home for the audience.  All come from the speakers, Bryan Vartabedian, Neil Mehta, Warren Wiechmann, and Jennifer Salopek.

“Every provider should be prepared to deal with unsolicited requests via digital media.”

“On public platforms, physicians are under no obligation to respond to solicitations from prospective patients.”

“Patients put their trust in us, and it is our obligation to educate them in real and digital environments.”

“We are in the age of the public physician.  We need to function in this new environment.”

This session really hit home for me, as I realized that there are great folks studying this new field, which itself is moving as fast as a teenager’s thumbs on a smartphone texting a friend!

The group launched an extremely helpful resource toolkit for digital literacy, found here. This toolkit is a work in progress, but marks an important step for those educators who need help in teaching the future generation.

How Doctors, Nurses and Consumers Can Make One Another Better

This session was a real treat, as the speaker was Anna Quindlen, the Pulitzer Prize-winning author.  She spoke with no slides whatsoever (what a concept at a medical conference!).  However, one could hear a pin drop in the room (which required an overflow room to accommodate all those who wanted to hear her speak).  Anna spoke from the heart about real-life interactions with the medical profession, some of which shed a light on the humanism that still exists in medicine, and others which provided, well, simply put, an “opportunity for improvement” regarding communication interactions with patients and families.  Given my interest in using emerging technology in medicine and medical education, I really loved these comments (paraphrased here):

 “There is no technology that can take the place of humanism; despite technological advances, human touch is more necessary than ever before.”  

And this one, reflecting on her own work as a writer, was truly profound: 

“In the drama of my own body, I have become both the story and the reporter.”

I think the session can best be summed up from this statement by the moderator, Richard Levin: 

“We must keep the ‘care’ in healthcare.”  

Yes, we must!  Anna, thank you for sharing your stories with me and so many others.

I think these two sessions provided a perfect intersection between the need to “push technology” while still “going back to the basics” of humanism in medicine.  Lest those who feel technology is obliterating the human connection, I would tend to disagree: the lunchtime discussion with the digital literacy speakers demonstrated to me that we can have both humanism AND technology together. 

Yes, we can have our cake AND eat it too!