In the evolving health care environment, medical educators must deliberately and effectively ensure the preparation of the next generation of physicians to provide high-quality patient care. Based on the perceived value in preparing future physicians, competency-based medical education (CBME) is becoming the cornerstone of medical education programs.1 The fundamental principles of CBME include the following: (1) Medical education should be grounded in the health care needs of the patient population; (2) the focus of training should be on learner attainment of desired outcomes; and (3) the continuum of education, training, and practice should be seamless.2 At this time, the continuum from undergraduate medical education (UME) to graduate medical education (GME) is far from seamless,3–6 and there is a need for more meaningful communication at this important educational transition point. Participants in the American Medical Association’s (AMA’s) Accelerating Change in Medical Education consortium7 recently engaged in a series of discussions about how to improve the UME-to-GME transition with a communication at the end of medical school. In this Perspective, we describe the problems in the current state and make 5 recommendations to the medical education community to frame the next steps for addressing these issues and generate a research agenda to inform policy and best practices.
Although we discuss a UME-to-GME educational continuum, this is not the lived experience for our learners.8,9 From their perspective, there is minimal alignment in the development of knowledge and skills from UME to GME.9 Recent CBME efforts, such as the Accreditation Council for Graduate Medical Education (ACGME) milestones10 and the Association of American Medical Colleges (AAMC) Core Entrustable Professional Activities for Entering Residency,11 have striven to standardize and connect the desired outcomes of UME and GME; however, there is still a lack of acknowledgment of learners’ different developmental trajectories.12 Medical school graduates are not uniformly meeting residency entry-level competency expectations,4,13,14 yet many students are not using the final year of medical school to enhance their skills or to address their deficiencies.15,16 A communication at the UME-to-GME transition is necessary to promote a continued awareness of the developmental arc of individual learners.
Efforts to improve communication at the UME-to-GME transition have mostly focused on the residency application process. The Medical Student Performance Evaluation (MSPE), which remains the primary method of communication, is transmitted along with the medical school transcript to residency programs as part of the application package for the Match.17 In 2016, the AAMC MSPE Task Force released recommendations to improve standardization of the MSPE across medical schools and to have the MSPE “highlight the 6 ACGME core competencies when possible.”18 The utility of the MSPE hinges on the quality of the data populating it, and there are increasing concerns regarding the objectivity and reliability of clerkship assessments and grading.19–21 As more medical schools embrace principles of CBME,22 the quality of competency data included in the MSPE should improve.
Even with these advances in the MSPE, there are multiple challenges with communication between UME and GME programs.23 First, the competitive residency application process creates disincentives for medical schools to provide complete and transparent communications of student performance to residency programs. Medical schools’ match rates are used as quality and reputation indicators, both in terms of percentage of students matched and the quality of the matched programs. There is a perception among UME educators that any relative areas of weakness will not be tolerated by receiving GME programs and that sharing such information would put students at risk of not matching. Second, since the MSPEs are transmitted to programs on October 1, very little information from the final year of medical school is included. This year is a time when critical deficiencies in students’ performance should be addressed, knowledge and skills consolidated, and additional skills learned to prepare for residency. Finally, residency programs receive large numbers of applications but have limited resources to review them, which creates a push for the use of standardized scores or norm-referenced data to differentiate applicants. Thus, there is limited communication of criterion-referenced competency data at this critical educational transition.
While patient handovers have been accepted as vital for the transfer of information and planning for upcoming care, this sense of importance and accountability has not been embraced for the purposes of planning for learners as they transition from medical school to residency. There is an opportunity—indeed, a duty—for medical schools to engage students and educators in a similar process to provide a trustworthy and responsible handover of educational information.24 An educational handover at the conclusion of medical school would serve several important purposes. It would both encourage and document learner growth since it would include information about student progress during the final year of medical school—including the achievement of core entry-level residency competencies. Keeping a spotlight on performance during the final year would also incentivize intentional, individualized curriculum development. Additionally, the educational handover could be a driver to foster students’ development of self-directed learning (SDL) practices throughout medical school. SDL is a process that involves learners seeking feedback; identifying their own gaps in knowledge, skills, and attitudes; and formulating plans to fill these gaps.25 SDL is often limited during medical training because of lack of feedback, challenges with gap identification, and difficulty with plan formation.26 An educational handover from UME to GME would serve as an opportunity to address these challenges25 and allow the graduating medical student to be an engaged participant at this key educational transition point.
Pilot experiences with ACGME milestones–based handovers transmitted to residency program directors at the conclusion of medical school have been conducted by the University of Michigan Medical School for students entering emergency medicine,27 surgery,28 pediatrics,29 and obstetrics–gynecology residencies.30,31 Other pilots have been initiated at Oregon Health & Science University, Virginia Commonwealth University School of Medicine, University of Virginia, and Vanderbilt University School of Medicine. Table 1 provides brief descriptions of the competency frameworks used and communication goals at these institutions. These pilots have set the groundwork for improving communication from UME to GME programs. To encourage implementation of the educational handover, there is a need to articulate shared recommendations that can inform policy and best practices.
Five Recommendations for the Educational Handover
In April 2018, the Warren Alpert Medical School of Brown University hosted a meeting of the 32 medical schools that comprise the AMA’s Accelerating Change in Medical Education consortium. The meeting included a debate on the optimal timing for communicating information about the competence of medical students as they transition to residency. Two of the authors (H.K.M. and D.H.) presented short perspectives, pro and con, about providing measures of learner performance as part of an educational handover from UME to GME. Following the 2 presentations, approximately 30 people participated in a breakout discussion facilitated by another author (G.C.M.). The wide-ranging discussion explored the educational handover from the perspectives of UME leadership, residency program directors, students, residents, faculty, administrators, and national thought leaders.
After everyone had ample opportunity to share their thoughts, concerns, and questions regarding an educational handover and the initial issues raised during the session, the facilitator asked all participants to make up to 3 recommendations regarding educational handovers. These recommendations were shared verbally with the group and written on whiteboards distributed throughout the room. The group then participated in a verbal process to cluster the recommendations around themes. During the ensuing discussion, 10 distinct themes emerged and were written on one of the whiteboards. Each participant was asked to vote (using a dry-erase marker) for up to 3 themes so that a prioritized list could be created. The voting revealed a clear consensus for 5 major themes. One of the authors (G.C.M.) used notes from the session to formulate recommendations from these themes to frame potential next steps for developing a UME-to-GME educational handover. The 5 recommendations were presented to all conference participants and a reactor panel (composed of national leaders in medical education, as well as a resident and a student) at a large session on the last day of the conference. These themes and recommendations, slightly revised, are shared below.
The purpose of the educational handover should be to provide medical school performance data to guide continued improvement in learner ability and performance.
The educational handover should occur after the Match because the goal of sharing the information is not for resident selection but rather for resident preparation. From day 1, new residents serve on the front lines of patient care.32 By understanding entering residents’ skill levels, program directors will be better able to prepare trainees for the delivery of safe clinical care. The handover will make it explicit to learners that there are expectations of them that are derived from a social compact; that is, they have a responsibility to their patients and the profession regarding continuous improvement throughout their professional career. It will also communicate the importance of acknowledging individuals’ different developmental trajectories in acquiring the knowledge and skills necessary for patient care.
The process used to create an educational handover should be philosophically and practically aligned with the learner’s continuous quality improvement.
The educational handover should not be the first time students engage in SDL or self-reflection. The process should start early in medical school and should include multiple cycles of data collection, feedback, and reflection by learners on their own performance and opportunities to obtain coaching. Further, there should be a clear expectation of goals, a timeline for the achievement of these goals, and ample time to initiate efforts to make improvements. The intent is for cycles of assessment, learning, and improvement to occur continuously through the learner’s educational and practice experiences.
The educational handover should be learner driven, with a focus on individualized learning plans (ILPs) that are coproduced by the learner and a coach or advisor.
Although performance data are critical, learners should be empowered to take an active, rather than passive, approach to their own development to be optimally prepared to begin residency. Coaches and advisors will need to guide the development of the ILPs since many learners struggle to identify their learning gaps and goals.26,33 The ILPs included in the handover should serve to guide the trainee’s transition into residency and help the residency program provide appropriate support. These ILPs could transition into a platform for the semiannual residency program reviews between the resident and the program director.34
The transfer of information within an educational handover should be done in a standardized format.
The standardized format and content of the educational handover should primarily align with the needs of the recipient, who will be using the information to make decisions about the learner’s readiness for aspects of patient care. In the case of the UME-to-GME transition, this means that the needs of program directors should be clarified and that their perspectives should guide the selection of content for the communication. Additionally, the appropriate framework for the communication needs to be determined.
Together, medical schools and residency programs must invest in adequate infrastructure to support learner improvement.
The infrastructure needed to support learner improvement includes, but is not limited to, the following: coaches and advisors to help learners process data; systems that can provide performance data to learners; opportunities to improve performance before residency, such as transition-to-residency courses; and the ability to design and implement ILPs. These infrastructure investments at the medical school and residency levels will be necessary to put the theoretical principles of CBME and SDL into practice.
Challenges and Next Steps
Current practices around the UME-to-GME transition drive medical students to focus on appearing to be competitively prepared for residency; an educational handover could be an important step toward a more seamless continuum that encourages learners to focus on actually preparing for the care of patients. Successful implementation of such a handover, however, will require a fundamental culture change across the continuum regarding the purposes and practices of assessment.
A formalized educational handover could communicate to all stakeholders the current competency of the graduating student and reinforce the premise that every physician—in training and in practice—has areas for continuing growth. Executed properly, the provision of meaningful feedback and learning support at the time of transition has the potential not only to enhance trainee well-being35 but also to improve patient safety36 as students transition into residency roles with increased levels of responsibility for patient care. While we hope that medical educators will embrace the handover recommendations, there are many challenges related to incentives and priorities that need to be addressed for the UME-to-GME educational handover to be operationalized on a large scale.
The initial challenges lie within medical schools. Historically, UME programs have focused more on the delivery of content (process), with less emphasis on assessing the performance of individuals or teams (outcomes). Authentic workplace-based assessments coupled with a formative feedback process are necessary for the UME-to-GME transition to evolve toward a competency-based continuum of learning. Improving the quality of criterion-referenced assessment data requires an institutional culture that supports continual improvement processes of both the health system and the individuals working within it.19,20 Attaining such a state will require a significant investment of resources that may be difficult for some medical schools to support; however, encouraging exemplary programs are emerging.22,37 These institutions are collecting competency-based assessment data from the start of medical school and using that performance evidence to drive a structured process of iterative ILPs that supports continually striving toward excellence. These programs have also developed the curricular flexibility needed to adapt to learners’ performance deficits, providing learners with targeted experiences aligned with their developmental needs.
Regarding the actual handover of information from UME to GME programs, Family Educational Rights and Privacy Act (FERPA) regulations apply.38 It is important to remember that while medical school graduates are transferring from one educational setting to another (residency), they are also transferring from an educational setting to an employment setting. FERPA protects the privacy of learners in both contexts. The handover communication will need to comply with FERPA. In addition, learners’ perspectives on this communication need to be elucidated—engendering learners’ trust in the process will require careful attention to validity and equity.
From the GME perspective, trust is also an issue. As we implement responsible handovers, bidirectional feedback loops will be an important aspect of the improved educational continuum. Currently, GME programs provide limited feedback to medical schools about the performance of their graduates. While individual medical schools send surveys about their graduates to program directors, standardization of these survey forms is needed to support meaningful communication from GME to UME institutions. Without this standardization, the process will be overly onerous for program directors. Medical schools should be incentivized to address deficiencies in their curricula or assessment structures if program directors report that their graduates are not optimally prepared for residency expectations. Improving this bidirectional communication will be an essential aspect of improving trust between UME and GME programs.
The effort to create an educational handover will only be justified if GME programs are positioned to use the information to support the successful transition of early residents. Similar to UME programs, GME programs face challenges in gathering assessment evidence and adjusting each trainee’s experience accordingly. Ideally, program directors would use the content of the educational handover to implement curricular modifications. In some cases, thoughtful placement of incoming residents in specific clinical services would be indicated. Such flexibility in curricular assignments and clinical scheduling is currently not available; schedules are created based on factors such as vacation requests and service needs and not necessarily on the competency-based developmental needs of individual trainees. Therefore, a plan for use of the handover will be needed.
Although the execution of these recommendations will be challenging, this is the time for grappling with the complexity of these issues. Pilot innovations by the Education in Pediatrics Across the Continuum (EPAC) project36 and the Consortium of Accelerated Medical Pathway Programs (CAMPP)39 have begun to address some of the complexities of implementing competency-based transitions between medical school and residency. Both of these initiatives have limited their pilot groups to medical students who are selected to match to residencies at their own institutions. Now we have the opportunity to generalize the lessons learned from the EPAC and CAMPP pilots to build toward individualization of the learning process40 for all trainees on both sides of the UME-to-GME transition.
It is also important to acknowledge that no single institution or organization will be able to solve these complicated issues—these challenges need to be tackled in a cooperative fashion. An appropriate next step may be to convene responsible UME and GME stakeholders. Since medical school graduates migrate across educational and health care systems, there is incentive for a shared responsibility to support the optimal preparation of new residents. A collaborative medical education continuum that focuses on learners’ individual developmental trajectories from UME through GME would support the vision of a physician training system that is continually striving to provide patients with the best possible care.
The authors wish to thank all of the American Medical Association’s (AMA’s) Accelerating Change in Medical Education consortium members who participated in and contributed to the discussion.
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