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Internal medicine's new curriculum

FCIM's guide for eductors will be voluntary, but its making waves

From the September 1996 ACP Observer, copyright © 1996 by the American College of Physicians.

By Edward Doyle

As they put the finishing touches on a landmark curriculum document for internal medicine education, medicine's leaders are still grappling with the difficult issue of exactly how young internists should be trained to enter the changing practice environment.

The Federated Council for Internal Medicine (FCIM), composed of representatives from internal medicine's leading organizations, is creating a curriculum "resource document" to help medical educators better prepare residents for their profession. If the document is approved—it may be by the end of the year—it will mark the first time that internal medicine's leadership has agreed on how to train its residents.

The FCIM document is expected to accelerate internal medicine's move toward more outpatient training and to help educators focus more on primary care disciplines not typically emphasized in internal medicine programs. The goal is to produce internists who can handle not only the traditional duties of internists, but also provide care in areas like dermatology, orthopedics and office ob/gyn.

While educators will be under no obligation to restructure their programs using the document, the fact that an influential organization like FCIM is trying to define a gold standard for internal medicine education has some medical educators worried about whether regulatory agencies might use the document to accredit training programs and whether the teaching of internal medicine may be altered. As a result, FCIM's curriculum document is causing the profession to take a hard look at how it trains its residents—and what it means to be an internist.

For years, internal medicine leaders have been talking about the need to create some sort of standard curriculum almost as much to help improve internal medicine's public image as to help residents be better prepared for work. The number of top medical students choosing internal medicine as a career has fluctuated in recent years, and health systems have been complaining that physicians—including internists—are finishing their training unprepared to practice in managed care.

"We were afraid that we weren't meeting the needs of the managed care organizations," explained Harold C. Sox Jr., FACP, chair of FCIM's task force on curriculum and a Regent of the College. "We were also very concerned that students who understood what employers were looking for were shunning internal medicine because it hadn't awakened to what the marketplace was demanding."

Leaders are counting on the FCIM curriculum document to give everyone from medical students to managed care directors and patients a better idea of what internists do—and why they are important. "Curriculum is an instrument through which a profession defines itself and its mission," explained Jack Ende, FACP, one of the principal architects of the project. "It shows that internal medicine is a discipline that is worth signing onto if you're a student, or supporting with GME funding if you're in government."

Defining skills

To better define internal medicine, FCIM has included detailed lists of exactly what internists should learn in training—clinical competencies—that are organized by each medical specialty and subspecialty area. For cardiovascular disease, for example, the curriculum document names the types of arrythmias residents should see during residency, as well as skills they should be familiar with, such as pacemaker management and congestive heart failure.

The approach may seem simple enough—define who you are by what you do—but because the document's lists go into a fair amount of detail, they have created considerable debate. Some clinicians initially felt that their particular areas of expertise—women's health, for example—did not receive enough emphasis. In response, the FCIM task force worked closely with hundreds of internists in both academia and practice to forge a consensus among internal medicine's numerous groups about what should be included in the lists.

Some critics also worried that internal medicine's Residency Review Committee (RRC), which accredits training programs, would make the document's recommendations mandatory and revoke accreditation for programs that don't follow them exactly. However, RRC officials have repeatedly said that their special requirements for internal medicine will not directly cite the FCIM document.

For others, however, problems with the document grew out of a fierce debate about education theory. The issue: Does teaching principles lead to the learning of details, or does focusing on details like those listed in the document lead to the learning of principles?

Francois M. Abboud, MACP, who represented the Association of Professors in Medicine on the FCIM task force and is chair of the department of internal medicine at the University of Iowa College of Medicine in Iowa City, summed up the debate by explaining that some educators felt the best way to teach is to focus on principles rather than details. "It's the old issue of how do you teach people," he said. "Do you give them a list of things they have to read about or do you give them general principles?"

Arthur H. Rubenstein, MACP, a past president of the Association of Professors of Medicine and chairman of the department of medicine at the University of Chicago, was concerned that a curriculum document that provides too much detail could be viewed as overly restrictive and authoritative. "I worried that if you had that kind of detailed curriculum that had the imprimatur of all of internal medicine, there would be a feeling that that was the only way to do it, that that was Ôthe right way' to do it," he said. Dr. Rubenstein would prefer a curriculum approach that uses a broad outline that can be implemented locally.

FCIM has responded to these concerns by emphasizing that the document is a resource for medical educators, not a curriculum that tells them how to do their job. That's why FCIM officials have even stopped referring to the document as a curriculum—it sounds too formal and prescriptive—and now use the less imposing title of "resource document."

"The final version will in fact be framed more as a resource document for local curriculum development rather than a prescriptive curriculum," explained Dr. Ende, who is associate dean for network and primary care education and professor of medicine at the University of Pennsylvania in Philadelphia. He said that while there is a role for the profession to identify medical education's gold standard and the competencies residents should attain, actual training programs should reflect the values, mission and resources of local institutions. "The FCIM document is no more a curriculum than a menu is a meal," he elaborated. "You eat the meal; the menu just describes what is likely to arrive at your plate."

Good grades

Downplaying the document's curriculum-like nature seems to be calming educators. Program directors who have reviewed it have given it high marks, and a number are already using the document, which is still in draft stage and only available for review. Ultimately, program directors will welcome the document, predicted Herbert S. Waxman, FACP, ACP's Senior Vice President for Education. "It's extraordinarily helpful to be able to go, for example, to the chief of cardiology and say 'Read this. It's a list of the competencies that should be gained by residents. How can we best achieve this in our program?' " he said.

That move may put educators at ease, but it does raise questions about the document's purpose. If internal medicine's best and brightest agree that this is how residents should be trained, shouldn't educators be implementing its recommendations in full and not just picking and choosing the sections they like? In a perfect world, perhaps, but FCIM understands that the fiscal realities of medical education can be prohibitive.

Many training programs are already under financial strain, and asking them to implement the document in full could require hiring new faculty at a time when many organizations are undergoing cutbacks. To hold programs to the goals set forth in the document, Dr. Sox said, is neither fair nor realistic. "We need to achieve educational reform and we need to do it in a timely fashion," he explained, "but not at the expense of killing off departments of medicine by foisting on them unrealistic requirements."

In addition, say educators, there is no one solution that can suit the country's 400-plus internal medicine training programs, and forcing one curriculum on all could threaten innovation. "If it's rigidly codified and we do away with the flexibility, we will do away with the innovation," said Gerald E. Thomson, MACP, Immediate Past President of ACP, associate dean of the College of Physicians and Surgeons at New York's Columbia University, and chair of FCIM during much of the document's creation. "You've got to have folks trying new ways and new approaches to education and training."

Nonetheless, the FCIM document is trying to effect change. In an effort to help move more of internists' training outside of the hospital, for example, the curriculum reminds educators to carefully consider which setting is best—inpatient or outpatient—for each clinical competency. And to broaden the focus on internal medicine education, the clinical competencies include such topics as dermatology, ophthalmology and substance abuse.

The FCIM document also lists what it calls "integrated disciplines," clinical areas such as nutrition and nursing home care, and non-clinical areas such as medical ethics, management skills and medical informatics. The goal of the integrated disciplines is to teach physicians not only the mechanics of caring for a condition like heart disease, but to do so in complex settings that recognize such factors as patient finances and humanistic concerns.

Building a better internist

In the simplest of terms, the FCIM document is trying to steer educators from producing the old-fashioned internist—the master diagnostician who spares no expense in the quest for a definitive differential diagnosis. As Dr. Ende said, "We have to break away from the model of the internist as the meticulous detective tracking down each and every little weed and practice a more outcomes-focused kind of medicine in which we do what's effective, what's been shown to work."

Some would like to see internal medicine adopt an even broader focus. "We're not fulfilling social expectations in terms of the kind of doctors we're producing," said Robert E. Wright, FACP, who represented the Association of Program Directors in Internal Medicine on the FCIM task force and is program director of the Scranton Temple Residency in Scranton, Pa. "I support training physician-scientists, but at this point there is a more compelling need to train generalists. We are here to produce physicians who are going to take care of sick people."

But with less time spent on inpatient care and more time on learning an integrated approach to medicine, what will happen to the character of internal medicine? Will internists trained under the guidance of the FCIM document still have time to learn how to make the tough diagnosis, to pursue scholarly interests, to do the things that have marked the essence of internal medicine over the years?

Educators say that the increased emphasis on outpatient experiences and integrative disciplines is not a lowering of standards. "What used to be considered high-minded medicine, the very meticulous exhaustive differential diagnosis and the overly aggressive ordering of tests and procedures, may have been less effective than the way medicine is practiced now," Dr. Ende said.

And Dr. Sox, who is chairman of the department of medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., said that the outpatient environment can be just as intellectually challenging as the inpatient environment. "The other day at morning report we talked about a patient who is overweight and has hypercholesterolemia and abnormal glucose tolerance and was being treated on an outpatient basis," he said. "The issues that come up in dealing with a series of problems like that, the need to reason logically and in depth, those are at least as sharply defined in the outpatient setting as the inpatient setting."

But clearly, there are some limits to just how much internal medicine can change and still retain its distinct character. "If most of the time our residents are in an ambulatory setting, then training will de-emphasize the analytical aspects of internal medicine," said Dr. Abboud, who represented the Association of Professors of Medicine on the task force. "That will become a danger because when you see a patient on the inpatient unit, you have time to really think through the problem. You can come back and see the patient two or three or four times. You can come back and look at the X-ray. You can get a consultant. In a clinic, the patient is there for half an hour, so you can't do all of that."

But as more and more care—even for the very sick—moves out of inpatient settings, it will be a transition that internists will have to learn to make. "If internal medicine were to be essentially all in the outpatient setting, internal medicine would lose its special character," Dr. Sox said. "We would not be turning out the type of physician that communities desperately need. Internal medicine's unique contribution is caring for the sickest patients and the most complicated patients, the ones that other physicians for whatever reasons don't feel up to dealing with."


The key questions: an overview

  • 1. Will it be required? FCIM officials stress that using the dicument will be purely voluntary and the Residency Review Committee, the body that accredits training programs, insists it will not make it mandatory now or in the future, but some eductors remain nervous.
  • 2. How much detail? FCIM's approach—listing the specifics of what resident should learn—makes some eductors fear that the document may stifle innovation in internal medicine education.
  • 3. Will it change internal medicine? Will a curriculum document that moves internal medicine more toward outpatient clinics and subspecialties like dermatology and ophthalmology—traditionally the domain of specialties like family medicine—change the profession's character?

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