Are internists ready to respond, or asleep at the concert?
By David A. Fleming, MD, MA, FACP
Recently my wife and I attended a delightful jazz concert with our son-in-law at one of our local bistros. It was small, dark, and crowded with jazz aficionados (like my son-in-law) and less sophisticated listeners (like me). As the combo was finishing their last set, there was commotion at a table nearby, soon followed by the public address announcement that, as physicians, we at once dread and anticipate: “Is there a doctor in the house?”
Over the years I have heard and responded to many such calls and mentally have tried to keep myself prepared. Of several physicians in the room, I was the first person there, the CPR algorithm already working in my head. The music immediately stopped, the lights came up, and there was ... total silence, all eyes in the room looking at the single person standing ... me. Before me was a pallid, middle-aged man leaning back against the wall, eyes closed, breathing shallow, mouth slightly ajar, surrounded by 5 anxious companions. While reaching to check a carotid pulse, I firmly shook his shoulder and ... he woke up!
He immediately looked around and saw hundreds of concerned faces and a strange man standing over him demanding, “Are you OK?” He sheepishly responded, “Yes, I was asleep.” After a pregnant pause, I disengaged and returned to my seat, satisfied with “another great save,” at which time the concert promptly ended and everyone left.
These are times I am profoundly thankful for my training as an internist and the instinctive skills I have relied on for decades. As an older physician, I perhaps have more wisdom than knowledge of the latest in medical science. However, I still feel I have much to offer both my patients and my students.
The College is in the midst of active discussions and negotiations with the American Board of Internal Medicine (ABIM) concerning the need for and appropriateness of the new and rigorous Maintenance of Certification (MOC) program that continues to challenge busy internists who want and need to remain certified, defined in part by the ABIM as the ability to pass a rigorous, secure, knowledge-based exam every 10 years. One major argument made by ABIM is that it has an obligation to society to ensure that internists are competent, including identifying those with a poor knowledge base. Many in ACP, and beyond, are asking whether the exam is relevant to practice and whether there is evidence that MOC really protects patients. These concerns are being taken seriously by both ACP and ABIM, and productive, ongoing discussions between our organizations continue.
As a physician I must always ask, “Am I ready?” As a clinician educator I must ask myself and my faculty, “Will they (our residents and fellows) be ready?” when the call invariably comes and perhaps when it is least expected. Like many of you, I was trained in the Oslerian tradition by mentors who themselves were excellent general internists, while also subspecialists in most cases. Being an excellent internist means paying meticulous attention to detail in the deductive process about each patient. It means being complete and thorough in both mind and deed.
One of my favorite William Osler quotes says it all: “One finger in the throat and one in the rectum makes a good diagnostician.” The visual image aside, Osler is informing us as to the importance of completeness and meticulousness in our clinical method. Are we ensuring that in the modern paradigm?
In our modern training environment, are we training good diagnosticians in spite of the many external pressures that influence them and their mentors? I observe the brilliant minds and eager faces of our trainees, most of whom will go into subspecialty training, all of whom are very smart, and many of whom may well have done very few, if any, rectal, pelvic, funduscopic, or complete lymph node exams. I wonder in the years to come whether these important skills will still be available to the majority of our graduating trainees.
I also wonder if the recently declining pass rates for physicians on their first attempt taking the MOC secure exam are in some way a reflection of a subtle shift away from the traditional Oslerian ideals of meticulousness and diagnostic excellence due to a multitude of other demands now being placed on our physicians and our training programs. Even though the vast majority of applicants ultimately pass the recertifying exam, an initial pass rate of only 78% is still concerning. It may not be that recertifying exams are getting that much harder or becoming less relevant, although both claims are possible.
Regulatory pressures on training have increased in recent years on top of the mandate to limit duty hours. In 2009 the Accreditation Council for Graduate Medical Education (ACGME) levied a requirement that residents graduate with 22 observable behaviors (milestones) designed to secure 6 core competencies: patient care, medical knowledge, professionalism, system-based practice, practice-based learning and improvement, and interpersonal and communication skills. The Next Accreditation System (NAS) in 2012 then moved assessment of these mandated competencies into a continuous process, thus further pressuring training programs to assess trainees’ performance.
A 2011 article in Annals of Internal Medicine proposed adding high-value care as a critical seventh general competency. A recent Annals article by our chief executive officer and executive vice president, Steven Weinberger, MD, FACP, and coauthors suggested that patient-centered education should be the “next revolution in medical education,” embracing a culture change that will better prepare trainees to meet the needs, goals, and preferences of their patients. The authors also suggested that training needs to include more emphasis on ambulatory care, integration of humanistic skills (including the perspective and active participation of families and patients in decision-making), and faculty development to promote these attitudes and skills.
These are lofty goals that respond to skills needed by physicians in the modern paradigm of health care and the importance of remaining patient-centered as physicians. They are also concepts with which I am completely in agreement and that I fully support. But are there unintended consequences to adding further demands to already very demanding requirements of training? There have been concerns expressed in response to such proposals, both that we may not be making important changes soon enough, while others are concerned that by adding more and more requirements to training we may be further distracting residents from developing the core concepts and analytical skills necessary to becoming competent and skilled internists. Some feel that we should “putt or get off the green” regarding an increase in ambulatory training, arguing that this and other needed changes are too slow in coming. Others have argued that clinical competence is not defined by the attitudes, knowledge, and skill acquired in training, but by how these attributes are incorporated into actual patient care. More recently, concerns have been offered that specific milestones for assessing trainees overemphasize nondiagnostic aspects of medical practice. These are observations that should give us pause.
We need to do everything possible to ensure the graduation of lifelong learners and internists who are prepared, not only in knowledge and skill, but also in wisdom. I pray that those sitting in the bistro and enjoying some nice jazz will also be ready to respond when I become unresponsive, hopefully just having a good nap.
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