Wednesday, June 28, 2006

Redesigning Residency Education: the Annals of Internal Medicine "Lays It Between the Lines"

The Annals of Internal Medicine featured three articles on the redesign of internal medicine graduate training programs, i.e., internships and residencies.(1-3) The articles enjoyed considerable consensus on elements of program reform, and provided important principles and some concrete suggestions. Those interested in graduate medical education would surely enjoy reading them.

The articles asserted some major problems afflict current training programs:
  • Residents do not deal with the broad spectrum of patients whom real internists must treat. "Teaching service tends to be composed of the sickest patients, many with multiple acute and chronic medical problems and complex, frustrating discharge-planning issues." "The inability to provide patient-centered care because of inadequate resources and poor continuity also drives away patients with less complex conditions, narrowing residents' breadth of experience."(1)
  • Residents often work in dysfunctional environments, particularly out-patient clinics. "Clinics often have inadequate number of personnel and inadequate physical resources and can be frustrating, chaotic places to practice." (1) "Ambulatory training experiences frequently take place in teaching clinics with many dysfunctional components...." (2)
  • Residents still must spend too many hours providing direct patient care, are not always adequately supervised, and have little time for thinking and reflection. "The educational value of inpatient teaching services can be recaptured only if services are reconfigured to ensure that residents have ...adequate time for reflection."(1) "Service needs of the training institution rather than the educational needs of the trainee have often driven the design of residency training programs. These service needs may be translated into excessive resident workloads or patient care responsibilities that do not contribute to the resident's education or career development. Excessive resident workloads, typically driven by service needs and reflected in excess duty hours or excess patient loads, have adverse effects on many aspects of the trainees' development...."(2)
They also noted some pervasive obstacles to reform. However, the three articles seemed to have difficulty expressing these directly. Maybe their authors were thinking about the immortal words of Peter, Paul, and Mary, (I Dig Rock 'n' Roll Music) "if I really say it, the radio won't play, so I have to lay it between the lines."
Below are my attempts to summarize these obstacles more directly, with accompanying quotes from the articles in support:
  • Residency training programs are under financial pressure from the teaching hospitals in which they reside. "Financial pressure on teaching hospitals has intensified, encouraging the pursuit of clinical and grant revenue at the expense of resident education."(1) "During the past 3 decades, the environment of internal medicine residency programs has been increasingly driven by service needs and financial presures of teaching institutions." (1)
  • Faculty are distracted by the need to generate money from clinical practice and research grants. "Faculty face pressures to increase clinical productivity, compete for external funding.... Such pressures discourage faculty members from assuming teaching activities and educational leadership roles." (1) "The number of full-time fauclty has grown nearly 10-fold in the past 4 decades, not for educational purposes, but principally to provide clinical services."(1)
  • Residencies are funded by the federal government, but the money goes to hospital administrators who decide how to use it, and often use it for purposes other than education. "Although funding of graduate medical education is linked to patient care services provided by residents, federal funds do not flow directly to training programs. Instead, the affiliated teaching hospital receives and distributes the money to each training program. This system places an emphasis on inpatient clinical service rather than the quality of education, regardless of where the teaching occurs."(1) "Control of graduate medical education means control of its financial support and accreditation. The sponsoring hospitals receive funds for residency stipends and teaching salaries largely from the Centers for Medicare & Medicaid Services (CMS). The hospital controls the flow of dollars to the training programs. The formulas for distributing money seem arcane at the federal level and mysterious at the local level." (3)
  • Hospital administrators force trainees to perform service to the hospital to the detriment of their education. "Hospital administrators, reacting to fiscal pressures, have used the resident workforce to accomplish tasks that could be performed just as well by other health care practitioners. Hospitals have also expanded residency programs to meet increasing service demands without considering the untoward effects on resident education"(1)
  • Physicians and educators do not control residency programs, hospital executives do. "Internists do not control the resources needed to effect change in residency education. Hospital executives and accrediting institutions wield the power to effect change."(3)
So hospitals are paid by the federal government to provide graduate medical education, but hospital executives take the money and spend it on other things. So that leaves residents with too much service work, and little time for education. Ditto for their faculty. Thus, reading somewhat between the lines, these articles make a case that the leaders of teaching hospitals often ignore the hospitals' core mission, that which makes them teaching hospitals, even while they are taking money from the federal government which was meant to support that mission.
To put it politely, these articles suggest that there is a widespread failure by teaching hospital administrators and executives to fulfill their "duty of obedience," their obligation as leaders of not-f0r-profit organizations to fulfill their primary mission, which is to teach as well as provide patient care.
Here is how Fitzgibbons et al suggest a solution, also politely:

"The allocation of graduate medical education funding should be transparent, with a portion specifically designated for direct support of residency training programs. Program directors should work with hospital leadership to ensure that residents' time is well utilized from an educational perspective. Teaching hospitals must demonstrate institutional competence, which includes appropriate distribution of educational funds, mechanisms to resolve the conflicts between service and educational needs, and a commitment to supporting efforts to enhance the learning environment. "(1)
To put it more directly, in my humble opinion, administrators and executives of teaching hospitals should uphold their organizations' mission. If they fail to do so, they need new jobs, and to perhaps suffer other disincentives. Fitzgibbons et al above suggest that some teaching hospitals have shown institutional incompetence. That is a disgrace. But things will not change until they are held accountable. Physicians, especially those who are supposed to be training the next generation of physicians, should be the first to call for their accountability.

1. Fitzgibbons JP et al. Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine. Ann Intern Med 2006; 144: 920-926. (Link here.)
2. Weinberger SE et al. Redesigning training for internal medicine. Ann Intern Med 2006; 144: 927-932. (Link here.)
3. Schroeder SA, Sox HC. Internal medicine training: putt or get off the green. Ann Intern Med 2006: 144: 938-939. (Link here.)

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