Maniate, Jerry M. MD, MEd; Karimuddin, Ahmer MD, MECd
To formally integrate the perspective of trainees into discussions pertaining to the medical education system, we created a set of guiding principles. This report discusses the motivation for this development and describes the process by which we created these principles, from the unique perspective of medical residents, for ensuring in Canada a quality postgraduate medical education (PGME) system (known in the United States as residency or graduate medical education [GME]). We also discuss ways in which the principles will be used by the Canadian Association of Internes and Residents (CAIR) to promote and advocate for the residents to ensure quality in the PGME system.
Physicians have been entrusted by society with the dual responsibilities of healer and professional. As a profession, medicine, in conjunction with governments and the public, has invested significant time and resources in creating mechanisms, in the form of regulatory authorities, to ensure that its members are providing appropriate and safe medical care for the public. Elaborate medical education systems have also been created through professional programs at colleges and universities to ensure not only that physicians are adequately trained but also that they maintain their clinical competency throughout the duration of their practice. To this end, continuing education programs that are designed to allow the maintenance of clinical competence are available throughout a professional's career. With so much invested in the clinical competency of physicians, there is a need for adequate and appropriate mechanisms to ensure that educational systems provide the highest-quality training possible and are responsive to the changing demands of the patient population as well as to changing technologies and research.
The Association of American Medical Colleges (AAMC) noted in its policy guidance on GME1 that
Conducting high-quality GME has always been a demanding undertaking. Ensuring an optimal learning environment and creating a proper balance between education and patient care activities have been the principal challenges to medical educators…. 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 and focus its attention on enhancing the learning environments where GME is conducted.
Michael Whitcomb, then-editor of Academic Medicine, noted in his January 2003 editorial2 that, after a few years during which little had been accomplished, while the focus was placed entirely on the work-hours discussions, “It is clearly time to begin to focus on the overall quality of GME.”
Historically, most quality-assurance mechanisms, such as accreditation, have been top-down—that is, they were created and implemented by the educational colleges and other medical organizations to evaluate medical schools, residency training programs, and continuing education departments. Typically, such an approach has not factored in the perspective of the trainees. In their study of the impact of resident work-hours limitations on medical students' educational experience, Jagsi and colleagues3 noted that the students “have a unique vantage point from which to observe outcomes of work-hours reform that do not affect them directly.”
Klessig and colleagues4 reported on the results of a pilot survey designed to clarify and identify the components of quality in internal medical residency training.4 Those authors had included both faculty and residents as raters of the items of the survey, which examined the training process and outcome measures. They concluded that “[F]urther development of evaluation tools must include all groups that have vested interests in residency training, including trainees and future employers.”
In recent years, trainees (i.e., medical students and, especially, residents and fellows) have sought to play a greater role in quality-assurance processes. With a growing sense of responsibility for ensuring a quality medical education system for themselves and future generations, trainees have become active participants in the existing mechanisms of quality assurance. In addition, appreciation has grown for the fact that trainees bring to various issues and discussions a different perspective that can often broaden the understanding of the topic and assist with the process of successful educational change, which requires all participants not only to understand but also to adopt new practices and behaviors.5
The Role of Residents in Canada's PGME System
In Canada, the Royal College of Physicians and Surgeons of Canada (RCPSC) and the College of Family Physicians of Canada (CFPC) have been entrusted with the responsibility of ensuring quality residency training (PGME) programs through an extensive process of standards setting, program accreditation surveys, and trainee evaluations that serves to guarantee that residents are prepared for independent practice of a clinical specialty or subspecialty on completion of their training. The CFPC is responsible for the accreditation and standards of all family medicine residency training programs, and the RCPSC is responsible for the accreditation and standards of specialist residency training programs in Canada.6,7
Within Canada, residents have played an active role in the PGME system at the local, provincial, and national levels. CAIR is the national organization that represents over 7,500 residents across Canada. Through a process of collaboration and consensus building, CAIR aims to advance the interests of residents with regard to educational and professional issues and well-being issues, such as intimidation, harassment and discrimination, and resident safety. For example, CAIR has developed position papers and policy papers on a number of topics affecting resident education, such as resident well-being, international medical graduates, the Canadian Residency Matching Service, the future of family medicine, and residents' debt. CAIR actively collaborates with other national medical organizations, such as the Medical Council of Canada, the Association of Faculties of Medicine of Canada, and the Canadian Medical Association, to ensure that the perspectives of residents are represented, especially with regard to issues pertaining to and either directly or indirectly affecting PGME.
Why CAIR Created the Principles—Contributing the Residents' Perspective
Whereas there are many indirect beneficiaries from the medical education system, including the patients and, by extension, society and governments, two dominant and direct stakeholders involved in process and structure have been identified—the educators and the learners. Educators have traditionally included physicians and other university faculty members, but, increasingly, there is recognition of the valuable role that patients and the public play as educators within medical education. In Canada, learners typically follow a spectrum of lifelong learning from undergraduate trainees (medical students) and postgraduate trainees (residents and fellows) to practicing physicians (those participating in continuing education).
Whereas discussions and the medical education literature frequently point to the importance of educational practices' being “patient-centered,” there is a growing appreciation of the importance of ensuring that a “learner-centered” approach is also practiced. The “patient-centered” approach emphasizes experiential learning of skills and knowledge by the trainee, with the patient acting as a mediator.8 “Learner-centered” education is an active process of self-directed learning that occurs under the close supervision of interested and experienced faculty members.9 This approach is generally used in educational institutions, such as academic or community health facilities, in which a clinical environment is created with a focus on PGME.
CAIR is regularly invited to contribute to and actively participate in discussions on issues pertaining to PGME. CAIR developed the Principles of Quality Postgraduate Medical Education to enable the organization to thoughtfully evaluate and respond to proposals and questions by providing a framework within which to craft responses. A number of medical organizations have produced documents concerning quality medical education, which are available in either published or unpublished literature. These documents include organizational reports, conference proceedings, accreditation standards for training programs, objectives of training, or competency frameworks such as the RCPSC's Canadian Medical Education Directions for Specialists 2005 Physician Competency Framework10 or the CFPC's Four Principles of Family Medicine.11 The General Medical Council, in collaboration with the Postgraduate Medical Education and Training Board, jointly published the Principles of Good Medical Education and Training in 2005.12 It should be noted that all of these documents were written from an educator's perspective. We did not identify any policy documents or position papers from Canada or the United States in the medical education literature that were written from the learners' perspective and that set out goals for the delivery and evaluation of PGME.
How CAIR Created the Principles—Developing the Residents' Perspective
We initiated and led the process of developing a residents' perspective and a set of principles related to the medical education experience. We began this process with a brainstorming exercise to identify issues and concepts that were felt to be important to creating the “ideal” PGME system, defined as a brand new system of medical education that was not based on the status quo and historical or traditional practices. The initial issues and concepts identified were drawn from our personal experiences as trainees and also from the conversations and issues raised by other residents in the course of our work as members of the CAIR Executive Committee during the preceding three years, when the residents advocated for improving the quality of the educational experience. For example, over the years, residents have raised various concerns about the evaluation process, resident well-being, and resident safety. The available literature served as a template in the development of these principles by highlighting major areas of discussion.12
The process continued with an initial sorting (which we performed) of the identified issues and concepts into broad categories for placement in a draft document. During a nine-month period, we made presentations for extensive national-level discussions and consultations, which included a review of the principles by residents at local and provincial levels. The written and verbal feedback received from this national consultation process resulted in refinement of the issues and iterative incorporation of revisions into the document as a means of ensuring validation with peers and colleagues at the local, provincial, and national levels. Except for us, no established educators were formally involved in the review of the principles document.
At the culmination of this extensive consensus-based process, the resulting document, “Principles of Quality Postgraduate Medical Education,” was approved and adopted by the CAIR board of directors in April 2006 for public dissemination as an organizational document. This document appears in Appendix 1. The principles were divided into four main categories: (1) general principles, (2) educational issues, (3) certification, and (4) infrastructure issues.
How CAIR Will Use the Principles—Communicating the Residents' Perspective
The exercise of creating “Principles of Quality Postgraduate Medical Education” has been an extremely informative experience for CAIR, for two reasons. First, it allowed the organization to wrestle with and then clearly articulate issues and concerns pertaining to the residents' educational experience, which the organization will now take into account when advocating with its partners. Second, these principles are now recognized as a valuable and unique tool through which CAIR can communicate with its collaborative partners regarding the residents' perspective on a variety of issues. In addition, the principles will be used by CAIR in a number of ways with respect to evaluation, education, and quality assurance.
CAIR actively collaborates with other Canadian medical organizations and the Canadian federal government to ensure that the residents' perspective is represented, especially with reference to issues pertaining to and either directly or indirectly affecting PGME. “Principles of Quality Postgraduate Medical Education” will be used by CAIR to evaluate proposals pertaining to the Canadian medical education system that are submitted by other stakeholder organizations for residents' discussion and input.
We have presented these principles to initiate a discussion on the issues of education and evaluation from the residents' perspective at an international educational workshop at the 2006 RCPSC Annual Conference.13 The workshop received an overwhelmingly positive response, and several participants spoke about how they would use what they had gleaned from workshop to spur discussions with colleagues, pursue additional learning activities, and even reexamine the rotation-specific goals and objectives and the evaluation methods that they used for their residents.
One of us (J.M.) has used these principles as the framework for revising CAIR's existing preaccreditation survey questionnaires for RCPSC and CFPC residency training programs. As a part of the accreditation process, and with the assistance of CAIR resident survey members, the RCPSC and CFPC conduct on-site visits of their training programs on a six-year cycle. The Pre-Accreditation Survey Questionnaire is a detailed tool designed to examine, from the residents' perspective, all of the major areas that are pertinent to a resident's educational experience. As such, it often provides valuable insights into strengths and weaknesses of the training program that may not have been readily identified over the course of the on-site visit by the survey team.
The goal of PGME is to prepare physicians to improve the health and health care of the general public through continuing the education of graduated physicians. The PGME system must ensure that the trainee acquires both an adequate knowledge base and sufficient clinical experience to allow a determination that he or she is a safe and expert independent practitioner. As the AAMC policy guidance document1 stated,
The quality of residents' education and the well-being of residents themselves are among our most solemn professional obligations. Persistent calls for reforming GME to better meet these obligations have come both from within our community and from external sources. We must heed these calls, not because government regulation is the likely alternative if we do not, but because it is the right thing to do.
The guiding principles described here are the first such set of principles to be written from the residents' perspective, and thus they make a unique contribution to the medical education literature. Issues relating to PGME typically have been resolved at either the local level through the university or at the national level by the RCPSC or CFPC during accreditation. These principles serve as a valuable tool to ensure a consistent understanding of the residents' perspective on key issues that affect trainees and their educational experience, regardless of where the training program is situated.
These principles are intended to be used as a template to ensure that the unique perspective of residents is present in discussions affecting the PGME system. As a national organization advocating for improving resident medical education, CAIR has proposed that this set of principles be used as criteria to guide PGME and that these principles serve as a benchmark against which proposed PGME changes can be evaluated to judge both the impact of the proposed changes on a resident's training experience and their effect on the integrity and strengths of the Canadian PGME system. Given the broad, national membership of CAIR—that is, all PGME trainees, irrespective of specialty training—it may be difficult to duplicate elsewhere the national consensus process that was achieved with this project. However, these principles will serve as a template for trainees in PGME or GME systems in other countries to explore areas of strength and weakness in those systems that may affect the trainees' educational experiences.
CAIR will use these principles to fulfill the multiple functions of evaluation, education, and quality assurance as it seeks to strengthen Canada's PGME system and ensure a positive educational experience for all resident trainees. These principles also open the door for future educational research to explore the effect of these principles on the PGME system, their relevance to medical education systems in other countries, and even the faculty perspective on the principles.
The authors wish to thank Cheryl Pellerin for her administrative support and advice and Maria Athina Martimianakis, Nancy McNaughton, Dr. Glendon Tait, and Dr. Brian Hodges for their editorial assistance.