WHITCOMB, MICHAEL E. MD
Most of the papers that appear in Academic Medicine this month address issues that relate in one way or another to the education of resident physicians. The range of topics covered provides some insight into the magnitude of the challenge now facing program directors and others responsible for the design and conduct of graduate medical education (GME) programs. At present, many of those responsible for GME are focusing much of their attention on only one aspect of this challenge—that is, trying to determine how to comply with the resident duty-hours limits recently adopted by the Accreditation Council for Graduate Medical Education (ACGME).
Several of this month's papers provide information relevant to that issue. The two that describe the regulations in Ontario and Quebec that govern duty hours are particularly important. Residency programs in those provinces have had to comply for more than a quarter century with duty-hours limits that are more stringent than those adopted by the ACGME. Given this, it is important to note that there are no data to suggest that the duty-hours limits have affected adversely the quality of the care provided by Canadian residents, or the quality of GME in Canada. With regard to the latter, the regulations also make it clear that residents are to be relieved of all but emergency patient care responsibilities in order to attend regularly scheduled educational activities.
Some might suggest that the Canadian experience is not relevant to the debate occurring in this country, because there are different expectations in the two countries about residents' performances. However, this argument fails to recognize that most of the graduates of Canadian residency programs are eligible to sit for the certification examinations of the U.S. specialty boards, and those who take the examinations perform quite well.
While the duty-hours issue is an extremely important one, it is imperative that those responsible for GME shift the focus of their attention to an examination of the overall quality of GME programs. In October 2001, more than a year ago, the AAMC issued a document entitled “AAMC Policy Guidance on Graduate Medical Education.” In that document, which is published in this month's journal, the AAMC states that “focusing on excessive duty hours is to focus on the symptoms, not the root cause of the problems affecting GME. If fundamental improvements are to be made in the quality of residents' education and in the quality of residents' life, the academic community must rededicate itself to the core educational mission of GME.” I don't think that it is possible to overemphasize the importance of that statement! So what is to be done?
To begin, those responsible for GME must examine critically the educational design of residency programs. In conducting this examination, they must be committed to the principle that above all else, GME programs must prepare residents to provide optimal care for the kinds of patients they will encounter most frequently when they enter practice. This means, of course, that the programs must be designed so that they provide ample time for residents to learn and gain experience in the clinical venues where those kinds of patients now receive their care. They also must put in place rigorous methods for assessing whether or not residents have acquired the knowledge, skills, and attitudes they are expected to while in residency training, and even more important, whether they possess the ability to perform the kinds of complex, integrative tasks required in providing patient care.
To assist in this effort, others in the academic medicine community, particularly health services researchers, must conduct studies to define the scope of practice that the majority of residents will experience when they enter practice and the quality of the care provided by program graduates during their initial years in practice. It is essential that these data be collected. Absent an understanding of the scope of practice that program graduates will experience when they enter practice, there is no rational basis for the design and conduct of GME programs. Similarly, without data on the clinical outcomes produced by new practitioners, there is no way to evaluate the real quality of residency training programs.
The challenges inherent in achieving the objectives outlined above are daunting. It will be difficult to overcome the prevailing attitude that there is nothing inherently wrong with the current design and conduct of GME programs. It will be particularly difficult to reach agreement on eliminating certain patient care experiences currently included in residency programs, regardless of how removed they may be from the scope of practice of new practitioners, without first reaching agreement on how the services provided by residents during those experiences will be covered. Those involved in addressing this issue must agree that it is not acceptable for residents to be required to spend an undue amount of time caring for patients with complex conditions that they will not be responsible for managing once they enter practice.
Despite the difficulties ahead, the academic medicine community must take the current challenge seriously, and begin to undertake the work needed to effect necessary changes in the ways that residents are being trained. This imperative arises from the growing body of evidence documenting both the sub-standard quality of medical care provided in a wide variety of clinical circumstances and the frequency with which life-threatening medical errors occur in this country. While a number of factors undoubtedly contribute to these poor clinical outcomes, those responsible for GME must be willing to consider the possibility that residency programs are not preparing residents adequately for the independent practice of medicine. In its recent report, the Commonwealth Fund Task Force on Academic Health Centers suggests this to be the case, and challenges academic medical centers to take more responsibility for ensuring the quality of the programs they sponsor. Thus, the academic community must be in a position to assure the public that GME programs are truly preparing residents to deliver high-quality medical care when they enter practice.
In his 1999 AAMC Presidential Address entitled “Honoring the E in GME,” Jordan Cohen called on the academic community to focus on the quality of GME. In September 2001, the AAMC Executive Council reinforced this point in the document noted earlier. Unfortunately, little has been accomplished in the past few years, because the academic community has focused its attention almost entirely on the duty-hours debate. It is clearly time to begin to focus on the overall quality of GME. The AAMC intends to play an important role in seeing that this occurs. More on that later.