Blog | Thursday, August 22, 2013

Lower ABIM pass rates are not just a work hour problem


You have to love the blogosphere. The latest big issue concerns lower ABIM pass rates. Here are a series of blog posts worth considering.

Dumber Doctors?

"One concern that has a ring of truth to it is that young doctors have become great 'looker-uppers,' and have lost the sense of what it's like to actually read and study medicine. While doctors enter the profession with a commitment to lifelong learning, some of us fear that the young folk only go far enough to commit to lifelong googling."

"Another key point: in today's era of restricted work hours, something has to give. Too often, when residents must complete the same amount of work in a limited amount of time, what's sacrificed is the didactic portion of the education: the stuff we do by running through case after case, discussing subtleties and action plans. When time is limited, the work's simply gotta get done."

Not Dumber, But Different

"I think that a big problem underlying the current examinations systems in most specialties and jurisdictions is that they ask questions that often have not changed with the times. Most importantly, they value the lower levels of learning (e.g. Bloom's Taxonomy level = 'Remember' and perhaps 'Apply') rather than critical reasoning and problem solving."

The Real Problem with Board Exams-and How to Solve It

"This week there's been a debate brewing about why so many young doctors are failing their board exams. On one side John Schumann writes that young clinicians may not have the time or study habits to engage in lifelong learning, so they default to "lifelong googling." On the other, David Shaywitz blames the tests themselves as being outmoded rites of passage administered by guild-like medical societies. He poses the question: Are young doctors failing their boards, or are we failing them?"

Of course I have read these blog posts and tried to make sense of the discussion. I have the advantage of starting as a ward attending in January 1980. I have worked with residents and students for 33 years and counting.

We have two big problems. We have changed work hours without changing how we admit and follow patients. We have not decreased the number of patients, just the time in the hospital. In order to meet the hours, we have less productive rotations like "night float". We have less time for didactic sessions. We have interns and residents taking days off during the week, thus impairing any sense of continuity in an educational offering.

At the same time, the pressure on attending physicians for patient care has risen and many attending physicians do not spend enough time teaching.

With that as a background let me propose solutions.

1. Attending physicians should teach, and residents should focus on learning the basics. Sure we can look some things up on the internet. But we can only look things up that we are aware are holes in our knowledge base. But we all must know the basics. We must have a developed strategy for approaching common complaints. We must know how to care for the common admitting problems.

2. Attending physicians should focus on teaching residents and students how the think. On my rounds we often search the internet for information. But the Internet cannot teach us how to approach problems. We cannot depend on searching for all the information. Often when we search the internet, we are looking for something that we know partly and need more information.

3. We should consider a different attitude towards testing. I love the idea of defining the necessary information that we expect graduating residents to know. We focus too much on the rare, the trivia, and the unusual. We need that experience, and a strategy for evaluating the unusual, but we must know the usual in depth so that we can recognize when the patient is not usual.

I personally do not consider Millenials and Gen X different from us baby boomers. We lived in different times, but we too disliked the tests. We wanted to learn the basics and learn how to think. Our residents are wonderful and want to be the same type of physicians that we have become.

We in medical education must think differently about rounds, about what we teach, and how we teach it. We should not blame the current generation. We should try to remember the 70s and 80s; we were not that different. The current generation is wonderful; they just have different constraints. We have handicapped them, and we have to work with them to develop solutions.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.