On October 4 – 5, 2013, the American Medical Association hosted the “Accelerating Change in Medical Education Conference” in Chicago, IL., bringing together leaders in the realm of medical education for discussions aimed at “closing the gap between current physician training and the needs of our evolving health care system.”
At the conference, many of the discussions focused on the undergraduate portion of medical education at medical schools. However, I also attended a lively discussion of the accreditation process for graduate medical education—also known as residency—led by Dr. Timothy Brigham, MDiv, PhD, a senior vice president of the ACGME, the accreditation board that certifies residencies as meeting the standards of training in their field.
As he noted in his talk, “every system is perfectly designed to perform the result it produces.” While this quote is one that is commonly repeated within quality improvement literature, he reflected on how it applies to medical education as well. When residents and program directors are being held to facts-based standardized exams and static lists of requirements that are dissociated from patient care, how can we expect them to develop empathetic doctors or innovate on their educational programming?
His concerns about the medical education system are not theoretical. The erosion of empathy throughout residency is well-documented. With the advent of duty hours, it becomes even more imperative for residencies to train doctors not based on volume alone, but on deliberate learning. Furthermore, many studies have demonstrated that physicians practice the way they are taught:no matter where they end up, doctors have similar clinical outcomes as their residency program did.
When thinking about the ACGME’s work in this way, it is clear how high the stakes are. However, when the ACGME’s new regulations required program directors to document improvements in clinical competency, altruism, teaching and outcomes in their residents, program directors protested. By changing their requirements without changing the underlying system, the ACGME was forcing residency directors to confront the shortcomings of the system without giving them the tools to actually improve resident education.
As this ACGME leader describes it, the ACGME wants to improve the graduate medical education system by altering the list of requirements from being purely prescriptive to a list of formative “milestones” that more directly reflect a resident’s development throughout residency. This new system would be focused less on punitive action and more on supporting residencies in the process of iterative improvement.
There are many parts of this improved system, including a different schedule for ACGME visits and a renewed focus on outcomes, but a key component that stuck out to me was the Milestones Project. The essential idea is that as they go through graduate medical education, residents should move from being “advanced beginners” in various competencies towards becoming “competent” or even more than competent, as shown in the figure below.
Each specialty will develop milestones that allow their faculty providers to note where an individual resident is on this progression. For example, an intern may still be at the beginning stages of the “managing health care systems” competency, but may have demonstrated “advanced beginning” or even “competent” levels of “clinical reasoning.” Each specialty society has already been asked to develop milestones relevant to their specialty, which detail exactly which dimensions of a resident’s progression should be rated and what the resident needs to demonstrate to reach each stage on that progression. Here’s an example from internal medicine:
The hope is that since this evaluation is based on a progression, faculty raters will not feel compelled to give every resident an arbitrary 7 or 8 out of 9, but select their rating based on where they feel that resident is in their development. Additionally, the evaluation is meant to be completed by at least 10 faculty members to determine the final rating (to be completed twice yearly) to insure a more reliable result.
Obviously, with any new system—particularly a system as far-reaching and with such high goals as this one—the risk that the system will not work out as planned with the initial implementation is very high. For one thing, the new evaluation method greatly increases the burden on faculty to critical evaluate each resident, and forces that effort to be spread over a much greater number of dedicated teaching faculty than ever before. It also makes the assumption that given this information on each resident, residencies will be able to provide the individually tailored training needed according to each resident’s educational needs.
Promisingly, in implementing this new system, the ACGME is taking its cues from the quality improvement literature; their new system and its implementation is based around iterative cycles of improvement. These milestones have already been tested with some success in the Singaporean medical training system. In implementing the milestones in the United States, the ACGME is beginning with only certain specialties before expanding the program to all specialties. For the sake of my future education and the education of my classmates, I wish them all the success in their endeavor.