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Considerations for Physician Training in a New Era of Medical Education

Robson, Jacob

Journal of Pediatric Gastroenterology and Nutrition: February 2013 - Volume 56 - Issue 2 - p 111–112
doi: 10.1097/MPG.0b013e31827fc770
Invited Commentaries

University of California–San Francisco, San Francisco, CA.

Address correspondence and reprint requests to Jacob Robson, MD, University of California–San Francisco, Fellow in Pediatric Gastroenterology, 500 Parnassus Ave, MU408E, Box 0136, San Francisco, CA 94143 (e-mail:

Received 7 November, 2012

Accepted 26 November, 2012

The author reports no conflicts of interest.

See “Assessment of Nutrition Education Among Pediatric Gastroenterologists: A Survey of NASPGHAN Members” by Lin et al on page 137, and “Methods and Effects of a Case-based Pediatric Gastroenterology Online Curriculum” by Feist et al on page 161.

During the last 20 years, the landscape of physician training in the United States has changed at an incredibly rapid pace. The most notable changes include the recent limitation of trainee work hours (1) and a new focus on trainee attainment of minimal core competencies before progression to unsupervised practice (2). Physicians who trained even 10 years ago may hardly recognize the framework for resident and fellow training today. These changes have effectively forced training program leaders to branch out beyond traditional didactic education sessions and trainee assessments with generic rating scales. In this issue of the Journal of Pediatric Gastroenterology and Nutrition, 2 innovative educational efforts are chronicled, capturing the grassroot efforts to identify best practices in this new era of medical education.

In their article “Methods and Effects of a Case-based Pediatric Gastroenterology Online Curriculum,” Feist et al (3) discuss the challenges of presenting a comprehensive didactic gastroenterology curriculum to residents and students during an inpatient rotation. With work hours restrictions necessitating frequent patient pass-offs and limiting trainees from providing continuous care to patients from admission to discharge, predesigned case-based curricula ensure trainees are exposed to key pediatric gastroenterology topics and patient presentations during their rotation. Feist et al astutely point out the difficulties in assembling the full team for didactic teaching during the busy workday, with several residents now on “night team” duty and others breaking off to handle acute patient care issues or to attend continuity clinic. So to allow learners autonomy to complete the curriculum when it works for their schedule, they instituted an innovative case-based online curriculum, followed by live conferences to summarize teaching points. This is one of the first publications in the pediatric literature that documents an effective case-based curriculum, with residents demonstrating both improved medical knowledge and self-confidence with the material after the course (4). This predefined teaching curriculum also ensures that residents will receive a uniform educational experience on key gastroenterology and nutrition topics, rather than a random sampling of “zebras” from the inpatient ward or topics specific to the attending physician's field of interest. One shortcoming of this curricular assessment is that it only shows whether trainees gained medical knowledge and self-confidence. This has been a recurring issue in competency-based education. Although we have paper/pencil tests to assess medical knowledge and learner self-report scales to follow confidence levels, the assessment of competency acquisition in areas such as communication, professionalism, and systems-based practice has been much more difficult (5). As curricula such as this continue to emerge, it will be important to expand the scope of assessment to include the application of medical knowledge, along with the integration of other core competencies (eg, professionalism, practice based learning), into observed patient care interactions. Lastly, because self-report of confidence tends to outpace actual care delivery skills (6), it will be important to use assessment data not just from the learner and supervisor but also from patients, parents, nursing staff, and colleagues—a true 360-degree approach.

In “Assessment of Nutrition Education Among Pediatric Gastroenterologists: A Survey of NASPGHAN Members,” Lin et al (7) perceived a need for improvement of nutrition curricula and then conducted a survey of clinicians in the field that confirmed the inadequacy of present educational methods. Similar to Fiest et al, Lin et al document the need to make educational tools available to physicians in a nontraditional format. Journal articles and review books were noted to be less desirable formats for continuing medical education than Web-based modules, which are interactive and can be used at the learner's convenience. Additionally, an overarching theme of this article was the importance of accountability in medical training. Stemming from recent Institute of Medicine reports that document wasteful spending and inadequate quality in patient care, the Accreditation Council for Graduate Medical Education has redirected its focus in physician training to ensure production of competent physicians who are well trained to serve the needs of the American public. Lin et al contribute here by documenting that physicians do not feel adequately trained in nutrition counseling, and even experts in the field (NASPHGAN members) have large holes in their nutrition knowledge. Nutrition counseling is an example of an educational domain that uses skills from multiple Accreditation Council for Graduate Medical Education core competencies, including medical knowledge, patient care, communication, and systems-based practice. Nutrition counseling could be referred to as an “Entrustable Professional Activity,” a key, easily observable activity in medical training that can be used to assess trainees’ professional progression and readiness for additional responsibility (8). Once nutrition counseling is effectively brought into educational curricula, it is then paramount to document that this education eventually translates to patients’ improved nutritional knowledge and better food choices. Ultimately, we need to measure the outcome of such training on our patients’ overall health.

For too long, curricula in medical education have gone unchallenged, leading to a lack of best practices that are truly evidence based. Only now are we challenging notions that overtired residents may not learn well and that trainees who have not hit certain key milestones in their career development may not be ready for unsupervised practice. This is an exciting time in medical education because we are finally pushing ourselves to be accountable to our patients and American society as a whole, exploring new ways to tailor care delivery to the needs of the consumer. It is our duty to change the scope and practice of medical training, as society and the medical delivery systems change. Although individual publications such as those discussed above will not change the face of education on their own, they serve to form a foundation for a growing body of literature from which we can establish the best way to train doctors and to assess their ability to improve and deliver excellent care.

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