Nasca, Thomas J. MD; Heard, Jeanne K. MD, PhD
In their fascinating exploration of the perspectives of physicians, residents, and hospital managers taking part in the national revision of residency training in the Netherlands (initially in obstetrics–gynecology and pediatrics), Wallenburg and colleagues1 use a targeted survey technique to explore the range of perspectives on the “modernization of medical training.” This modernization, they point out, is characterized by a move toward competency-based curricula and is occurring throughout Western medical education.
The “competency movement” that brought the Accreditation Council for Graduate Medical Education–American Board of Medical Specialties (ACGME-ABMS) Six Domains of Physician Competency (the Competencies)2 to the United States, then, is not unique in the world. Among many, our colleagues in Canada created the CanMEDS 2005 framework, our colleagues in Great Britain have done pioneering work in specialty-based competency description and assessment, and our colleagues in the Netherlands have begun roll-out of specialty-specific, competency-based curricula using the CanMEDS 2005 framework. In each country, the motivation to create a core of explicit, performance-based expectations merged with a desire to introduce, formalize, and demonstrate a broad set of skills related to the management and teamwork responsibilities of each physician (i.e., Systems-Based Practice in the ACGME-ABMS Competencies).
The Competencies both attempted to codify what were, in general, accepted as existing excellent outcomes (in Medical Knowledge, for example) and to produce positive change in other dimensions of physician practice (e.g., Communication, Practice-Based Learning and Improvement, and Systems-Based Practice). The Competencies were also intended to establish agreement on a core set of dimensions of each Competency in each specialty, a core set of evaluation tools to document progress of trainees in each domain of competency at each level of training, and a clear relationship between the Competencies and a commitment to lifelong learning in clinical practice through initial certification and maintenance of certification programs in each specialty.
Wallenburg and colleagues' work in the Netherlands provides us with a framework within which to examine the current context of graduate medical education (GME) in the United States. This work demonstrates four unique and often conflicting perspectives of the GME experience: the accountability perspective, the educational (outcomes) perspective, the work–life balance perspective, and the trust-based perspective. Here, we explore the conjecture that each of these perspectives is operative in the United States to a greater or lesser extent and that certain dimensions of these perspectives extend far beyond the confines of the educational environment.
The Accountability Perspective
Despite the failure of health care reform initiatives in the current United States Congress, demand for enhanced accountability and transparency of the health care system, and of GME in particular, is evident. The House of Representatives health reform bill contains language that would legally codify teamwork and other systems-based practice competencies and require government agencies to audit both the faculty's ability to teach these competencies and the ACGME's ability to evaluate program effectiveness. The Medicare Payment Advisory Commission continues to scrutinize indirect medical education reimbursement through Medicare, arguing that these costs cannot be justified at the current payment levels.
The teaching missions of our safety net hospitals increasingly must vie with the competing needs of society for use of local or state funds. Intermediary Letter 3723 set expectations related to billing for services for supervising physicians in the teaching environment and provided accountability for billing, and its impact has been significant. Although it has clarified the rules for billing, Intermediary Letter 372 has had the unintended consequence in many settings of altering significantly the foundational relationship between the supervisor and resident. The enhanced regulations affected the opportunity to create a GME environment of graded authority and responsibility under supervision.
The Institute of Medicine (IOM) has challenged the ACGME's authority to oversee resident duty hours standards.4 Indeed, the appropriateness of the profession's self-regulation of resident duty hours and other dimensions of the learning environment has been challenged on multiple occasions.
Finally, the impact of the IOM's groundbreaking explorations of medical-error-related mortality in hospitals5 has spawned a zero-tolerance-for-error culture which challenges us to devise a model of experiential education that also ensures patient safety, both for residents' patients today in the teaching environment, as well as their patients tomorrow, when they enter the unsupervised practice of medicine.
The level of scrutiny and accountability illustrated in these examples is not unique to GME. Continuing medical education, undergraduate medical education, board certification programs, and licensure have all been subjected to similar or greater levels of scrutiny. This is a manifestation of society's movement from trust of the medical profession to a more skeptical viewpoint, manifested by demands for accountability and transparency. Only through transparency and accountability can we gain, regain, and reaffirm the trusting relationship with the public that is essential to ensure adequacy of training and maintenance of competence of practicing physicians.
The Educational Perspective
In medical education, we have a greater responsibility than do most other disciplines to not only ensure that our graduates have been exposed to a curriculum that meets national standards for breadth and depth of experience but also to demonstrate that our graduates can actually perform the duties of a specialist in their chosen discipline. Prior to graduation, each resident must demonstrate that he or she is capable of practicing independently. Currently, specialty boards and GME programs are moving toward a clearer, specialty-specific articulation of the core elements of each of the Competencies that must be mastered before entering the unsupervised practice of medicine. In this fashion, we will be able to ensure the public of the level of performance of each graduate, not only in Medical Knowledge but also in the five other Competencies. Eventually, the outcomes observed will drive local curriculum development to optimize outcomes of trainees, with the aspirational goal of optimizing the care of patients.
This seemingly clear, unambiguous goal raises many questions, however. Most obviously, are there precisely six Competencies? Should Procedural Skills be a separate Competency? Do we have psychometrically sound tools to measure the Competencies?
These are all valid questions, and they must be addressed over time. However, we cannot permit perfection to be the enemy of good. We are currently evaluating residents using less-than-ideal tools. The first step in development of highly reliable, valid, and useable tools is to agree on what we want to evaluate. The Milestones Project, currently under way, is accomplishing that goal, specialty by specialty. We will develop, over time, tools to measure the elements of the Competencies with greater fidelity. Most important, we must proceed unified as a profession. As noted above, we are potentially only a vote away from codification of certain physician competencies into law. Other governments have already mandated that these directions be taken. Only with proactive, enlightened professional action to ensure that our trainees achieve the Competencies through best practices in education will such mandates be avoided in the United States.
The Work–Life Balance Perspective
In our experience, this perspective is somewhat oversimplified, especially in light of how most physicians actually practice. The movement toward a more reasonable balance between personal and professional life for physicians began long before the competency-based modernization of medical education. Furthermore, our experience with medical students, residents, fellows, and young faculty runs counter to the perspective that younger physicians are not as motivated toward the professional commitment to altruism and effacement of self-interest as we in the more senior ranks.
The clinical practice of medicine is evolving, as are the individuals entering the field, and it is our responsibility as medical educators to instill in these wonderful young individuals the ability, motivation, and desire to live a life marked by altruism and effacement of self-interest. One is perhaps born with altruistic tendencies, empathetic views of others, and other key characteristics of the outstanding physician. But one does not become an altruistic, empathetic professional without mentors who nurture those elements and create the circumstances within which those behaviors are encouraged, recognized, and rewarded.
However they choose to balance personal and professional life, physicians must practice with sufficient frequency and with sufficient volume to ensure continued competence. Whether we practice part-time or full-time, our patients deserve physicians who appear at their bedside fit for duty in all respects and who are willing and able to provide the dimensions of care required in their discipline.
The Trust-Based Perspective
As medicine and medical care march inexorably forward and medical education systems attempt to prepare young physicians for the future, certain durable dimensions must remain unchanged. Earning the trust of patients and trainees must never be confused with paternalism, nor should that trust be offered blindly. Trust between resident and faculty member is not dependent on the nature of the education system but, rather, on individual trustworthiness. Faculty members must be committed not only to their discipline but to the effective teaching of that discipline. They must maintain not only their medical expertise but also their educational and evaluative expertise. They must not only be empathetic and concerned for their patients but also exhibit this level of care for their trainees. They must encourage questioning and never resort to intimidation or retribution. And they must, to the best of their ability, model the behaviors of which they speak. If residents do not learn to trust, they do not learn to be trustworthy.
In our opinion, trust is absolutely essential if we are to meet our prime purpose: to provide healing, health, and well-being to those we serve.6 Many have written of the importance of trust as the pillar of our relationship with each patient, and our collective relationship with the public and society. There is, however, another bond of trust that is required for each physician as an individual, and the profession as a whole, to cement relationships of trust with patients and society. That bond is the trust between and among physicians, and the trust between and among the members of the microsystems of care within which we practice. Trust among physicians is based on the belief that we each possess the required attributes of the Competencies in each of our specialties, and that we can depend on each other to come to the aid of our patients whenever and wherever they need our assistance. This is the mutual respect that is the bond of any group of physicians, and any health care team, allowing each to rely on the others' skills to achieve a desired outcome in our patients, regardless of our respective disciplines or positions on the health care team. This mutual respect is the unspoken recognition of each others' contributions, and in common parlance it is called honor.7
Altruism, the quiet, persistent bravery of doing the right thing for the right reason even when not in our own best interest,8 drives us to support each other as we attempt to care for each of our patients. Whether in a managed care environment, a patient-centered medical home, a tertiary teaching hospital, a downtown health center, or a homeless clinic, each of us relies on others to help care for our patients, and in the process we cement the trust of the individual, and collectively the public, for the physician, the profession, and all the other professionals with whom we have the privilege of working.
This dimension of trust must remain in whatever “modernization of medical education” develops, in every jurisdiction of the globe. The patients of the world deserve no less.
Pursuing Purposeful Change
In summary, we believe that the perspectives on “the modernization of medical education” identified by our colleagues in the Netherlands are operative in the United States to varying degrees, both within and outside the medical educational environment. The world is changing around us, and dimensions of our current educational efforts must change in anticipation of future needs. We must be accountable and more transparent. We must reap the promise of the Competencies. We must embrace and nurture the new learners and new paradigms of clinical care delivery. We as faculty must model the behaviors we seek in our residents. However, some things must not change. We must remain trustworthy and solidify that trust in every interaction—educational, clinical, interprofessional—in order to gain, regain, and retain the trust of the public we pledge to serve.