American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, January 27, 2014

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 Accreditation Council for Graduate Medical Education (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.

Alexander M. Djuricich, MD, FACP, is Associate Dean for Continuing Medical Education and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis. This post originally appeared at Mired in MedEd, where he blogs about medical education.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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