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Supporting Our Residents: A Time for Vision and Voice

Sklar, David P., MD

doi: 10.1097/ACM.0000000000002242
From the Editor

July is the month of transitions at academic health centers (AHCs) as graduating residents leave, new interns arrive, and other residents move up to their next levels of responsibility. Some faculty will suddenly be supervising less-experienced residents and thus must recalibrate expectations and become prepared to step in and take over care responsibilities for cases that had previously been routine. Yet in spite of the disruptions and surprises seemingly lurking around every corner, there is also a palpable buzz of excitement that infects everyone—the nurses, the clerks, and even the most grizzled attendings. Part of this reaction is amusement when watching new interns get lost in a stairwell, or seeing new residents’ bewilderment when they must suddenly provide consultations about problems they may never have encountered. But part of it is also the opportunity to see the world, and the medical system in particular, through new eyes.

For example, the intoxicated homeless man who visits the emergency department regularly and usually is allowed to sleep for awhile and leave with little testing or treatment several hours later can become transformed in July. To the new interns, the man is a fascinating case of altered mental status with signs of head trauma. He needs a head CT scan, a battery of blood tests, intravenous fluid, and consultations from psychiatry, social work, neurology, neurosurgery, and internal medicine. The differential diagnosis of this man’s condition has expanded, the durations of his visit and nursing care have increased, and while little may be gained from all of this scrutiny, sometimes our old assumptions about a chronic patient such as this one are proven wrong. A new intern may find a subdural hematoma or a sodium level that is dangerously low or signs of blood loss, all of which need treatment. The new eyes come without the old biases but also without the experience that has guided the use of scarce resources over the past year. Faculty can also be transformed as they develop relationships with new learners and begin the long process of building trust and providing feedback while creating a safe care environment for patients.

The July transitions offer a fresh perspective that can inspire us to find solutions to problems that have resisted our efforts in the past, like improving value in our health care system. It is also a time to reflect on our problems in graduate medical education (GME), the needs of our residents, and the progress we have made in finding solutions. In this editorial I look back at some of the problems that we have discussed in Academic Medicine over the past five years and then focus on some recent areas of concern and on additional areas I believe bear close watching over the coming year.

During the last five years Academic Medicine has published (1) a special workforce issue in December 2013 with many articles related to GME, its challenges, and its responsibility to provide our various communities the kinds of physicians who will meet their needs; and (2) a GME-focused issue in September 2015 that gave context and historical perspectives in GME. My editorials1 , 2 in both these issues offered my visions for solutions to the problems being discussed. I also wrote an editorial3 after the publication of a report on GME4 in 2014 by the the Institute of Medicine (IOM) that critiqued that report’s recommendations and gave some options for improving them. In addition, the other editors of Academic Medicine and I challenged readers with the 2014 Question of the Year5: “How can we ensure that our graduate medical education system will prepare trainees for practice in new systems of care delivery?”

Much progress has been made over the past five years, as evidenced by the examples of innovations in GME recently cited by Thibault6 in our journal. Most recently, in October 2017, a workshop sponsored by the National Academies of Science, Engineering, and Medicine focused on GME metrics and outcomes and provided a continued impetus for change that was initiated with the IOM report.7 While many valuable suggestions have been made for improving GME, implementation has been complicated by changing political priorities and lack of political agreement about the role of government in health care, medical education, and workforce development.

At the same time other issues have become priorities for GME, in particular resident burnout and wellness, competency-based medical education (CBME), curricular development and assessment, the need for better alignment of GME goals with those of the clinical delivery system, and the selection process for GME. I will focus the rest of this editorial on these recent issues, which have been increasingly discussed in our journal.

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Resident Burnout and Wellness

Dyrbye et al8 have noted that the percentages of burnout in medical students and residents are higher than for persons in comparable age-matched populations. Fortunately, leaders of the NAM, the Association of American Medical Colleges, and the Accreditation Council for Graduate Medical Education have taken on the problem of clinician burnout as a joint priority and are leading a NAM-sponsored work group to characterize the burnout problem and offer solutions.9 There will likely be recommendations from this collaborative that will apply to the needs of residents as well as other learners in the clinical environment.

Shanafelt et al10 identified factors associated with clinician burnout: excessive workload, clerical burden and inefficiency in the practice environment, a loss of control over work, problems with work–life integration, and erosion of meaning in work, all of which are prominent in GME. The authors recommend addressing burnout by reducing documentation requirements and national regulatory burdens, creating institutional supports, and fostering individuals’ self-care habits, all of which would be helpful to residents.

In this month’s issue, Edmondson et al11 provide a particularly poignant resident perspective:

I felt as if I was running nonstop along a hamster wheel, constantly exhausted and fatigued but going nowhere. Every hour of every day was spent fighting and pleading and being yelled at, occasionally by attending physicians and all too often by consulting physicians and other staff who seemed to feel pleasure at making me feel small and wanting me to acknowledge my inexperience with every interaction. On top of that, I was embarrassed by the extent of my depression and afraid to schedule an appointment with a psychiatrist. So, I put on a mask and performed an imitation of a happy, successful young physician while the suffering continued to boil below the surface.

Edmondson et al identified aspects of the hospital and educational environment and culture that could be changed to provide a culture of wellness. When I read the words of the anonymous resident quoted above, I realize that in spite of our many well-intended efforts to educate the next generation of physicians, we have failed to recognize the severe stress encountered by many of our residents in the course of their training and have not done enough to create a supportive learning environment. If there is only one issue among the priorities for improvements in GME that we address, I hope that will be it, because without a healthy cadre of residents, our other educational initiatives will fail. Similarly, if our teaching faculty are burned out, they will not have the energy, enthusiasm, or creativity to forge the critical relationships of trust with residents that underlie our educational programs, which are increasingly competency based. Thus approaching the needs of residents and faculty together offers the most comprehensive solution to burnout in GME.

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Competency-Based Medical Education

CBME, which focuses on the achievement of specific capabilities through exposure to problems, reflection on their meaning, and practice for improvement with feedback, has grown and spread through all specialties and health professions. The trusting relationship with faculty is a critical component of CBME because the faculty are responsible for the patient care and the workplace-based assessment of the resident and provide the vital link between patient safety and medical education in GME.

The mastery of a competency has been conceptualized as a journey with various stopping points along the way, known as milestones, that trainees need to reach and that can be described and assessed. Another valuable CBME concept is an entrustable professional activity (EPA), which typically describes an activity, such as the delivery of a baby, that may encompass several competencies—such as communication, patient care, medical knowledge, and professionalism—and requires supervisors to judge how much trust and what level of independence they will give a trainee to perform the EPA.

While each specialty has defined milestones and EPAs in its own way, the effect of a common language has unified the CBME framework. In this issue, Edgar et al12 describe the areas of overlap between specialties in the milestones related to the competencies of communications, professionalism, systems-based practice, and practice-based learning. This overlap demonstrates a substantial consistency in the steps to achieving competency. Also in this issue, Young et al13 describe the development of end-of-training EPAs in psychiatry, which can serve as a methodological model for other specialties that are considering using EPAs as part of CBME. Both articles attempt to provide guidance for residents and faculty who are attempting to identify appropriate ways to measure the achievement of competence, including competence in areas outside of medical knowledge and patient care.

A current challenge of CBME is to train residents and faculty how to participate in a workplace-based assessment that includes effective feedback. Hoang and Lao14 in this issue discuss the use of mixed methods in assessment so that “the weaknesses of quantitative analysis are compensated by qualitative analysis, and vice versa.” Also in this issue, Sargeant et al15 describe a feedback approach that involves relationship building; exploring a resident’s reactions to feedback; the resident’s understanding of the feedback’s content; and coaching, which includes a plan to guide the resident’s future learning and reflection. One resident described aspects of the process in the following way:

Traditionally, feedback focused on what the person didn’t do well. But that doesn’t give the person much insight into how to improve. So, sitting down to talk about the specific strategies … like who the learner can seek help from, definitely helps.

In their study, the authors noted that success of the feedback model depended particularly on the relationship between the resident and the faculty member. They suggested that their model fits well within current frameworks of formative feedback, coaching, and practice.

CBME also has implications for the duration of training because some residents may achieve competence ahead of or behind the traditional schedule of rotations. A time-variable model for residency education has recently been reviewed by Lucey et al.16 They assert:

Competency-based, time variable education views health professions education as a continuous process, beginning when a student enters a health professions school and ending when that individual retires from the profession…. Advancement through the stages of formal education and into practice is based not on the passing of time but on the demonstration of trustworthiness.

The time-variable CBME approach offers the opportunity to individualize training for each resident but will provide logistical challenges for rotation scheduling and coverage of clinical care responsibilities that have often been based on the clinical needs of hospitals, not the educational needs of residents.

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Alignment of GME and Clinical Care Delivery

Integration of the competencies with quality measures for patient care can help align GME with care delivery priorities and demonstrate that the quality of medical education and the quality of clinical care are intimately linked. Excellent medical education cannot take place without excellent clinical care. In this issue, Schumacher et al17 provide an example of how quality measures that are sensitive to resident behavior can be developed. They assert that “educationally sensitive patient outcomes intentionally map a provider’s education to his/her abilities and then to intended outcomes for patients.” They identified likely activities of residents who were caring for patients with asthma, bronchiolitis, and closed-head injuries that could affect the outcomes of patients and could link educational quality with clinical care quality.

Caverzagie et al18 go further by suggesting not only that quality measures for clinical performance be linked to resident competency assessment but also that the GME program be evaluated and receive payments partially based on the health system’s performance on patient care quality measures. They defend this approach by noting that “the value of care provided at teaching hospitals should serve as a predictor of future practice patterns of graduates.” They propose payment for GME based on performance in the areas of value and cost of care, access to care, reducing disparities, patient safety, physician well-being, and other important patient care and educational parameters. The funding approach described by Caverzagie et al would be a radical departure from the traditional separation of educational program assessment and clinical care assessment and would reinforce recommendations of Sklar et al19 for alignment of medical education and clinical care delivery through a common purpose and payment incentives. Such an approach would also prepare residents for the practice environment they will face upon graduation, which will pay clinicians partly on the basis of their performance on quality measures.

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Residency Selection

Finally, there has been increasing attention focused on the selection process for residents. This process has become increasingly stressful, inefficient, and expensive. The use of United States Medical Licensing Examination (USMLE) Step 1 Board exams to screen applicants for interviews for residency has affected the learning priorities of medical students, who realize not only that they need to pass the exam but also that they have to achieve a high score to stand a chance of an interview for many residency programs. Prober et al20 note:

Beyond concerns about inappropriately using the absolute USMLE score as a sole screen for residency applicants, there are additional unintended consequences to placing so much emphasis on applicants’ USMLE scores. We regularly learn of students who have decided to abandon their plans to apply to certain specialty areas because they believe that their application will not be considered in the initial screening process because of a USMLE score around the median. This often is despite other achievements that might suit the student for that specialty. Other students who have high scores are encouraged to pursue the more competitive specialties because they might otherwise “waste their intelligence.”

The authors recommend more attention to performance on clerkships and the demonstration of clinical reasoning, professionalism, and functioning as part of a team.

I also am concerned that use of the USMLE exam as a screening tool may disadvantage underrepresented students, who may have entered medical school with lower scores on the Medical College Admission Test that would tend to predict a lower score on the USMLE exam. By overvaluing the scores of the USMLE exam in the selection process, we may be undervaluing the importance of diversity and holistic admissions in our GME programs.

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Financial Threats on the Horizon

There is one other issue on the horizon that bears watching in the coming year. This issue relates to the 2014 IOM recommendations on transparency, accountability, and financing that thus far have not been followed.4 At the time of the IOM report there was concern that GME funding through the Medicare system was at risk and that having better information about how Medicare funds were being used and how they met important governmental responsibilities to the public would help prevent funding cuts. Now with recent tax and budgetary decisions that increase the prospect of growing federal budgetary deficits, there may be renewed pressure on entitlement programs, including Medicare, to be cut to make up for some of the deficit. While GME Medicare funding is a small part of total Medicare funding, it still represents billions of dollars annually that could be used to reduce current and future governmental deficits.

Without a clear rationale for how the Medicare funding of GME is improving access and quality of care for Medicare recipients, reducing costs of care, and increasing transparency for the use of the funds from hospital to hospital, it will be more difficult in the future to advocate GME funding. Some AHCs provide barriers to access of care for Medicare patients in spite of accepting Medicare funding for their GME programs. Such behaviors could increase scrutiny of the Medicare financing of GME. At the state level, Medicaid funding for GME may also come under scrutiny as Medicaid programs undergo a general reassessment. In addition, the inadequacy of the physician workforce, particularly for rural and underserved populations, may undercut requirements for residency training needed prior to licensure for independent practice, as discussed by Orlowski.21

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Encouraging Developments and the Challenge Ahead

As I reflect on the continued evolution of the GME system, I am mostly encouraged; many of the issues discussed above, like the selection process for residency, are within the control of our community, and our community is presenting good ideas22–24 for solutions. I also am encouraged that the current focus on resident burnout and the growth of CBME will lead to an examination of the clinical learning environment and relationships between faculty and residents. Our faculty and residents have substantial control over the clinical environment. Without the residents and faculty, the teaching hospitals and clinics would not function. But many decisions that have led to distress in our current clinical environment have not adequately addressed the impact of changes on our faculty and residents. Electronic medical records, staff support, clinical hours, and child care are examples of areas where support is connected to the well-being of our students, residents, and faculty and their ability to provide safe, high-quality care and form trusting, productive relationships. Resident empowerment as described by Thibault6 is certainly part of the solution. Such empowerment fosters trust, and I believe our AHCs will be the better for supporting it.

The voices of faculty, residents, students, and other health professionals are not being heard above the din of chaotic changes blowing across the health care system. At some point, and I hope it is soon, those voices must deliver a loud and cohesive message that makes the case for supporting GME and health professions education and how such support will help our country achieve the best health possible at a funding level that we can afford. Our health care community must help carry those messages forward to institutional and political leaders. Academic Medicine looks forward to publishing articles that assist our residents and faculty in developing and disseminating their messages and in carrying out more effective advocacy.

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© 2018 by the Association of American Medical Colleges