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What’s the right way to redesign residency training?

A new set of proposals aims to juggle residents' different career goals and programs' training needs

From the June ACP Observer, copyright 2006 by the American College of Physicians.

By Phyllis Maguire

PHILADELPHIA—For Lydia Siegel, ACP Associate Member, the fact that internal medicine is now discussing a major overhaul of residency programs makes this an exciting time to be in training.

All the details about how internal medicine training should be redesigned “are now on the table," according to Dr. Siegel, a third-year primary care resident at Boston’s Brigham and Women’s Hospital and a member of ACP’s Council of Associates. She made her remarks at the Associates Luncheon held during Annual Session, where most of the discussion centered on newly proposed recommendations to retool internal medicine training.

Those recommendations come in an ambitious plan approved by ACP's Board of Regents. The proposal, posted on the Annals of Internal Medicine Web site, advocates for some changes in medical student education, but primarily focuses on residency training redesign.

Proposed changes would enhance ambulatory training during residency; foster more in-depth team-based learning; balance institutions' service needs with residents' educational concerns; and provide the right infrastructure and remuneration for a group of core faculty, to safeguard teaching.

'2+1=?'

One component of the series of proposals is a training model known as “2+1.” The model—which would preserve residents' three years of training—would consist of approximately two years of core internal medicine training, with approximately one year (typically the last year) available for residents to customize their training and experiences based on ultimate career goals.

Residents could use that last year to focus on hospital-based or ambulatory care or both, depending on which setting they plan to practice in. If they are planning to enter a subspecialty, they could focus on experiences that would be of particular value in their ultimate career, augmenting and complementing their later fellowship training.

"We want to move away from a one-size-fits-all approach to training," said Steven E. Weinberger, FACP, ACP's Senior Vice President for Medical Education and Publishing, who helped write the proposal and who attended the luncheon. "The plan is designed to give maximum flexibility to trainees.”

Many residents at the luncheon had questions about the model. Cristin A. Kiley, ACP Associate Member, a member of the College's Council of Associates who is stationed at Madigan Army Medical Center in Tacoma, Wash., said she was concerned that allowing residents to customize their third year of training might cause hardships for smaller programs.

“The service obligations are already fairly heavy with the new work-hour rules,” she explained. “Without those senior residents, someone else would have to cover.”

But Dr. Weinberger made it clear that in a tailored third year of training, senior residents would still be integrally involved in training junior colleagues. "The idea that senior residents would be spending their third year in the cath lab is not what's being considered," he said.


Sameer Badlani, ACP Associate Member: Will customized training limit internists' long-term career options?



Sameer Badlani, ACP Associate Member, chief resident at the University of Oklahoma-Tulsa and a member of ACP's Council of Associates, asked if having residents customize their third year might work against internists' long-term career options.

"What if you choose a hospital-based track—but then find, after several years, that it's too hectic and you want to go into primary care instead?" he asked. Would physicians have gaps in office-based skills because they'd spent their third year more focused on hospital medicine?

And would physicians who want a mid-career change in the focus of their practice need to get additional training? Dr. Weinberger pointed out that the “core” component of every internist’s training would still provide the critical foundation upon which new practice-based learning and experience could be obtained later in either hospital- or office-based practice.

Additionally, "it's still very much an option to do a traditional track" in residency, without a focus specifically on either ambulatory or hospital-based internal medicine, he said.

Several residents wondered if a third year of tailored training would encourage even more residents to enter a subspecialty. But Boston's Dr. Siegel said she envisions the overall model for redesign, particularly during the “core” experience, "strengthening [training] in the outpatient setting," instead of giving residents the "very squeezed" outpatient training they now receive amidst so many inpatient duties.

The dialogue underscored the many issues that will have to be decided in engineering a redesign of training. Dr. Siegel urged her colleagues to stay engaged in the discussion.

“We need to embrace change,” she told the residents and fellows attending the luncheon, “or we will be swept up in them.”

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