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Internal medicine residency training in the 21st century: Aligning requirements with professional needs

2005; Elsevier BV; Volume: 118; Issue: 9 Linguagem: Inglês

10.1016/j.amjmed.2005.06.009

1555-7162

Mitchell Charap, Richard I. Levin, R. Ellen Pearlman, Martin J. Blaser,

Primary Care and Health Outcomes

The role of the Accreditation Council for Graduate Medical Education (ACGME) and the Residency Review Committees (RRCs) in governing the education of residents has increased substantially during the past 25 years.1Accreditation Council for Graduate Medical Education. Program Requirements in Internal Medicine. Chicago, IL: 1980.Google Scholar, 2Accreditation Council for Graduate Medical Education. Program Requirements in Internal Medicine. Chicago, IL: 2003.Google Scholar Increased requirements have resulted in many improvements and innovations in residency training. However, this trend has inevitably diminished the role of faculty in determining the structure of training at their own institutions. The current ACGME residency requirements restrict medical educators from responding to the dramatic changes that are occurring in the practice of internal medicine. The widening chasm between practice and educational requirements are detailed and suggestions for improved alignment are outlined in this commentary. In 1980, physicians training in an internal medicine residency worked in the hospital more than 90 hours per week for at least 24 of the 36 months of training.3Charap M.H. Reducing resident work hours unproven assumptions and unforeseen outcomes.Ann Intern Med. 2004; 140: 814-815Crossref PubMed Google Scholar They had the time to develop their skills in history taking and physical diagnosis while admitting and managing hospitalized patients. Residents improved their interpersonal and communication skills by dealing with patients and their families, because most of the patients stayed in the hospital for 1 week or longer. Medical residents attended conferences 2 to 3 times per week and attended grand rounds when they could. Residents were not expected to spend much time in the clinic, because it was believed that most ambulatory medicine could be learned after residency; training time was short, and the emphasis was on very ill patients. Residents had no education in health care financing, and there was no expectation that they should.1Accreditation Council for Graduate Medical Education. Program Requirements in Internal Medicine. Chicago, IL: 1980.Google Scholar At the end of 3 years, residents may have felt a mastery of inpatient medicine but were not entirely comfortable with the prospect of taking care of patients on their own. Residents were profoundly respectful of the enormity of the information and skills necessary to be a good physician. In 2004, internal medicine residency training continues to be a 3-year curriculum. However, the information that residents must assimilate has increased substantially. An examination of the medications used for common diseases illustrates this point. The increase in pharmacologic options during this interval is astonishing, with similar trends in all subspecialties. For example, in its annual reviews of antihypertensive agents, The Medical Letter listed 15 drugs in 1981 and 61 in 2003; for antibacterial agents, there were 39 in 1980 and 159 in 2004.4Oral antihypertensive drugs.The Medical Letter. 1981; 23: 45Google Scholar, 5Oral antihypertensive drugs.The Medical Letter. 2003; 45: 34-40Google Scholar The breadth of internal medicine, in terms of information about pathophysiology, diagnostic testing, and treatment modalities, has increased at a rapid rate over the past 25 years.6Adams R.D. Harrison's Principles of Internal Medicine. Ninth Edition. McGraw Hill Professional, New York, NY1980Google Scholar, 7Kasper D.L. Harrison's Principles of Internal Medicine. 16th Edition. McGraw Hill Professional, New York, NY2005Google Scholar Through technology, the practice of medicine is also becoming more efficient. Computerized records, order entry, and information systems have reduced wasted time. However, computerization has not reduced the time it takes to talk to or examine a patient, nor has it reduced the need and time required to study the ever-expanding knowledge base that defines the field. In 1980, the RRC for Internal Medicine (RRC-IM) required that residents have experience in all the medical subspecialties. The mandated activities were to occur in both hospital and ambulatory settings. Exposure to dermatology, neurology, and psychiatry was included, but the RRC-IM guidelines stated, "It is not essential or even desirable that residents rotate through all of these subspecialty areas." In addition, internal medicine training programs were to be aligned with strong programs in surgery, radiology, and pathology. The RRC-IM requirements were listed on a single typed page.1Accreditation Council for Graduate Medical Education. Program Requirements in Internal Medicine. Chicago, IL: 1980.Google Scholar By 1990, the requirements had grown. Training in medical ophthalmology, otorhinolaryngology, and nonoperative orthopedics was required. The RRC-IM mandated that ambulatory care constitute at least 25% of the internal medicine residency experience. Emergency medicine and critical care medicine rotations were more fully delineated. For geriatric medicine, both clinical exposure and a formal curriculum were added. The RRC-IM also mandated exposure to medical ethics, cost-effectiveness, and medical information sciences. Research was strongly encouraged. The program requirements now had grown to 7.5 typed pages.8Accreditation Council for Graduate Medical Education. Program Requirements in Internal Medicine. Chicago, IL: 1990.Google Scholar At the same time, the RRC-IM restricted the number of patients for whom the residents were to be responsible. Interns were not to carry more than 12 patients or to work-up more than 6 new patients on an admitting day. Resident duty hours were restricted to 80 hours per week when averaged over 4 weeks, with 1 day off in 7. It was the perception that full compliance with these rules was not enforced, and the RRC-IM was careful to include the following caveat that embodies the touchstone of the internist's world: Physicians must have a keen sense of personal responsibility for continuing patient care, and must recognize that their obligation to patients is not automatically discharged at any given hour of any particular day of the week. In no case should the resident go off-duty until the proper care and welfare of the patients is ensured.8Accreditation Council for Graduate Medical Education. Program Requirements in Internal Medicine. Chicago, IL: 1990.Google Scholar In 2003, duty hours were further restricted by ACGME.9Accreditation Council for Graduate Medical Education. Report of the ACGME Work Group on Resident Duty Hours. Chicago, IL: June 11, 2002.Google Scholar The current RRC-IM documentation no longer includes the above statement and in fact makes no mention of the paramount obligations and responsibilities of physicians to their patients. One major and unintended consequence of the new duty hours requirements has been that an increasing percentage of medical residents work longer night shifts in a much less supervised environment.3Charap M.H. Reducing resident work hours unproven assumptions and unforeseen outcomes.Ann Intern Med. 2004; 140: 814-815Crossref PubMed Google Scholar Across the United States, there are fewer educational opportunities at night, when only a small number of faculty members are in the hospital. In this new paradigm, little opportunity exists for the development of meaningful interpersonal relationships between residents and patients or between residents and other health care professionals; residents are largely on their own.3Charap M.H. Reducing resident work hours unproven assumptions and unforeseen outcomes.Ann Intern Med. 2004; 140: 814-815Crossref PubMed Google Scholar It was believed that the increased free time that accompanies reduced duty hours would facilitate residents to study independently. However, there is no evidence to suggest that this outcome has actually occurred. By July 1998, the RRC-IM had increased the ambulatory requirements from 25% to 33% of the total clinical exposure.10Accreditation Council for Graduate Medical Education. Program Requirements in Internal Medicine. Chicago, IL: 1998.Google Scholar The increased requirement occurred in the context of the emergence of the primary care provider as the gatekeeper in the managed care systems of the late 1980s and early 1990s. More graduates of residencies were beginning careers in general internal medicine, and it appeared sensible to focus both the curriculum and clinical experience on ambulatory patient care. Over the years, curricular and administrative requirements were further broadened. By 2004, the RRC-IM Program Requirements for Residency Medical Education document had become 21 pages. The required conferences include all those mentioned in 1990: clinicopathologic conferences, grand rounds, morbidity and mortality review conferences, and literature reviews. However, now conferences were also mandated on medical genetics, medical informatics, law and public policy, pain management, domestic violence, physician impairment, substance abuse disorders, risk management, and quality improvement. It is stipulated that these particular conferences use at least 150 hours.2Accreditation Council for Graduate Medical Education. Program Requirements in Internal Medicine. Chicago, IL: 2003.Google Scholar Taken individually, each requirement has validity, but cumulatively they require time and effort to implement and restrict the ability of program directors to respond to the changing practice environment. This past year, residency programs were instructed by ACGME to develop training for residents in 6 core competencies. The addition of these competencies to the program requirements has further increased the required "curriculum" and the need for novel methods of assessment. Each addition places a burden on both the program staff and the physicians, who already have a very full schedule. Although several of the competencies are not new, the need to provide training in "systems-based practice" and "practice-based learning" is new terrain for residency education. For example, at the New York University School of Medicine, the new curriculum on systems-based practice and practice-based learning was squeezed into an already packed inpatient and outpatient core curriculum. Residents must prove their competency through elaborate 10-station Observed Simulated Clinical Encounters. In addition to the competencies, the RRC-IM now mandates scholarly activity. Residents do not take electives in other critical areas because they feel the need to focus on their research experience. Although such scholarship is laudable, it has a cost: Residents must sacrifice taking other clinical rotations and complete 3 years of training with far narrower clinical exposure. RRC-IM is responsible for ensuring that education takes priority over service. For example, RRC-IM requirements concerning adequate ancillary staff, sleeping quarters, and educational resources create a much more productive use of housestaff time during all rotations. RRC-IM also provides the program director authority over all aspects of training. However, because all aspects of training are determined by RRC-IM, program directors spend much of their time ensuring compliance with the requirements. Despite, or perhaps because of, their expansion, the RRC-IM program requirements are not aligned with the rapid evolution in the practice of medicine. For example, in 1998, RRC-IM required that one third of all clinical experiences occur in ambulatory settings, which was consistent with the secular trend toward careers in general internal medicine, in which ambulatory care is central to the practice.10Accreditation Council for Graduate Medical Education. Program Requirements in Internal Medicine. Chicago, IL: 1998.Google Scholar Over the past 5 years, graduates are increasingly choosing careers in subspecialties in which ambulatory medicine is less critical.11National Resident Matching Program. Positions Offered and Filled by U.S. Seniors and All Applicants 2000-2004. Available at: www.nrmp.org//res_match/tables/table5_04.pdf. Accessed June 6, 2005.Google Scholar Furthermore, in recent years, a new career option within internal medicine has emerged: hospital-based medicine. Increasing numbers of graduating residents entering general internal medicine are working in strictly inpatient hospital settings.12Goldman L. Modernizing the paths to certification in internal medicine and its subspecialties.AJM. 2004; 117: 133-136Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Increasing percentages of graduating residents are choosing procedure-oriented fellowships in fields such as cardiology, pulmonary and critical care medicine, and gastroenterology.13Newton D.A. Grayson M.S. Trends in career choice by US medical school graduates.JAMA. 2003; 290: 1179-1182Crossref PubMed Scopus (192) Google Scholar The reduced inpatient experience mandated in the past decade may not provide the requisite skill set necessary for functioning as a first-year fellow or provide a sufficient basis for a career as a hospitalist. Nevertheless, there remain many graduates entering general internal medicine and other subspecialties for whom the 33% ambulatory requirement is needed. These residents may need more exposure to varied ambulatory practice settings, including settings in which physicians work as part of a larger team. Training in internal medicine has changed greatly in the past 25 years, with the following major differences: •The knowledge base of internal medicine has increased dramatically.•The program requirements have expanded exponentially.•The autonomy of the program director has diminished.•Duty hours have decreased by mandate, decree, and legislation.•Outpatient mandates have increased disproportionately to inpatient requirements.•The subspecialties are both increasingly complex and attractive to residents.•Increasing percentages of graduating residents choose hospital-based careers. There is simply insufficient time to educate internal medicine residents in 3 years in the present regulatory environment. As a profession, program directors need to develop a strategy to maximize the efficiency of the graduate medical educational process. Basic skills still need to be honed, and specialty skills specific to each resident's future career need to be introduced. But now, physicians-in-training are pulled in multiple directions and are asked to develop skills and knowledge in areas that appear neither essential to their professional development nor appropriate for the next phase of their lifelong learning. For example, knowledge of adolescent medicine, rehabilitation medicine, and otorhinolaryngology may be appropriate for a minority of residents but should not be aminority of residents requirement for all. Furthermore, the new duty hours restrictions represent an additional reduction in exposure to patients, and thus to the natural history of illness.3Charap M.H. Reducing resident work hours unproven assumptions and unforeseen outcomes.Ann Intern Med. 2004; 140: 814-815Crossref PubMed Google Scholar It is easy to understand why the requirements have grown. Internists need expertise in a wide range of topics, and RRC-IM appropriately increased the requirements to cover these areas. However, the reality is that residency programs simply cannot satisfy these ever-increasing requirements other than as paper achievements responding to paper audits. During this same period, fellowships in disciplines such as cardiology, gastroenterology, pulmonary, and critical care medicine have extended their programs by 1 or 2 years, a change that was justified by the increased complexity of the respective disciplines. Eric B. Larson, MD, and his colleagues suggest a similar extension in the internal medicine residency, calling for a fourth year for those physicians who want to acquire advanced skills and knowledge for a specific career pathway such as hospital medicine or geriatrics. Those completing this year would earn a certificate of added qualifications.14Larson E. Health care system should spur innovation summary of a report of the Society of General Internal Medicine.Ann Intern Med. 2004; 140: 639-643Crossref PubMed Scopus (51) Google Scholar With a flat or declining percentage of US medical school graduates choosing a career in general internal medicine,11National Resident Matching Program. Positions Offered and Filled by U.S. Seniors and All Applicants 2000-2004. Available at: www.nrmp.org//res_match/tables/table5_04.pdf. Accessed June 6, 2005.Google Scholar the authors of this commentary doubt that such an approach is appropriate. From a funding perspective, given the climate of cutbacks in federal support, the added year also is unlikely to be economically viable. The first approach to this problem is a moratorium on increasing program requirements. If new mandates are added, older, less necessary ones should be eliminated. However, an immediate review and reduction of all of the requirements are in order. The RRC-IM should revisit its management of residency education, grant programs, and their faculties; provide broader leeway to find "best practices" for training to be accomplished in the local environment; and recognize that the diversity of competing interests will be better served by such flexibility. To achieve the well-intentioned goals of the RRC-IM and to adapt to the ever-changing practice environment, leaders in graduate medical education need to restructure the current system to make it more, not less, flexible. Instead of lengthening the residency, the authors suggest that the first 2 years of training be designed to provide a common foundation for future internists seeking diverse career goals. Goldman12Goldman L. Modernizing the paths to certification in internal medicine and its subspecialties.AJM. 2004; 117: 133-136Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar and Blackwell and Powell15Blackwell T.A. Powell D.W. Internal medicine reformation.AJM. 2004; 117: 107-109Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar have made similar suggestions in recent articles. This core curriculum will be determined by leaders in graduate medical education and be subject to approval by the Association of Program Directors in Internal Medicine and the Alliance for Academic Internal Medicine. The basis of the curriculum development should be the core competencies as determined by the ACGME and the Institute of Medicine.16Institute of MedicineCrossing the Quality Chasm. National Academy Press, Washington, DC2001Google Scholar In such a system, the third year of training would be sufficiently flexible to meet the residents' diverse educational needs. For example, the 33% ambulatory care requirement and the nonmedical specialty requirements might be reduced for those individuals planning to enter medical subspecialties. Such steps would provide more time for inpatient exposure, in line with the educational needs of this group. For those pursuing primary care internal medicine practices, the third year of training should emphasize ambulatory care, and the curriculum should be designed to address the needs of providers who work in an increasingly managed environment. Future hospitalists will need a different program that focuses on training physicians to function effectively in hospital settings. The duty hours restrictions that have existed for 15 years in New York and for 1 year in the rest of the United States—in their rigidity rather than their restriction—are detrimental to the development of an improved educational process such as the one outlined. Aside from the threat posed to the development of young physicians' professionalism, these restrictions significantly reduce the number and intensity of patient interactions.3Charap M.H. Reducing resident work hours unproven assumptions and unforeseen outcomes.Ann Intern Med. 2004; 140: 814-815Crossref PubMed Google Scholar The duty hours regulations need to be made more flexible and must explicitly incorporate the touchstone of responsibility noted in this article. During block rotations, such as intensive care unit or intense general medicine rotations, the hours served should be appropriate for the setting. On the other hand, duty hours regulations are necessary, and we realize these regulations are now a permanent facet of residency training. Because such restrictions inevitably lead to an increasing percentage of resident hours spent in nighttime rotations, the authors suggest developing new standards for off-hours education. An in-house attending or senior fellow supervision must be mandatory for these rotations, and rounds must occur as frequently as they do during the day. Such a change will necessitate more funding for supervision from hospitals, insurance systems, and state and federal governments. ACGME has granted other RRCs the autonomy to restructure their individual accreditation processes.17Accreditation Council for Graduate Medical Education. Stoll D. Simplifying the Accreditation Process. 2004 Annual ACGME Meeting. Chicago, IL: 2004.Google Scholar This autonomy has led, in several specialties (such as otolaryngology and plastic surgery), to creative approaches to accreditation, greater collaboration between the RRCs and their constituents, and greater overall satisfaction. In each of these instances, the program requirements have been reduced. Recently, the RRC-IM announced its Educational Innovations Project,18Accreditation Council for Graduate Medical Education. Educational Innovations Project. Available at: www.acgme.org/acWebsite/RRC_140/140_EIP_%20PR205.pdf. Accessed June 6, 2005.Google Scholar which is designed to foster competency-based education and outcomes assessment, and which may lead to a similar reduction in requirements in the future. In 2004, Allan H. Goroll, MD, and colleagues proposed a new model for accreditation based on outcomes, not process.19Goroll A.H. Sirio C. Duffy F.D. Leblond R.F. Blackwell T.A. Rodak W.E. et al.New model for accreditation of residency programs in internal medicine.Ann Intern Med. 2004; 140: 902-909Crossref PubMed Scopus (83) Google Scholar Goroll et al's article calls for the RRC-IM to diminish its program requirements and its tightly managed approach to accreditation and replace the present system with a new competency-driven curriculum. This undertaking is laudatory, but as Goroll et al suggest, it will take years, and the new educational innovations project will likely accelerate such a transformation only slightly. The problems noted in this article already have had a substantial negative effect on medical education, and continuation of these problems will further reduce the ability of residency programs to experiment with curricular reform. A more immediate response is needed that includes the following measures: •An immediate moratorium on new program requirements, unless they are accompanied by equivalent reductions in existing requirements.•An external ("blue ribbon") review of all RRC-IM requirements by a group of nationally recognized medical educators who have no affiliation with ACGME.•The development of a 2-year core curriculum.•Increased flexibility in the third year to meet the diverse career interests of current residents.•Greater flexibility in the duty hours requirements. For example, allow averaging over the block rotations to foster the development of both professionalism and clinical acumen.•Program faculty or senior fellows should be deployed in novel ways, especially using the Internet to provide 24-hour in-house supervision for the increased nighttime resident contingent.•Restatement of the guiding principle of good medical care and training: "Physicians must have a keen sense of personal responsibility for continuing patient care, and must recognize that their obligation to patients is not automatically discharged at any given hour of any particular day of the week. In no case, should the resident go off-duty until the proper care and welfare of the patients is ensured."8Accreditation Council for Graduate Medical Education. Program Requirements in Internal Medicine. Chicago, IL: 1990.Google Scholar This commentary does not address all the issues related to redesigning the educational continuum in internal medicine, such as assessing outcomes, continuing education, and certifying (and recertifying) internists. However, the commentary provides concrete recommendations for making immediate changes. The leaders of internal medicine—particularly of academic internal medicine—must understand, confront, and overcome the increasing chasm between the current training requirements and the realities of medical practice.