As medicine moves forward, training must keep pace
By Lynne M. Kirk, FACP
Since I finished residency 26 years ago, the way I practice medicine has changed significantly.
I now provide many services that I didn't train for, including office gynecology, wound care and office orthopedics. I have become adept at using an electronic health record, which allows me to access clinical data on the care provided to my patients by other physicians.
I collaborate closely with a nurse practitioner and a diabetes clinical nurse specialist; for some of my patients with complex chronic diseases, these other professionals provide significant instruction and assistance. And I make ready use of online evidence-based clinical decision support, which helps me handle complex illnesses or difficult diagnoses. As a clinician, I have taken on many roles that weren't included in my training: information manager, multidisciplinary team leader, systems analyst, patient educator and psychosocial counselor.
Yet despite these changes in clinical practice, today's internal medicine residents—including those in the program in which I teach—are trained much the same way I was almost three decades ago.
They spend most of their time on inpatient services caring for very ill patients and only one or two half-days a week in the continuity clinic. Even then, they are often called away to fill inpatient responsibilities.
The patients being treated by today's residents in continuity clinics were probably first seen in the inpatient teaching service. That means many of these patients have multiple, often unstable, complex chronic problems—as well as the psychosocial problems and socioeconomic difficulties that can accompany serious chronic illness.
Caring for these patients would be difficult even for an experienced clinician with many resources. Treating them can be overwhelming for a new physician in a teaching clinic without the staff support and information technology we have come to rely on in clinical practice.
A plan for reform
Educational leaders in internal medicine have recognized the mismatch between training and practice.
Educational leaders in internal medicine have recognized this mismatch between training and practice. Led by ACP's Education Committee, they have summarized their concerns and reform proposals in a paper posted online on the Annals of Internal Medicine Web site.
Those concerns include how to optimally fulfill the educational needs of internists who will ultimately pursue a variety of career paths; how to increase the attractiveness of internal medicine, especially office-based general internal medicine; how to balance the service requirements of institutions sponsoring training programs with residents' educational requirements; and how to give faculty enough time to effectively teach residents and students.
The Annals report focuses primarily on graduate medical education, but also offers guidance for changes in premedical education and medical school. It outlines a strong plan for redesigning internal medicine training and includes the following recommendations:
Define the design model for residency training. The report recommends keeping internal medicine residency training at three years but establishing core competencies to be mastered in the first two years. This would give residents flexibility in their third year to develop skills and knowledge in areas in which they plan to practice, as either an internal medicine specialist or subspecialist.
Integrate educational and service needs. The report encourages training programs to better balance their institutions' service needs with residents' educational needs. This is especially important to maintain quality education while complying with duty hour limits.
Enhance ambulatory training. The report calls for improving ambulatory training by enhancing resources in continuity clinics and increasing the time residents spend in the ambulatory setting, free from the competing demands of inpatient care.
Utilize team-based care. The report recommends more team-based care during training to help residents develop the skills to lead and participate in multidisciplinary care.
Develop faculty models. The report advocates for new models for teaching and faculty development. It recommends identifying “core faculty” for training programs who will be given enough time and remuneration to devote themselves to teaching, as well as an infrastructure to support and recognize their contribution.
Stressing professionalism. The report's final recommendation is to more explicitly address professionalism throughout medical education. It points to the "Charter on Medical Professionalism," developed by the College, the ABIM Foundation and the European Federation of Internal Medicine as a basis for teaching and assessing professionalism.
Making it happen
How can such significant reform take place? Fortunately, several other internal medicine groups have been having similar discussions and the College is working with those groups to further define core competencies for internal medicine training. In addition, the Residency Review Committee for Internal Medicine has approved several proposals to implement innovations in residency training.
As a profession, we must continuously reflect upon the best possible way to train internists and incorporate educational innovations to improve that training. Those of us currently teaching in residency programs can critically assess how our programs can better meet trainees’ learning needs. And we can work within our own institutions and professional organizations, including the College, to help define the specialty's core competencies that all internists need as a basis for practice.
Our goal should be to improve internal medicine programs to train better prepared, more satisfied physicians who have the knowledge and skills to provide the best possible care to patients.
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