Although I have deep respect for everyone who contributes to educating the next generation of physicians, I also feel that the current hierarchy in graduate medical education is harming American health care. This means that the best students go to the best training programs, get the best jobs, and then teach the best students, creating highly reputable centers of excellence. That's great, but how often do we think about the opposite? Less competitive students receive the least competitive slots in less competitive training programs, receive weaker training, and ultimately end up teaching the next generation of their peers in the same environment. And so on, creating a center of troubling mediocrity. Should ACGME accept this as just a manifestation of the “American way” or should it intervene?
As a hospitalist who has worked in eight states and in a variety of academic and community settings, from centers of excellence to local training programs, I can only speak to a small portion of graduate medical education, but I can only speak to a small portion of what I have seen so far. From what I've been through, I feel the following. We have a duty to raise a red flag.
More specifically, the rural internal medicine program I worked for relied almost entirely on post-match “scrambles” to fill slots each year. As an educator, I felt that I had a responsibility to provide each of these residents with the appropriate education, but I was surprised that their in-training exam scores were as low as the 0th percentile and the exemplary scores above the 30th percentile were as low as 1. I was horrified to see that there was only one. When I arrived, the first-time pass rate for the ABIM board exam was 33 percent. There were no morning debriefings or bedside rounds, residents did most of the daytime lectures themselves (with almost no faculty present), and the hospital had only a few specialized services (dialysis, MRI, catheterization, etc.). There was no testing room). All complex cases have been transferred. As expected, most of the teachers would have been trained in this program, but who else would be there? Finding warm-hearted organizations to “staff” residents, let alone individuals dedicated to providing a high-quality education, was a struggle. Sadly, the basis of our residents' board exam preparation consisted of running through thousands of sample board review questions over and over again. Unfortunately, it's not the same as learning a foreign language without visiting the country. The clinical subtleties of history, examination, diagnostic reasoning, and careful clinical decision making cannot be learned from mastering exam questions. I believe, and I have documented, that all of the above has resulted in a number of substandard and sometimes dangerous medical practices. (Some internal medicine graduates went on to staff local emergency rooms, compounding the problem.)
The fact that this small hospital's chief financial officer (CFO) appears to have more control over the structure of resident schedules than the program director raises concerns that residents are being used primarily as cheap labor. confirmed. For example, my attempt to introduce interactive daily morning reporting instruction was quickly halted by his CFO because it affected discharge time.
I am not criticizing the residents or educators themselves in this situation. They were doing the best they could based on their experience, training, and resources. But most of them have never witnessed “excellence” and I believe there is an opportunity here.
As an educator, I believe that in any profession, it is invaluable for trainees to witness excellence firsthand. Just as a young athlete attends a professional sports camp and watches a professional game, the experience can be transformative. The reality is that in rural programs, trainees never have the opportunity to witness excellence.
So what's the solution?
Honestly, the best bet is to expand training programs in medical centers of excellence, give the majority of physicians the opportunity to train in those settings, and ultimately bring small communities to a standard of excellence. I think the idea is to be able to provide a platform for people with disabilities, while at the same time eliminating the need for doctors to provide medical care. Accreditation of hospital-based programs without a complete platform of services or specialties. These hospitals can and should be satellites of larger programs, but they should never be their homes.
Since such disruption is unlikely, the alternative is that all physician trainees in the United States should be given and required the opportunity to experience centers of excellence for a significant portion of their training. I am thinking.
Consider the following:
- Formally link all rural or small community programs to at least one academic research center as a sister organization.
- Exchange both faculty and residents (including chief residents) between the rural and academic programs throughout the year.
- Link live streaming interactive conferences and big rounds from academic centers to smaller programs.
- Require residents to formally report on the management and outcomes of all patients transferred to the referring hospital (ideally with resident-to-resident communication about cases between the two facilities).
- Faculty and trainees on both sides will benefit from this “prince and pauper” type of exchange. Educational methods, quality of documentation, clinical decision-making, and guideline-based management will all be significantly impacted. (This exchange would also likely reduce unnecessary patient transfers to academic centers because it would improve the clinical knowledge, experience, and confidence of rural physicians).
Certainly, program directors reading this are probably cringing at the logistical nightmare and additional costs that this exchange will create. Presumably, faculty and residents in top training programs have little desire to be “hamstrung” or “burdened” by working with rural programs (and that weaker residents Local programs may be resentful because they may be embarrassed or fearful of marginalizing patients). Despite some “condescending” or “off-base” decisions by academic doctors, I believe that the ultimate benefits to American health care will more than offset the costs.
Every health system has a mission statement of wanting to provide the “best possible care” to all patients, but the current hierarchy in graduate medical education makes it unlikely that this can be achieved, especially in rural areas. yeah.
David M. Mitchell is a hospitalist.
