To the Editor: I have recently reviewed an article by Harber and Ducatman, “Training Pathways for Occupational Medicine” (2006;48:366–375). I appreciate the authors’ many insightful comments, questions, and approaches to define and achieve necessary competencies and ideal training products effectively, but I do not believe that the perceived and cited disadvantages of the “Nontraditional Residency Training Programs” are representative of at least two of these programs: University of Pennsylvania Medical Center/Penn’s Practicum Program and Medical College of Wisconsin/MCW’s MPH Program. I became a diplomate of the American Board of Preventative Medicine (ABPM) – Occupational Medicine (OM) via the “nontraditional” residency pathway and had completed these two programs. I have been working in the field of occupational medicine as a physician and consultant in Portland, Oregon, for over 10 years.
In a state (such as Oregon) where there is no traditional occupational medicine residency program, the nontraditional pathway is essential and probably the only feasible way for physicians who need the training to become occupational medicine specialists through the ABPM examination. Most such midcareer physicians cannot leave their states of residence or compromise their practice and family obligations for 2 years to complete the academic/MPH and practicum training. The two nontraditional programs are not “single-mentorship models” or “convenient educational approaches” to overcome short-term constraints; they are excellent programs producing competent occupational medicine specialists who are comparable to other specialists on the same measures, whose skills are valued and in high demand locally and nationally. Nontraditional training requires high levels of commitment, devotion, discipline, time, intellectual and practical energy and efforts from everyone involved (trainees and trainers).
Most, if not all, nontraditional residents are midcareer individuals who enter their formal innovative training with significant learning, socialization, clinical experience, and high motivation. The residents are constantly evaluated by their program directors, advisors/instructors, and onsite supervising physicians who are occupational medicine board-certified and have expertise in the field of occupational medicine and other related specialties. There are unified standards and objectives for all the required courses/projects/subject areas. The residents must demonstrate understanding and application as well as synthesis and evaluation of knowledge and skills through many academic and clinical proficiency evaluations, monitoring, feedback, and examinations. The Accreditation Council for Graduate Medical Education (ACGME) and the Council on Education for Public Health (CEPH) requirements are met, and outcome data from the training programs demonstrate high effectiveness in producing occupational medicine specialists at expert levels measured by course work and clinical training evaluations and examinations, the ABPM board certification examinations, professional advancement, reputation and success in providing expertise and services in the field, as compared with traditional residency programs.
The socialization certainly occurs consistently and continuously throughout (and after) the residencies, within the didactic and clinical settings, simultaneously and separately, in person and through electronics or other communications. This approach provides an ideal and balanced experience with practical training in the “real world.” Although each resident’s practice site may be unique in some aspects, consistency in requirements, processes, and evaluations are the same like in other academic centers. In fact, academic centers often require residents to travel to “real-world” settings to obtain the same type of training using the same requirements, processes, and evaluations. Academic center training as well as the innovative training provide multiple mentors who are academics and practitioners. The Penn program has a superior record measured by a variety of outcomes, eg, performance on the ABPM examination and professional advancement. However, the questions and estimates on the supply, demand, delivery, and satisfaction of the “market needs” of occupational medicine specialists in the future should be answered with further objective and continuous evidence.
Having completed the MCW and Penn programs, I find them to be excellent training opportunities for residents and fellows to acquire effective training. The major emphases placed on the thought process and values of the field with consistent individual and group interactions among faculty, trainees, onsite supervisors, and other occupational health professionals are highly valued. The data indicate many graduates of these two programs have performed very well on the ABPM board examination.
The faculty and mentors in these two programs are great sources of inspiration and guidance for the residents’ training and expansion of knowledge and skills. Fellow residents also share their special experiences and knowledge through many evidence-based presentations and discussions. Onsite supervisors/advisors are very supportive and committed to the residents’ training and provide ample opportunities for supervised, “hands-on” experiential learning, especially after identification of the areas in which they have deficiencies or less exposure. The residents, the faculty, and mentors all work together to ensure the employment job duties (approximately 35 hours per week) and the training/educational hours (additional and noncompensated 35 hours per week) will encompass the comprehensive educational goals. The innovative model of training offers at least as much, if not more, clinical supervision than the traditional model. Although the residents endure long hours of hard work, intellectual challenges, creative thinking and analysis, time management, and social adjustment, they are all highly committed to the success of the training; they are an effective team of trainees with high morale. The residents spend a great amount of time in the clinics or worksites to practice, study, research, and collect data for projects and presentations and to master the knowledge and skills required of a specialist in occupational medicine.
The innovative nontraditional approach provides not only the ACGME-required essential and comprehensive training in depth, but also the breadth and diversity of occupational medicine practice encountered by residents from different states, communities, and locations. The two programs provide networking opportunities with faculty, other specialists/professionals, and peers to improve learning and proficiency in essential and specific issues. At Penn, the 12 intensive on-campus monthly visits, the four onsite visits (by the core faculty to each resident’s practice worksites), and the constant communications among the faculty, the resident, and the onsite supervisors/mentors ensure the optimal planning, learning, teaching, discussions, observations, close monitoring, evaluation/feedback, quality assurance, and success of the residents. These programs provide the essential tools, means, and opportunities for training of many highly competent and motivated physicians.
The authors noted, “If residents are considered so experienced that they do not need clinical supervision, it then becomes unclear that they benefit from the mentored professional growth in the (nontraditional) residency setting.” Before entering the nontraditional pathway, my colleagues and I asked a similar question of whether the residents must commit and devote such great amounts of additional time and energy to prove our competency and credentials. It was made clear to us that physicians who graduated from medical schools or non-ABPM specialty training must complete formal occupational medicine residency training to sit for the ABPM occupational medicine board examination. In addition, my colleagues and I want to ensure adequate academic and clinical proficiency in all of the core and related competency areas required for occupational medicine specialization. The Penn Practicum Program and the MCW’s MPH program have successfully provided the necessary education and training to help us address society’s needs.
Gina Sheedy, MD, MPH
Occupational Medicine Consulting Services
Lake Oswego, Oregon