Eyeing a training overhaul: Should residency be revamped?
From the October ACP Observer, copyright © 2005 by the American College of Physicians.
By Bonnie Darves
When Vineet Arora, ACP Member, completed her residency in 2003, she landed a job as an academic hospitalist at the same institution where she'd completed her graduate training: University of Chicago.
She realized she felt completely comfortable taking care of the often complicated inpatients in the urban hospital environment, but wondered how she would have felt had she chosen a suburban office practice instead.
"We don't see many young internists going into office-based primary care, and I think that's because residency prepares you for the inpatient experience, not the outpatient one," said Dr. Arora, who chairs ACP's Council of Associates (COA). "I've often thought: Why can't we shift training so that it's more in line with practice and give residents more flexibility to pursue electives?"
Dr. Arora and four other recent internal medicine graduates detailed what they called the "training-practice gap" in the June 2005 issue of The American Journal of Medicine. The article outlined the wide discrepancy between the Oslerian generalist model and the often conflicting demands of 21st century practice. The authors suggested that training programs as currently structured do little to prepare residents for the economic and logistical demands of office practice.
In doing so, they joined the growing debate over whether—and how—to configure internal medicine residency training. Does the current one-size-fits-all three-year training model, which has remained virtually unchanged for at least 20 years, prepare physicians for office-based practice, not to mention the many other career paths—academic, research and subspecialty—that internists take?
'We're recognizing that there are different types of internists and that it may make sense to customize training.'
—Steven E. Weinberger, FACP
Recent efforts to revitalize internal medicine and attract more physicians to the field have, as a matter of course, spawned discussion about whether the current training model should be scrapped in favor of training "tracks" or variable multi-year configurations.
"We're recognizing that there are different types of internists," said Steven E. Weinberger, FACP, the College's Senior Vice President for Medical Knowledge and Education, "and that it may make sense to customize training."
At the same time, Dr. Weinberger pointed out, "there is a core body of information and skills common to all internists," and that proposals that would shorten general internal medicine training are coming at a time when the field is becoming more complex.
Over the past several years, the potential models for redesigning internal medicine training have focused on a period of "core" training common to all internists, followed by a period of customized training based on residents' future plans.
Suggested tracks for the latter include ambulatory internal medicine, hospital-based internal medicine, a combination of office- and hospital-based internal medicine, or an internal medicine subspecialty.
Most leaders within internal medicine training agree that all residents need better models for office-based training during their core years. But proposed models differ as to how long that training should last.
The current three-year model includes traditional inpatient and office-based training, followed by subspecialty fellowships. In one proposed model, the core training period would be cut to two years—at which point, training would begin for those residents who want to become subspecialists.
While some subspecialties still support the concept of three years of general internal medicine, the idea of reducing core training to two years has been proposed by leaders in cardiology. But for many residents, the downside of such an approach would be that residents would have to apply for a subspecialty fellowship very early in residency, well before housestaff have sufficient experience to make such a choice.
"A lot of people think the proposed model of only two years of core training is being driven by subspecialties, so they could essentially crank out more cardiologists, for example," said Benjamin J. George, ACP Associate, a two-year veteran of ACP's COA and the College's representative to the internal medicine residency review committee. Dr. George is serving an hematology-oncology fellowship at Brooke Army Medical Center in San Antonio.
But another emerging model has garnered a significant amount of support. Under this scenario, internal medicine residency training would still be three years, but the first two would have a common curriculum and set of experiences for all trainees, followed by a customized track during the third year.
"We continue to believe that it takes three years to train in internal medicine, but we also recognize that the [current] model needs to be revamped," said John P. Fitzgibbons, FACP, immediate past president of the Association of Program Directors in Internal Medicine (APDIM) and Governor for ACP's Pennsylvania Eastern Chapter. "At present, we're effectively training people to be hospitalists, not ambulatory care [internists]."
According to Dr. Fitzgibbons, who also chairs the department of medicine at Lehigh Valley Hospital in Allentown, Pa., APDIM is leaning toward this latter model. In its white paper on training program redesign, which is now being readied for publication, APDIM calls for an initial two years of general training plus a customized third year, which may focus on either ambulatory or hospital-based training. That third year would also provide future subspecialists some experience targeted to their career goals.
Stick with the status quo?
"The residency years have to cover the 'bread and butter' in enough depth so that people are truly prepared when they go out there [into practice]," said Lawrence M. Phillips, ACP Associate, Chair-Elect of the COA and a cardiology fellow at North Shore University Hospital in Manhasset, N.Y. Dr. Phillips said he supports the current three-year model, but with modifications.
As a former chief resident, Dr. Phillips is concerned that denying residents a third year of general internal medicine will stunt their professional development.
"There's an important learning curve that occurs in that third year," he said. "It's not the 'raw facts' at that point—it's the integration of the facts. That's what I experienced, and that's what I saw in other residents when I spent a year as chief resident."
Moving to a shorter period of overall training, he pointed out, would short-circuit that process and remove third-year residents from their key roles as educators and team leaders. Having three years of core training also gives internists more flexibility, Dr. Phillips said, to switch practice settings later in their career, from hospitalist to academic medicine, for instance, or to private practice.
To help redesign residency programs, Dr. Phillips said he supports breaking down training into its components—knowledge, skills and procedures—and deciding what's fundamental and still relevant. For example, internal medicine residents are now required to master thoracentesis, yet rarely perform the procedure after they sit for their boards.
"We need to tailor the skill sets we learn to the actions we will be taking in practice," he said.
ACP's Education Committee is now preparing a position paper on the pros and cons of graduate medical training redesign. That follows a Board of Governors resolution passed last spring that ACP support a paradigm shift in internal medicine education. At the same time, the Alliance for Academic Internal Medicine formed a working group at the beginning of this year that is formulating redesign recommendations.
The Society for Hospital Medicine (SHM) is also tackling the issue of the requisite skill set for hospitalists by developing a set of core competencies. Those will be a framework for curriculum development in hospital medicine, said Alpesh N. Amin, FACP, MBA, a co-author of the core competencies and an associate program director at University of California, Irvine. These core competencies, which are set to debut in early 2006, aren't directly related to efforts to revamp internal medicine training, he said, but are a parallel effort.
"The idea of core competencies is to define what we think hospitalists ought to know," Dr. Amin said. "It's the first step in helping to define the field of hospital medicine."
The Accreditation Council for Graduate Medical Education (ACGME) is also taking a hard look at core competencies. The organization's six-year-old outcomes project calls for improving residents' competency in six different key areas, including systems-based practice and practice-based learning and improvement.
Residency programs are now grappling with how best to train and evaluate residents in those areas. (See "Residency program focuses on quality, care systems." ) The ACGME's internal medicine residency review committee seeks to bridge that gap by rolling out an educational innovation project next year. That program will encourage novel outcomes assessment in residency programs and creative approaches to internal medicine training. The intent, according to APDIM's Dr. Fitzgibbons, is to lighten regulatory requirements and allow selected programs to try alternative training approaches that might one day become the basis for changes in residency education.
Separating training from service
In their American Journal of Medicine article, Dr. Arora and her co-authors flagged what they saw as another huge factor in the "training-practice" gap: the intense service demands on residents. Because residents are responsible for managing large numbers of complex inpatients, the article pointed out, there's little or no opportunity to explore outpatient practice or participate in quality improvement initiatives.
"There was little flexibility to pursue elective time or to understand other areas because of the demands of service," said Dr. Arora. "It was the service obligation that got me thinking: What if serving the needs in the inpatient setting is interfering with the educational mission?"
There is no easy answer to that question, she added, because of training programs' financial underpinnings and the critical roles residents play in treating uninsured or underserved patients and in teaching. If patient loads were lightened so residents could pursue electives in ambulatory care, quality improvement or systems-based care, who would assume the service—and who would pay for it? (Also see "Medical school report card.")
"The public and policy-makers need to be aware that the training system they've 'purchased' is not working," said Dr. Arora. Regardless of how training programs are revamped—and any effort, she said, should include input from COA members and current residents—the focus should be on outcomes and proficiencies, not time blocks.
Changes need to address quality improvement and patient safety factors because those reflect the current practice environment, both inpatient and outpatient. And ultimately, Dr. Arora proposed, programs need to be structured to "disconnect service from education" and funded accordingly, to allow teaching hospitals to address the resulting provider shortages.
"Someone needs to sponsor these changes [financially]," said Dr. Arora, "and measure their outcomes to make sure they produce the improvements they were designed to achieve."
Bonnie Darves is a freelance writer in Lake Oswego, Ore.
While internal medicine as a whole wrestles with how—or if—to revamp training programs, one organization is making a bold leap into the future.
Last July, the internal medicine residency program at Providence St. Vincent Medical Center in Portland, Ore., welcomed its 11 new interns into a substantially changed program. That program's focus now extends well beyond clinical excellence to incorporate the many domains of performance improvement.
One residency program is incorporating system design and management into almost all of housestaff's didactic sessions and grand rounds.
"We believe that first-rate physicians, besides being excellent clinicians, must have the skills necessary to identify systemic problems, think of solutions and lead the implementation of those solutions," said Steven D. Freer, FACP, who directs the program and chairs the department of medicine. "I want our graduates to understand the conceptual framework of system performance and improvement, and be able to apply it wherever they practice."
Rather than having residents exposed to systems theory and quality improvement concepts through a rotation, that training is being interwoven into the department's work and program design.
Residents will be taught to think in those terms as they learn to care for patients, Dr. Freer said. They also can pursue advanced training in other areas such as medical informatics during their third year through arrangements with other regional institutions.
The objective, he explained, is to produce a new breed of internists who think in terms of care systems, continuity and population-based health care delivery, rather than focusing only on individual patient diagnosis and treatment. "Well designed systems must enhance the physician's ability to take ownership of and responsibility for the care of his or her patients," he said. "This is fundamental to being a physician."
According to Dr. Freer, most traditional training programs attempt to address the Accreditation Council for Graduate Medical Education's core competency requirement of systems-based practice through isolated rotations and lectures. That design, he claimed, is tantamount to "putting a patch on" the existing training model.
"We are changing the content of nearly all of [residents'] learning experiences including their didactic sessions and even grand rounds to incorporate knowledge of system design and management," Dr. Freer said. "Under direct faculty mentorship, residents will identify system deficiencies, then design and execute projects to address them. This is an all-inclusive change in the way we train."
Charles M. Kilo, FACP, chief executive officer of GreenField Health in Portland, Ore., and a fellow of Boston's Institute for Healthcare Improvement, said the St. Vincent program is the first to take on a complete transformation of a department and a residency program around a mission of performance excellence. While early in the process, Dr. Kilo said the program is committed to substantive change in nearly all aspects of residency training.
"If the competency physicians need is in performance improvement in addition to clinical excellence, then you have to make fundamental changes in the environment in which residents learn and work," said Dr. Kilo, who serves as a consultant on the residency and departmental redesign. "We expect to graduate physicians with a much deeper knowledge of how to produce measurable quality care."
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