Residency Redesign in Internal Medicine American College of Physicians (ACP) Society of General Internal Medicine (SGIM) Association of Program Directors

Residency Redesign in Internal Medicine

American College of Physicians (ACP)Society of General Internal Medicine (SGIM)Association of Program Directors in Internal

Medicine (APDIM)

Common Themes

Interest in Internal Medicine, especially General Internal Medicine has declined, in part because training differs from practice.

Increase ambulatory training.– Quality of ambulatory clinics must improve.– Consider block outpatient (and inpatient) time.

Develop core curriculum, with reasonable expectations for achievement.

Common Themes (cont’d)

High-quality training must be linked to high-quality, patient-centered care.– Emphasis on EBM, quality improvement,

patient safety, cultural sensitivity, health disparities, professionalism, life-long learning

– Close resident supervision with graded independence

– Better assessment of resident competency

Residents must have experience and training in multidisciplinary team care.


Maintain three-year residency with flexibility to innovate.– ACP and APDIM propose two years “core”

training, with third year tailored to individual career goals.

– SGIM suggests reconsideration of meaning of Board certification.

Assign residents on the basis of educational needs, acknowledging risks.


Faculty teaching should be monitored, assessed and rewarded.– Faculty development essential– Promotion and rewards for educators

GME funding needs to be unlinked from hospital-based care.

ACP and SGIM suggest revision of medical school curriculum.

American College of PhysiciansOverall Goals

High quality, relevant experience with satisfied trainees

Effective education to facilitate acquisition of necessary competencies

Acquisition of the abilities needed to remain current and to understand and adapt to changing circumstances of healthcare

Weinberger SE, Smith LG, Collier, VU. Redesigning training for Internal Medicine. Ann Intern Med. 2006;144:927-932

ACPConcerns

Interest in general Internal Medicine careers down (54 to 27% from 1998 to 2003), possibly from:– Stress during residency– Inadequate ambulatory experiences– Unenthusiastic senior resident and faculty role

models


ACP RecommendationsUndergraduate

1. Use premedical education to decompress 1st year

2. Flexible 3rd year with well-functioning practice environments

3. Enthusiastic role models4. Late 3rd-4th year

1. Revisit pathophysiology, mechanisms of disease2. Understand translation of knowledge into practice3. Improve analytic, interpretive skills, preparing for life-

long learning4. At least one high-intensity clinical experience


ACP RecommendationsGME

1. Structure of residency– Retain 3 year duration

2 years of “core” training

1 year “customized” (future generalist: hospital and/or ambulatory emphasis; future subspecialist: “complementary” experiences)

2. Integrate education and service, limiting patient load per resident


ACP RecommendationsGME (cont’d)

3. Enhance ambulatory training– Increase ambulatory time– Eliminate dysfunctional clinics– Create block ambulatory time (no inpatient)

4. Utilize team care (including ambulatory/inpatient teams)

5. Develop “core” teachers with specific education competencies, reward them


ACP RecommendationsGME (cont’d)

6. Stress professionalism– Patient-centered, culturally sensitive,

evidence-based care– Patient partnerships– Lifelong learning– Self-evaluation, self-reflection– Social activism on behalf of patients


Society of General Internal MedicineConcerns

Ambulatory training seldom adequate– Inadequate infrastructure for longitudinal care– Case mix disproportionately complex– Time insufficient to develop continuity skills– Variable quantity, quality of block rotations

Vacations taken during block

Ambulatory residents are back up if emergency absence elsewhere

Holmboe ES, Bowen JL, Green M et al. Reforming Internal Medicine TrainingJ Gen Intern Med 2005; 20:1165–1172.

SGIMConcerns

Changed inpatient setting– Patients sicker, LOS shorter with residents

time taken with non-clinical tasks– Multidisciplinary teams have replaced

physician-centric model– Work hour rules promote fragmentation– Error research implicates poor supervision,

evaluation, teaching


SGIMConcerns

Problematic curriculum– No consensus as to core curriculum– Little study of best educational

setting/experience for acquisition of specific elements

– No definition of minimal competency to be achieved in each content area


SGIMConcerns

Little specific instruction re health disparities and cultural competency

Little specific instruction re life-long learning

GME financing does not match training needs, educational settings


SGIMRecommendations

1. Patient-centered care taught by example of high-quality interdisciplinary care

2. Better inpatient-ambulatory balance

3. Explicit teaching re health disparities, including teaching in social sciences

4. Define “core” knowledge, skills, attitudes

5. Greater flexibility in certification and in pathways to specialization


SGIMRecommendations

6. Better resident evaluation, a moral and ethical responsibility

7. Redesign clinical work, educational processes around interdisciplinary teams

8. Better supervision by faculty

9. Link GME funding to training environments that lead to satisfactory patient outcomes


SGIMRecommendations

10. Specific preparation for life-long learning

11. Reforms in undergraduate and continuing medical education as well

12. Collaboration to foster education research and disseminate best practices


Association of Program Directors in Internal Medicine

ConcernsEducation not patient-centered, linked to patient safety

Residents not exposed to career options

Interest in IM, especially GIM, is down

Core principles for redesign:– Link high-quality education and patient care– Redesign must be comprehensive

Fitzgibbons JP, Bordley DR, Berkowitz LR et al. Redesigning resident education in Internal Medicine:a position paper from the Association of Program Directors in Internal Medicine Ann Intern Med. 2006;144:920-926.

APDIMConcerns and Solutions

Educational environment– Too much inpatient emphasis– Sick inpatients not followed as outpatients– Outpatient clinics often chaotic– Poor outpatient care drives all but the sickest

away, distorting outpatient learning experience



Educational Environment: Solutions– Assign residents based on educational need– Continually evaluate effectiveness of

education– Emphasize on EBM and team approach to

quality and safety– Use carefully graded supervision



Inappropriate inpatient rotations– Insure diversity of diagnoses, time for reflection– Provide team leadership experiences– Use hospitalists

Ineffective ambulatory experiences– Provide continuity of care with team– Explore use of community-based practices– Provide ambulatory block rotations (no inpatient)– Teach QI principles in ambulatory setting


Restrictive Program Requirements– Allow for innovation, e.g., IM-RRC’s

Educational Innovations Project

Outdated curriculum– Develop core curriculum



Outdated curriculum (cont’d)– Maintain 3-year duration

Year 1: Balanced experience in ambulatory, inpatient, general, subspecialty

Year 2: Supervisory experiences and increased independence

Year 3: Tailored to career goals. Focus on team leadership skills and provision of safe, efficient, cost-effective care



Faculty issues– Monitor and assess faculty teaching– Provide for faculty development– Change promotion and reward system

GME funding– Transparent allocation to match to

educational needs– Evaluate “competence” of teaching hospitals


APDIMRisks/Obstacles

Student life-style, compensation issues

Dysfunctional health care system

Expense of competency-based advancement of residents

Residents not vital to hospital operation may become observers and expendable.

“Ideal” training environment may not prepare for later experiences.


APDIMRecommendations

Immediate– Year 3 experience with multidisciplinary team

leadership, instruction in systems-based practice, clinical quality improvement and patient safety

Short term (1-2 years)– Define core knowledge, skills, attitudes– Individualize Year 3– Institute faculty development programs– Experiment with new approaches, e.g. EIP

Long-term (3-5 years)– Change faculty promotion and reward systems– Change GME funding

Documents

Residency Redesign in Internal Medicine American College of Physicians (ACP) Society of General Internal Medicine (SGIM) Association of Program Directors