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.

Reflections on #AIMW13 and the APDIM Fall Meeting

I just finished a wonderful two days at the Academic Internal Medicine Week meeting in New Orleans.  This is a meeting bringing together organizations involved in internal medicine education and leadership, including, among others, the Clerkship Directors in Internal Medicine, and the Association of Program Directors in Internal Medicine.  It is this latter group to which I belong, and, as usual, this meeting did not disappoint.  I was not able to attend the entire meeting, but was present for the last two days.  Here are my brief thoughts on this meeting from those sessions I attended.

Direct observation has definitely come front and center as an important component of training.  Not just an an assessment tool OF learning, but rather as assessment FOR learning.  It needs to be the culture that we regularly observe trainees in their direct interaction with patients (akin to playing the piano: my teacher was there right next to me the entire time, giving constant feedback when I was doing something wrong or had held my fingers in the incorrect position!).

I attended a session on a writer’s club to improve scholarly output.  This session really was riveting for those who attended.  Probably the best discussion was on the fact that scholarly output does NOT have to be ONLY the peer-reviewed publication (although that certainly is excellent!).  Rather, we should consider other products which still demonstrate a scholarly approach.  Those products might include writing a policy, disseminating a curriculum, or creating a tool that others can use for evaluation purposes.  A phenomenal example of how to consider this (focusing on the scholarship of education) is this toolbox from the AAMC MedEdPortal on evaluating educators.

I also attended a great session by colleagues from the U of Cincinnati and Nebraska on considering tools that we ALREADY use to report the Next Accreditation System Milestones.  This session created my “A-HA” moment for how educators might look at Milestones and Entrustable Professional Activities.

The next day, I was on the docket with others focusing on innovation in resident ambulatory experiences.  I had the privilege of discussing our residency experience with teaching quality improvement to trainees.  Other leaders discussed “X+Y scheduling”, to help improve resident interest in doing primary care, ways to teach Evidence-Based Medicine in the ambulatory arena, and experiences in residents having a second continuity clinic with primary care physicians (known in their program as “Second Site”).

In the final plenary, on one of my favorite topics, utilizing emerging technology in medical education, four different programs discussed their experiences with what they were able to accomplish.  One was a current fellow who himself created a smartphone app focusing on evidence-based management of patients admitted/observed for chest pain.  The app link is found here (only available on iOS devices).  Another speaker taught us basics of using Podcasting for medical education, and two others demonstrated the use of iPads in medical education and how others might consider using tablets for that purpose.

For anyone interested, the presentations mentioned above, as well as all of the presentations that were loaded up, can be found here.

All in all, it was a phenomenal conference for me to attend.  Lots of great tweeting was done, as the conference encouraged the Twitter hashtag #AIMW13 for connections via this microblogging social network.  If you are interested, please see my tweets from 10/5/13 and 10/6/13, which were mostly dedicated to the content of this conference.

As a last note, I want to thank the incredibly professional staff of AAIM for hosting a phenomenal meeting, and especially the security staff of the Hilton Riverside in New Orleans Hotel for finding my misplaced keys!