To the editor,
I read your editorial on transitioning from training to practice and was reminded of the following: Recently, when I saw a postoperative patient following a tibial plateau fracture, she asked me when she would be allowed to walk on her injured leg. I explained — as I did before and right after surgery — that I recommend 3 months for all of my patients. She paused for a moment. “Why 3 months?” she asked. Before I could give an answer, she added, “What changes on that day?”
I explained that although there is average healing time in the population, there is always a range, or a distribution. While it may be that she is above average, we do not know a great way to estimate, let alone know for sure. This is true for her or for any patient. We are always in pursuit of perfection, but in an attempt to cover 95% to 99% or more of our patient population, we play it safe; or put another way, we stay inclusive to maximize outcomes for as many patients as possible.
Similarly, our residents are given 5 years of training followed by about 1 month of vacation, and then magically our residents become independent practitioners. While this time-threshold change is a source of discomfort to many of us, especially in light of contemporary discussions of competency-based training, I pause to wonder whether we are trying to push progress without the tools to do so.
There are many ways to change the transition from dependent to independent, but I will focus on competency-based training, as it is becoming the vogue for discussion. In order to make such a system succeed, there are five essential elements that we must accept: First, training competencies that predict future independent practice actually exist. Second, we, as a profession, can agree on which of these to target. Third, we have a way to accurately measure these competencies. Fourth, we can develop training methods that can modify (improve) competency skills globally. Fifth, our training format can accommodate such measurement and training methods in an individualized fashion. My impression is that we are making some headway into the second and third elements, have little insight into the first, blindly achieve the fourth most of the time, and have no idea how to achieve the fifth element even if given a mandate to do so.
My last comments center on the idea of somewhat “blindly” achieving proper education and training for the vast majority of our residents. Through years of educational evolution (individual, institutional, national), our profession has appropriately trained the vast majority of our residents. Improvements most certainly need to be made, especially in terms of efficiency. However, we should not fear or be perplexed by a time-threshold based advancement system per se. We use it precisely because it effectively and broadly covers the needs of almost everyone in a nonmodular system (like a surgical practice or residency). Although it seems blind, it is not blind at all.
Instead of attempting to personalize and modularize something that is not (residency, fellowship, first year or two of practice), we should instead focus on developing the tools to (1) educate principles and skills that predict future independent practice from a set that we agree to, (2) find ways to accurately measure acquisition of these principles and skills, (3) and develop training methods that can modify (improve) them.
I will argue the following for discussion: Keep them all for 5 years or maybe 6 (as time and experience alone have great value), design programs that will properly educate 95% of our residents with special deviations for the exceptional (at both ends), and let them be free to take the next step (as we do our patients). If we have educated them well (which is our responsibility), they will find their own transitions.