The fundamental objective of graduate medical education (GME) is to provide physicians with the knowledge and skills needed for their future practice. Ideally, in an environment of supervised guidance and graduated responsibility, residents would experience the broad range of medical conditions and circumstances that they are likely to encounter when they enter the independent practice of medicine. However, many are concerned that GME is not keeping pace with the changing demands of medical practice.
The subjugation of education to service, particularly inpatient service, has been a long-standing concern in residency programs.1–5 In addition, surveys conducted over the years have repeatedly suggested that, despite graduating residents with the requisite knowledge base to pass certifying examinations, training programs have not kept pace with the changing scope of practice that trainees encounter when they begin their careers. A 1991 Robert Wood Johnson Foundation survey of young physicians found that, although 80% of over 4,500 respondents thought that their formal medical education did a “good” or “excellent” job of training them for clinical practice, many felt unprepared to care for a variety of common conditions, including identifying depression, treating patients with severe disabilities, and treating elderly patients.6 Blumenthal et al7 conducted a similar national survey seven years later of over 2,500 residents and found that more than 10% of residents in each specialty again reported that they felt unprepared to manage one or more tasks relevant to their disciplines. Two thirds of physicians surveyed in a 2002 study conducted by Blendon et al8 reported that their training had not prepared them to coordinate care for patients or to educate patients with chronic conditions. The health care industry also has identified shortcomings of recent graduates, stating that an increasing amount of time and resources must be spent to reeducate physicians in the new competencies required in today’s workplace.9 Finally, recent graduates have added their voices to these concerns.10
The report by Grant et al11 published in this issue of Academic Medicine, “The Effectiveness of Pediatric Residency Education in Preparing Graduates to Manage Neurological and Neurobehavioral Issues in Practice,” contributes additional evidence to this body of literature that suggests that residency programs have failed to fully meet the challenge of preparing graduates to care for many of the patients whom they encounter in their practices. Dr. Grant, herself a pediatric resident, surveyed recent graduates of the University of British Columbia pediatric residency training program to assess their self-reported competency in various areas of pediatric neurology. Although a small study from a single residency program, the results are consistent with previous reports that suggest that residency training is too heavily focused on complex inpatient conditions to the exclusion of the conditions more commonly encountered in general practice.
How Did We Arrive at This State?
Twenty years ago, the prevailing wisdom in medical education held that the skills mastered in the care of complex inpatients could be readily transferred to the management of outpatients with similar conditions. This educational model made sense at the time. Patients requiring the coordinated care of multiple disciplines or more than the most modest adjustment in their medications were hospitalized. Problems were fully managed and stabilized prior to discharge. However, the current health care system functions very differently. Increasingly complex care is provided in outpatient settings where systems to coordinate care across specialties and to ensure patient understanding of complicated regimens is often lacking. Hospitalized patients are frequently discharged with numerous unresolved issues. In many ways, the tables have turned. The technological marvels of inpatient monitoring offer a sense of security and certainty in decision making that is wholly absent in the settings where most patients are treated. In many disciplines, it can be argued that providing quality care in the outpatient setting is more challenging and difficult than doing so in the hospital.
Educators have long recognized this shift in the model of health care delivery. Yet, residency training has changed little in response. Internal medicine, surgery, family medicine, and pediatrics have all embarked on major residency redesign efforts. However, in each case, there are real obstacles to implementing the kinds of changes that appear to be needed.
The most significant obstacle relates to the funding mechanism for GME. The largest single funding source is through the federally sponsored Medicare program. Its current structure creates financial incentives to assign residents to inpatient services or hospital-based outpatient clinics. Although graduate medical educators have attempted in recent years to move more educational experiences to outpatient settings that better reflect the current scope of clinical practice, this is costly for teaching hospitals. Inpatient services require substitute coverage at far greater cost than that provided by residents. In addition, for the most part, GME funding does not support training in community-based practices. As a result, residents tend to learn outpatient medicine in teaching hospital clinics. Like their inpatient counterparts, these clinics typically provide care to the most indigent and complex patient populations.12,13 Compared with faculty practices, hospital-based resident clinics serve patients with higher rates of chronic illness, poorer measures of health and functional status, and more significant language and health literacy barriers.
In addition, resident clinics are among the most chaotic of health care delivery settings. They are less likely than faculty practices to be supported by computerized record systems, adequate ancillary staff, and midlevel providers to assist with patient care. Because of inpatient service demands, residents’ schedules limit their ability to follow patients, especially those with chronic illness. All of these factors lessen residents’ exposure to care coordination systems and to shared care models between primary and specialty care. Thus, the systems needed to expose residents to the broad range of outpatient conditions and to train physicians to provide the safest and most effective care are generally lacking in the GME environment. Although it is widely accepted among recent graduates and medical educators that training in these environments is not optimal,10,14–15 educators struggle with how to provide more educationally relevant experiences given time constraints, reimbursement-driven service requirements, and poorly designed learning environments.
Narrowing the Training–Practice Gap
The medical profession as a whole has not articulated a coherent response to these current problems with GME. The changes needed are multifaceted, and some will require external pressure. Others will require a greater will within the academic medical community to address its own dependency upon residents to provide service that exceeds educational need. At the very least, the profession needs to acknowledge the steps necessary to facilitate change.
As a first step, a more standardized mechanism for monitoring the training–practice gap is needed. Ideally, this would involve the measurement of practice behavior and patient outcomes during residents’ training and into their early years of independent practice. However, until such measurement is feasible and reliable, standardized surveys of graduates one and two years into practice would provide valuable feedback to residency programs, much as the Association of American Medical Colleges’ Graduation Questionnaire provides feedback to medical schools about the adequacy of students’ educational experiences. These data would form the basis for discussions between educators, hospital administrators, and department chairs about the specific curricular and experiential changes needed in an individual program.
Second, teaching hospitals must embrace more fully their societal responsibility to ensure that graduating residents are prepared for the independent practice of medicine. Certainly, physicians are expected to gain further knowledge and refine their skills once in practice. However, as articulated by Grant et al,11 imparting the fundamental knowledge and skills that residents can reasonably be expected to need early in their practice should be a priority of residency training. It is also critical to ensure that residents are increasingly exposed to health care systems that have robust clinical information systems with decision support tools, the personnel infrastructure to help coordinate the care of patients with multiple chronic illnesses, and established quality-measurement and quality-improvement programs. Opportunities for residents to engage in quality-improvement activities such as practice improvement projects and to learn on simulators designed to improve patient safety could also contribute to reducing the training–practice gap.
Finally, the current inability to eliminate the training gap is very much linked to federal policies governing its financing. As noted above, it is important that residents be able to engage in clinical experiences outside the confines of teaching hospitals and that the preferential assignment of residents to meet inpatient service demands be eliminated. Because of changes in the organization, financing, and delivery of health care services in recent decades, teaching hospitals no longer provide the full range of patient care problems or practice models that residents need to experience for optimal training. Because federal funds from the Medicare program are central to financing GME, federal legislators must better understand the link between medical education and health care quality. Physicians inadequately trained to meet the demands of current medical practice are unlikely to provide the highest-quality care. Medicare policies that restrict the use of funds to support residents’ education in settings other than teaching hospitals make the redesign of residency education problematic in many clinical disciplines. Changes in these restrictive policies and demonstration projects of other financing models are needed to effect the necessary educational changes.
Closing the existing training–practice gaps in GME is ultimately in the best interest of patients. All can agree that improving patient outcomes and minimizing the occurrence of medical errors are national health care priorities. One of the important steps to achieving these ends is to close the existing training gaps in medical education. The quality of health care depends as much on the quality of the education and training of the nation’s physicians as it does on the redesign of the systems in which health care is delivered. The physicians-in-training of today are likely to confront a new practice paradigm: increased transparency, evaluation of their performance by payers, revenue linked to performance, and opportunities to practice differently with less system-related frustration. By combining improvements in medical education with needed systems changes, the medical education enterprise has the potential to realize the benefits of improved health care quality. Thus, all who are concerned about the quality of medical care should also be concerned about closing the training–practice gap.
1 The Commonwealth Fund Task Force on Academic Health Centers. Training Tomorrow’s Doctors. New York, NY: The Commonwealth Fund; 2002.
2 Institute of Medicine. Academic Health Centers: Leading Change in the 21st Century. Washington, DC: National Academy Press; 2003.
3 Cohen J. Honoring the “E” in GME. Acad Med. 1999;74:108–113.
4 Council on Graduate Medical Education. 13th Report. Physician Education for a Changing Health Care Environment. Washington, DC: U.S. Department of Health and Human Services; 1999.
5 The Blue Ridge Academic Health Group. Reforming Medical Education: Urgent Priority for the Academic Health Center in the New Century. Athens, Ga: Emory University; 2003. Report 7.
6 Cantor JC, Baker LC, Hughes RG. Preparedness for practice: young physicians’ views of their professional education. JAMA. 1993;91:360–364.
7 Blumenthal D, Gokhale M, Campbell EG, Weissman JS. Preparedness for clinical practice: reports of graduating residents at academic health centers. JAMA. 2001;286:1027–1034.
8 Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933–1940.
9 Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. A Report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academies Press; 2000.
10 Arora V, Guardiano S, Donaldson D, Storch I, Hemstreet P. Closing the gap between internal medicine training and practice: recommendations from recent graduates. Am J Med. 2005;118:680–687.
11 Grant E, Macnab AJ, Wambera K. The effectiveness of pediatric residency education in preparing graduates to manage neurological and neurobehavioral issues in practice. Acad Med. 2007;304–309.
12 Yancy WS Jr, Macpherson DS, Hanusa BH, et al. Patient satisfaction in resident and attending ambulatory care clinics. J Gen Intern Med. 2001;16:755–762.
13 Brook RH, Fink A, Kosecoff J, et al. Educating physicians and treating patients in the ambulatory setting: where are we going and how will we know when we arrive? Ann Intern Med. 1987;107:392–398.
14 Holmboe ES, Bowen JL, Green M, et al. Reforming internal medicine residency training. A report from the Society of General Internal Medicine’s task force on residency reform. J Gen Intern Med. 2005;20:1165–1172.
15 Bowen JL, Salerno SM, Chamberlain JK, et al. Changing habits of practice: transforming internal medicine residency education in ambulatory settings. J Gen Intern Med. 2005;20:1181–1187.