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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