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.
