THE
AMERICAN OPHTHALMOLOGICAL SOCIETY GUEST LECTURE SOME ISSUES IN GRADUATE MEDICAL EDUCATION* BY Robert G. Petersdorf; MD (BY INVITATION) PRESIDENT
ASSOCIATION OF AMERICAN MEDICAL COLLEGES
INTRODUCTION FIRST, LET ME SAY HOW PLEASED I AM TO BE WITH YOU TODAY. I AM
delighted that this distinguished group of ophthalmologists has seen fit to find time on its program to talk about graduate medical education. The Association of American Medical Colleges is deeply immersed in these issues as a parent of the ACGME, the LCME, and as the home of the Council of Academic Societies, the part of our organization that houses the faculty. Although the AAMC is an organization of institutional rather than individual membership, the institutions that the Association represents reflect the faculties that comprise them. The activities that the Association supports in its advocacy role-teaching, research, and patient care-represent the activities of individual faculty members. I believe it is very important for the Association and faculty organizations such as yours to work together. Graduate medical education, the training of housestaff and fellows, has always been at the heart of the AAMC's faculty activities. In 1967 the Coggeshall report, which is the basis on which the modern AAMC was built, made among its recommendations the following: *Presented at the One Hundred Twenty-Sixth Annual Meeting of the American Ophthalmological Society, The Homestead, Hot Springs, Virginia, May 23, 1990. TR. AM. OPHTH. Soc. vol. LXXXVIII, 1990
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1. The AAMC should seek positive and active relationships with key organizations interested in all aspects of education for the health sciences. 2. The AAMC should encourage greater participation in its affairs by individual faculty members. In October 1968, the AAMC sponsored a conference on "the role of the university in graduate medical education." A review of the discussion groups at the conference evokes a certain sense of deja vu. The questions posed included: 1. Who should control graduate medical education? 2. To what extent should the content of graduate medical educational programs be determined by the specialty boards? 3. Should residency training programs be controlled by the hospital or by the medical school? 4. How should graduate medical education be financed? Lest you be discouraged, and think that no progress has been made, let me assure you that at least one of the issues has been decisively settled in the last two decades. No one is now asking, "what should be done about the internship?" However, not all of the participants in that conference 20 years ago warrant an "A' in prognostication. One prominent speaker at that conference wondered about the effect on medical education of "the vanishing medical indigent." Would that were true. But some things never change, and some of the topics I will cover today will reinforce that truism. Before I begin to share ideas about graduate education with you, I want to put them in a contextual framework. A little over 2 years ago, the Association of American Medical Colleges adopted a major policy statement on housestaff hours and working conditions. 1 This occurred during a period of intense public scrutiny and debate over the conditions under which young physicians train. The scrutiny had been prompted by the Libby Zion case in New York, the consequent grand jury investigation, and the deliberations of the New York State ad hoc advisory committee on emergency services. These proceedings were widely reported in the media, and many professional organizations, in addition to the AAMC, sought to respond to this public challenge to improve working conditions in graduate medical education. We advocated an 80-hour work week-but not the ornaments on the Christmas tree that are part of the New York State regulations. The AAMC's internal discussion of the position paper on residency was intense and prolonged and reflected the diverse constituencies of the Association: the faculty and academic leaders of medical schools, students about to enter residency training, and hospital administrators in whose
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facilities residents train. Devising the AAMC position required thorough consideration by each of these different constituencies as well as compromises, so that the position arrived at made sense not just for one component of the AAMC's membership but for the entire academic medical center which is AAMC's constituency. I would like to suggest to you today that as we discuss graduate medical education, in general, we do not, as some do when discussing these issues, consider them in an adversarial format such as dean versus program director, or medical school versus teaching hospital as though the mission and objectives of these separate parts of the academic medical center are competitive rather than complementary. In our academic medical centers, the medical school and teaching hospital consist, after all, substantially of the same people, called faculty in one setting and medical staff in another. Our challenge is to work within this framework to achieve rational education programs. I believe that it is quite possible, and indeed necessary, that major changes occur in graduate medical education in the next decade. I also believe that these changes are more likely to be beneficial for the profession if all the concerned components of the academic medical center work in collaboration to achieve them. Let me pose, then, eight issues in graduate medical education that I believe need attention, and which require a sustained effort from all parts of the academic medicine community: 1. Innovation in education. Innovation is needed throughout medical education. The Association made this point most forcefully in its report on the General Professional Education of the Physician concerning Baccalaureate Education and Medical School Preparation, the GPEP report. Ebert and Ginzberg2 have suggested a redefinition of the medical school in graduate medical education. They propose that medical schools devise a program of four consecutive years of clinical training, in effect combining what is now the last two years of medical school and the first two years of graduate medical education. Quoting from their article in Health Affairs; "There are two reasons for this (proposal). First, much of the fourth-year medical student's time currently is spent on elective courses outside the framework of a coherent educational plan. During this year, the student devotes an inordinate amount of time, effort, and money applying for residency training, a process that involves visits to numerous teaching hospitals around the country. Second, if the clinical faculty had an opportunity to plan four years of clinical experience
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rather than two, more effective use could be made of the time through the design of a more rational curriculum." I believe that this is an interesting proposal, and that it is fundamentally sound. I have long been a vocal critic of the fourth year of medical school, in which it seems that our students learn more about the advantages of competing frequent flyer programs than they do about clinical medicine. If we are able to produce a more meaningful and better structured fourth year, then we may be able to put together a six-year program combining medical school and residency that would allow us to graduate an undifferentiated primary care practitioner. The principal difficulty in implementing the proposal is that GME is now separated from medical education by a distinct barrier. It is akin to having to cross a border when moving from one country to another, not only intellectually and conceptually, but also physically. This physical movement would come to a halt if the Ebert-Ginzberg proposal were implemented. This would be a major change, because, as it stands, today GME is a fairly autonomous system. Because the receptors for implementing this proposal are not available, I am not advocating the wholesale retooling of American medical education to implement it. But I do think it is an interesting idea that might be tried at a few schools and hospitals that can work together in a consortium setting. Educational innovation is definitely needed. While this proposal might go further than we want to go now, I would like to see academic medical centers-medical schools and hospitals-work together to achieve a more rational bridge between undergraduate and graduate medical education. Moreover, the concept that medical and graduate education are a continuum warrants consideration for the sake of economy and better manpower planning. In its most logical form this might require that a student remain in the same institution and its affiliated hospitals for both undergraduate and graduate training. This would mean the loss of one of the luxuries of our educational system, the ability to move from institution to institution between medical school and residency. However, in a progressively constrained external environment, this may be a price we have to pay. 2. New settings for clinical education. I do not wish to reiterate the obvious: -There is a decreasing number of inpatients in many of our teaching
hospitals. -The character of these patients has changed from having relatively mundane diseases to critical illnesses which have transformed many hospitals into giant intensive care units. -As a consequence of these developments, we need to move more of
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our teaching operation into the outpatient setting and into other less traditional inpatient settings like nursing homes. Although there has been much recent emphasis on the need to identify ambulatory settings for undergraduate teaching, I believe that clinical experiences in such settings are an equally essential part of residency training. The medical school and its affiliated hospitals are going to have to work together to develop linkages with clinics and physicians' offices where such training can take place. We must also realize that ambulatory teaching requires financial subsidy. To the extent that medical schools have control over a part of their budget, why not earmark some of that budget explicitly for teaching in the ambulatory setting? I do not think that teaching hospitals can shoulder the expanded budgets that an ambulatory teaching facility requires. It will take more than money, however. We need to retain or hire a cadre of faculty who feels more at home in the ambulatory setting than do most full-time academicians who have been raised on procedures and nurtured in critical care units. Many have found it useful to consider parttime or full-time employment of clinical (voluntary) faculty to achieve these goals. Many of these individuals who are excellent teachers and excellent clinicians are ready to make a change in career options. I have seen several examples where these people have made the transition easily, gracefully, and where they have made enormous contributions to the teaching setting. It is also fair to say that, based on a study done by the Association, internal medicine, in contrast to family medicine and pediatrics, has not done well in moving its training programs from the inpatient to the outpatient arena. In general, the surgical disciplines, with the notable exception of ophthalmology, also have not done well. 3. Assuring competency. Assessing the clinical skills of residents is a key component of any effective system of physician competence. The environment of the residency program provides an excellent setting for an ideal evaluation system which defines what is expected, observes performance, and reports on what was done and what needs improvement. Too frequently we find these elements missing in our residency programs. A recognition that evaluation needs are not always met is a challenge to our faculties. One could argue that a return to the earliest model of education and evaluation by preceptors is the appropriate route to take. However, within the range of material now taught, and the numbers involved in the education enterprise, such a model is no longer practical, and we must turn our attention to ways to make evaluation work in our
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current educational settings. Traditional evaluation tools such as the essay question or the multiple-choice examination are not sufficient to provide the type of evaluation needed. We must identify new evaluation models that assure validity, reliability, and fairness, and that will enable our faculties to do a better job. A few years ago, the AAMC undertook its clinical evaluation study, and learned a great deal about how medical schools evaluate students' clinical learning and skills. In the words of Edward Stemmler, then Executive Vice President of the Medical Center at the University of Pennsylvania, and now Executive Vice President-designate at AAMC, "What was striking and unexpected, although it should not have been, was the lack of understanding by faculty members of what was expected of them as evaluators. . . . the written evaluations recorded about each student's performance are essential to the understanding of the overall quality of each student. Yet, many of the faculty members felt themselves to be untrained for this task and unwilling to write negative evaluations even when they were quite willing to give negative evaluations verbally to the academic staff In a community of scholars accustomed to making assessments based upon objective data, few faculty members seem to be willing to write down their feelings. Yet, these feelings expressed by seasoned clinicians about developing clinicians are probably of great value."3 This statement is as true for housestaff as it is for medical students. I was the first chairman of the Committee on Clinical Competence of the American Board of Internal Medicine. After the oral examination was phased out, we instituted the hospital visit program and a series of program directors dinners. By these means, we trained, as best we could from a distance, the program directors to evaluate their residents in internal medicine. The clinical competence program in internal medicine has come a long way since its institution 15 years ago, but it still has a long way to go. As one who had made 48 visits to individual programs between 1978 and 1986, I saw the evaluations administered first-hand. Most were good and are getting better, but many also lacked intellectual rigor. I must be frank and state that the least effective clinical evaluation exercises were carried out in some of our major teaching hospitals where all residents were, ipso facto, considered clones of Osler. It is easier to evaluate residents in small training programs such as exist in your discipline. However, small size, in and of itself, does not assure thorough evaluation. It simply makes it easier. You still need a commit-
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ment to evaluation and a system to carry it out. The evaluation of young physicians is a professional responsibility that must be exercised by physicians, either in their role as faculty at the medical school as well as within the context of their specialty discipline as they certify residents completing their program. 4. Residency accreditation. The Association has a long history in calling for institutional or corporate responsibility in the accreditation of residency programs. This position is not based in an attempt to wrest authority from program directors. We advocate this because we believe that individual residency programs should be part of a coherent educational mission within a particular teaching hospital and its associated medical school. Each of us can cite from personal experience, I am sure, instances where a teaching hospital has had one or more residency training programs that were below the standards of the majority of the programs at that institution. What corporate responsibility in graduate medical education is about, is the obligation of all program directors as responsible educators to assure the quality of all of the hospital's educational programs. A difficult issue arises when Residency Review Committees mandate the size and nature of a residency or fellowship program even though that program is not appropriate for the hospital concerned. For example, a midwestern hospital located in a community replete with cardiologists objected to the Residency Review Committee's mandate to have a minimum number of fellows in cardiology despite the fact that the hospital requested a fellowship program half the size of that required by the Residency Review Committee. In my view, the rigidity on the part of Residency Review Committees in mandating the number or type of program is inappropriate. If the RRCs would work more closely with the host hospital and its medical school, the outcome might well be better for all concerned. 5. Working conditions. Earlier I alluded to the intense public and professional scrutiny that enveloped the debates about the working conditions of our residents. While much of the debate focused on the number of hours worked and the effect of resident fatigue on performance and patient care, a far more important issue, in my mind, is the need to assure that residents are appropriately supervised by faculty. There are still too many clinics, wards and operating rooms where the principle of graded housestaff responsibility is abused and where we have a serious problem with supervision of residents that should receive our immediate and personal attention. I hope that some of the same vigor that attended the debate over whether there should be a limitation of 80 working hours per
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week for residents will accompany the examination of residency supervision and will result ird implementation of needed improvements. It also seems clear that implementation of even the most modest proposals for limiting housestaff hours will require a number ofchanges in hospital operations that may include employing other health professionals to perform tasks now done by residents, expanding residency programs, a risky venture, in view of the likelihood that these residents may not be needed at the conclusion of their training, or eliminating residency programs in favor of employing staff physicians. Whatever means is chosen to implement changes in residency training and supervision, it will cost more. If new personnel are hired, the hospital will have to expend the funds for salaries and fringe benefits; if housestaff responsibilities are shifted to medical staff, more professional fees will be incurred. I cannot see it getting cheaper. One of the AAMC's recommendations is to implement whatever changes are made slowly, being sure to keep educational goals and maintenance of quality patient care clearly in mind. Bringing this off will require our best efforts as faculty members and educators, and as members of medical staffs. 6. Financing graduate medical education. For many years medicine enjoyed the luxury of having its educational costs routinely supported by patient care dollars. Not only were resident stipends and benefits an allowable cost, but so were supervising faculty and costs incurred in the educational process such as libraries and conference facilities. The changing patterns of reimbursement to a prospective payment system and discounted contracting have placed increasing emphasis on the cost of the service being purchased. Progressively fewer third party carriers whose insurance premiums have been rising at the rate of 25% a year, and employers who have been responsible for paying most of these premiums, will tolerate the degree of cost shifting that was in vogue in the past, and almost all insurance carriers are looking for prospective, fixed or discounted reimbursement plans or are offering preferred provider contracts. To this price competitive environment, we must add a growing reluctance on the part of third party payers to pay for educational costs with any part of their service dollar. Even when a teaching hospital can compete on an economic basis, it will find itself challenged to subtract out the strictly educational costs from its service contracts. The federal government has already begun to set limits on the circumstances in which it will cover the costs associated with residency programs, and there is reason to believe that this trend will continue to be the principal source of support for graduate medical education, I can
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foresee the time where we will have to look to sources other than patient care revenues for substantial sums to support graduate medical education. We recognize that, in the future, additional funding might be needed from state and local governments, special purpose federal programs, and private organizations. 7. Autonomy of specialty boards. This country certifies to the competence of the physicians who have completed graduate training through an elaborate mechanism of specialty certification. There are 21 primary specialty boards exemplified by the broad disciplines of internal medicine, surgery, obstetrics and gynecology, pediatrics, and a number of the surgical specialties. A number of primary boards also issue certificates of special or added competence in one or several subspecialties. Each certifying board is autonomous and generally self-perpetuating. Although the board certification system assures a generally high standard of quality, it is not, in my view, trouble free. Nowadays its major ailment is a disease I have termed "certifimania. "4 Certifimania is the tendency to issue more and more certificates of special or added competence. At any one time there may be a dozen such certificates under consideration. Recent ones have varied from electrophysiology under the jurisdiction of the subspecialty Board of Cardiology and its parent, the American Board of Internal Medicine, to transfusion medicine, proposed by hematology and internal medicine, to orthopedic trauma. A recent specialty certification sponsored by the American Board of Preventive Medicine is certification of special competence in hyperbaric medicine. The proliferation of these certificates makes one wonder what a primary or subspecialty certificate really means. I remain convinced that certifimania is unnecessary. For example, if a certified hematologist does not know how to give transfusions, what does he know? Does it really make sense to add yet a third tier to a specialty such as hematology? Likewise, one may question that if an orthopedic surgeon does not know how to take care of trauma, what does the initial certificate mean? Another form of indoor sport engaged in by the boards is to add a year to the basic period of specialty training. A number of years ago a brouhaha ensued when the American Board of Pathology lengthened its training requirements from 3 to 4 years. A few years ago, the American Board of Anesthesiology followed suit, and most recently, the American Board of Pediatrics has proposed adding a year of research to the requirements in each of its subspecialties. In fact, in these pediatric subspecialties, better than a year and a half is supposed to be spent in research and less than half the time in specialized clinical training. The economic implications of these added certificates or more pro-
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tracted periods for certification should not be ignored. Usually an added certificate means a fellowship of at least one and sometimes two years of additional training. Who will pay for this training? A related economic issue is that the mere possession of such a certificate may lead to higher fees in the subspecialties in which these certificates are issued. Increasing the number of certificates results in a progressively greater emphasis on specialization, subspecialization and sub-subspecialization, while the need, as recognized by most authorities in health care, is for more broadly-trained physicians who can take care of the entire patient rather than a small part of his anatomy and physiology. There is no question that advances in knowledge and, particularly, advances in technology, have made specialization necessary, but aren't we carrying it too far? It is not difficult for a specialty board to ask for and eventually issue certificates of added or special competence. All that is required is for the board to give 180 days notice, to have a forum of interested parties organized by the ABMS before its Committee on Certification (COCERT), and, if that committee does not find adversely, to implement its new certification program. If a new area of competence is proposed, the proposal must be approved by the American Board of Medical Specialties, but the last and final word is the board making the proposal. In effect, the ABMS cannot veto a proposal to issue a certificate of special competence. If a specialty board simply changes the duration of training, but does not add a new area of training, it does not require ABMS approval at all. The members of ABMS are naturally hesitant to disapprove a proposal made by one of their sister boards lest that board recall at some future date what another board has done to them previously. It is this system that has led some of us to call for increased accountability by the boards. The major reason is that the boards are making decisions about training requirements that require longer and more expensive training that others have to pay for. The payors in this instance are the teaching hospitals and, in some instances, the medical schools. Although organizations representing them, or the hospitals and schools themselves may make a statement to a forum considering a change in board requirements, to my knowledge, once a board has given notice to issue a certificate of special competence, it has, in the final analysis, not been rebuffed. I must say, in all fairness, that while the boards may prevail eventually, it is encouraging that their petitions are being subjected to greater scrutiny. Despite these encouraging signs, a system that is not subject to impartial scrutiny by others is fundamentally flawed. In my view, a peer review process, akin to what is invoked for research or training grants,
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should be instituted by the boards. I would suggest that such a process should result in greater restraint, and certainly will improve accountability. 8. Manpower distribution. Many have thought that a graduate medical education system that has been skewed to an overproduction of specialists and subspecialists at the expense of generalists would eventually right itself through market forces. In my view, market forces are not coping with the problem. The reasons why the market is unlikely to control residency training have been summarized nicely by Whitcomb and Caswell.5 These authors contend, and I agree with them, that the market structure for residency training is imperfect at best. Medical students are generally unaware of practice opportunities, both in terms of geography and specialties. Medical students also fail to analyze correctly and carefully the cost of their education, the debt they have accumulated, the risk that they take in pursuing a particular specialty and the financial return that practice of a particular specialty is likely to bring. The system with its matching program for graduate medical education tends to emphasize the buying power of the hospitals and training programs, rather than those of the trainee. This is particularly true in popular and highly competitive specialties such as ophthalmology. Perhaps most important in career choice is the extraordinary influence of the faculty in promoting specialization and subspecialization as opposed to primary care training. On the supply side the market forces are even weaker. There is virtually no link between practice opportunities in a community or a region and the training positions in the academic medical centers located in those regions. The number of residency positions is usually determined by the desire of hospitals - particularly when hospital directors are told that more residents will make the hospital more money - desire of the medical staff, and most particularly, the desires of program directors, chairmen, and even deans. I have been pointing out for a decade the excessive influence of these groups on training opportunities much to the detriment of our health care system. The other fact that makes the supply side inefficient is that until recently the cost of the training could be passed on without question to third party payers irrespective of the need for this training. Last, but by no means least, in many specialties, there has been an almost implacable tendency for program directors to ignore signals from the market place. These signals all seem to say, enough; we do not need any more specialists and subspecialists at the rate at which you are training them.
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There are many reasons why the system of graduate medical education needs reform. Unless we devise some reforms that are perceived not to be self-serving, we will almost certainly bring down upon us draconian measures by government that will not enable us to preserve our system of graduate medical education. If that comes to pass, we will have no one to blame but ourselves. I would like to see the discussions within the academic community not degenerate into arguments about whether it is the teaching hospital or the medical school that has the responsibility for implementing changes in graduate medical education. On the contrary, we need to work together to implement these changes. After all, it is not them and us, it is us and us, and we must get the individuals on specialty boards, on Residency Review Committees, in the ABMS and on the ACGME to look at issues in graduate medical education not from a narrow parochial point of view. On the contrary, they must work together to see to it that the educational enterprise, whether at the student, resident or fellow level, will reach the potential of which it is capable and for which we all strive. REFERENCES
1. Petersdorf RG, Bentley JD: Residents' hours and supervision. Acad Med 1989; 64:175181. 2. Ebert RH, Ginzberg E: The reform of medical education. Health Aff (Suppl) 1988; 7:5-38. 3. Stemmler EJ: Promoting improved evaluation of students during clinical education: A complex management task. J Med Educ 1986; 61:75-81. 4. Petersdorf RG: The President's Column. Acad Med 1990; 65:96. 5. Whitcomb ME, Caswell J: Sounding board: The market structure of residency training. N Engl J Med 1986; 314:710-712.
AMERICAN OPHTHALMOLOGICAL SOCIETY GUEST LECTURE SOME ISSUES IN GRADUATE MEDICAL EDUCATION* BY Robert G. Petersdorf; MD (BY INVITATION) PRESIDENT
ASSOCIATION OF AMERICAN MEDICAL COLLEGES
INTRODUCTION FIRST, LET ME SAY HOW PLEASED I AM TO BE WITH YOU TODAY. I AM
delighted that this distinguished group of ophthalmologists has seen fit to find time on its program to talk about graduate medical education. The Association of American Medical Colleges is deeply immersed in these issues as a parent of the ACGME, the LCME, and as the home of the Council of Academic Societies, the part of our organization that houses the faculty. Although the AAMC is an organization of institutional rather than individual membership, the institutions that the Association represents reflect the faculties that comprise them. The activities that the Association supports in its advocacy role-teaching, research, and patient care-represent the activities of individual faculty members. I believe it is very important for the Association and faculty organizations such as yours to work together. Graduate medical education, the training of housestaff and fellows, has always been at the heart of the AAMC's faculty activities. In 1967 the Coggeshall report, which is the basis on which the modern AAMC was built, made among its recommendations the following: *Presented at the One Hundred Twenty-Sixth Annual Meeting of the American Ophthalmological Society, The Homestead, Hot Springs, Virginia, May 23, 1990. TR. AM. OPHTH. Soc. vol. LXXXVIII, 1990
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1. The AAMC should seek positive and active relationships with key organizations interested in all aspects of education for the health sciences. 2. The AAMC should encourage greater participation in its affairs by individual faculty members. In October 1968, the AAMC sponsored a conference on "the role of the university in graduate medical education." A review of the discussion groups at the conference evokes a certain sense of deja vu. The questions posed included: 1. Who should control graduate medical education? 2. To what extent should the content of graduate medical educational programs be determined by the specialty boards? 3. Should residency training programs be controlled by the hospital or by the medical school? 4. How should graduate medical education be financed? Lest you be discouraged, and think that no progress has been made, let me assure you that at least one of the issues has been decisively settled in the last two decades. No one is now asking, "what should be done about the internship?" However, not all of the participants in that conference 20 years ago warrant an "A' in prognostication. One prominent speaker at that conference wondered about the effect on medical education of "the vanishing medical indigent." Would that were true. But some things never change, and some of the topics I will cover today will reinforce that truism. Before I begin to share ideas about graduate education with you, I want to put them in a contextual framework. A little over 2 years ago, the Association of American Medical Colleges adopted a major policy statement on housestaff hours and working conditions. 1 This occurred during a period of intense public scrutiny and debate over the conditions under which young physicians train. The scrutiny had been prompted by the Libby Zion case in New York, the consequent grand jury investigation, and the deliberations of the New York State ad hoc advisory committee on emergency services. These proceedings were widely reported in the media, and many professional organizations, in addition to the AAMC, sought to respond to this public challenge to improve working conditions in graduate medical education. We advocated an 80-hour work week-but not the ornaments on the Christmas tree that are part of the New York State regulations. The AAMC's internal discussion of the position paper on residency was intense and prolonged and reflected the diverse constituencies of the Association: the faculty and academic leaders of medical schools, students about to enter residency training, and hospital administrators in whose
Graduate Medical Education
303
facilities residents train. Devising the AAMC position required thorough consideration by each of these different constituencies as well as compromises, so that the position arrived at made sense not just for one component of the AAMC's membership but for the entire academic medical center which is AAMC's constituency. I would like to suggest to you today that as we discuss graduate medical education, in general, we do not, as some do when discussing these issues, consider them in an adversarial format such as dean versus program director, or medical school versus teaching hospital as though the mission and objectives of these separate parts of the academic medical center are competitive rather than complementary. In our academic medical centers, the medical school and teaching hospital consist, after all, substantially of the same people, called faculty in one setting and medical staff in another. Our challenge is to work within this framework to achieve rational education programs. I believe that it is quite possible, and indeed necessary, that major changes occur in graduate medical education in the next decade. I also believe that these changes are more likely to be beneficial for the profession if all the concerned components of the academic medical center work in collaboration to achieve them. Let me pose, then, eight issues in graduate medical education that I believe need attention, and which require a sustained effort from all parts of the academic medicine community: 1. Innovation in education. Innovation is needed throughout medical education. The Association made this point most forcefully in its report on the General Professional Education of the Physician concerning Baccalaureate Education and Medical School Preparation, the GPEP report. Ebert and Ginzberg2 have suggested a redefinition of the medical school in graduate medical education. They propose that medical schools devise a program of four consecutive years of clinical training, in effect combining what is now the last two years of medical school and the first two years of graduate medical education. Quoting from their article in Health Affairs; "There are two reasons for this (proposal). First, much of the fourth-year medical student's time currently is spent on elective courses outside the framework of a coherent educational plan. During this year, the student devotes an inordinate amount of time, effort, and money applying for residency training, a process that involves visits to numerous teaching hospitals around the country. Second, if the clinical faculty had an opportunity to plan four years of clinical experience
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Petersdorf
rather than two, more effective use could be made of the time through the design of a more rational curriculum." I believe that this is an interesting proposal, and that it is fundamentally sound. I have long been a vocal critic of the fourth year of medical school, in which it seems that our students learn more about the advantages of competing frequent flyer programs than they do about clinical medicine. If we are able to produce a more meaningful and better structured fourth year, then we may be able to put together a six-year program combining medical school and residency that would allow us to graduate an undifferentiated primary care practitioner. The principal difficulty in implementing the proposal is that GME is now separated from medical education by a distinct barrier. It is akin to having to cross a border when moving from one country to another, not only intellectually and conceptually, but also physically. This physical movement would come to a halt if the Ebert-Ginzberg proposal were implemented. This would be a major change, because, as it stands, today GME is a fairly autonomous system. Because the receptors for implementing this proposal are not available, I am not advocating the wholesale retooling of American medical education to implement it. But I do think it is an interesting idea that might be tried at a few schools and hospitals that can work together in a consortium setting. Educational innovation is definitely needed. While this proposal might go further than we want to go now, I would like to see academic medical centers-medical schools and hospitals-work together to achieve a more rational bridge between undergraduate and graduate medical education. Moreover, the concept that medical and graduate education are a continuum warrants consideration for the sake of economy and better manpower planning. In its most logical form this might require that a student remain in the same institution and its affiliated hospitals for both undergraduate and graduate training. This would mean the loss of one of the luxuries of our educational system, the ability to move from institution to institution between medical school and residency. However, in a progressively constrained external environment, this may be a price we have to pay. 2. New settings for clinical education. I do not wish to reiterate the obvious: -There is a decreasing number of inpatients in many of our teaching
hospitals. -The character of these patients has changed from having relatively mundane diseases to critical illnesses which have transformed many hospitals into giant intensive care units. -As a consequence of these developments, we need to move more of
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our teaching operation into the outpatient setting and into other less traditional inpatient settings like nursing homes. Although there has been much recent emphasis on the need to identify ambulatory settings for undergraduate teaching, I believe that clinical experiences in such settings are an equally essential part of residency training. The medical school and its affiliated hospitals are going to have to work together to develop linkages with clinics and physicians' offices where such training can take place. We must also realize that ambulatory teaching requires financial subsidy. To the extent that medical schools have control over a part of their budget, why not earmark some of that budget explicitly for teaching in the ambulatory setting? I do not think that teaching hospitals can shoulder the expanded budgets that an ambulatory teaching facility requires. It will take more than money, however. We need to retain or hire a cadre of faculty who feels more at home in the ambulatory setting than do most full-time academicians who have been raised on procedures and nurtured in critical care units. Many have found it useful to consider parttime or full-time employment of clinical (voluntary) faculty to achieve these goals. Many of these individuals who are excellent teachers and excellent clinicians are ready to make a change in career options. I have seen several examples where these people have made the transition easily, gracefully, and where they have made enormous contributions to the teaching setting. It is also fair to say that, based on a study done by the Association, internal medicine, in contrast to family medicine and pediatrics, has not done well in moving its training programs from the inpatient to the outpatient arena. In general, the surgical disciplines, with the notable exception of ophthalmology, also have not done well. 3. Assuring competency. Assessing the clinical skills of residents is a key component of any effective system of physician competence. The environment of the residency program provides an excellent setting for an ideal evaluation system which defines what is expected, observes performance, and reports on what was done and what needs improvement. Too frequently we find these elements missing in our residency programs. A recognition that evaluation needs are not always met is a challenge to our faculties. One could argue that a return to the earliest model of education and evaluation by preceptors is the appropriate route to take. However, within the range of material now taught, and the numbers involved in the education enterprise, such a model is no longer practical, and we must turn our attention to ways to make evaluation work in our
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current educational settings. Traditional evaluation tools such as the essay question or the multiple-choice examination are not sufficient to provide the type of evaluation needed. We must identify new evaluation models that assure validity, reliability, and fairness, and that will enable our faculties to do a better job. A few years ago, the AAMC undertook its clinical evaluation study, and learned a great deal about how medical schools evaluate students' clinical learning and skills. In the words of Edward Stemmler, then Executive Vice President of the Medical Center at the University of Pennsylvania, and now Executive Vice President-designate at AAMC, "What was striking and unexpected, although it should not have been, was the lack of understanding by faculty members of what was expected of them as evaluators. . . . the written evaluations recorded about each student's performance are essential to the understanding of the overall quality of each student. Yet, many of the faculty members felt themselves to be untrained for this task and unwilling to write negative evaluations even when they were quite willing to give negative evaluations verbally to the academic staff In a community of scholars accustomed to making assessments based upon objective data, few faculty members seem to be willing to write down their feelings. Yet, these feelings expressed by seasoned clinicians about developing clinicians are probably of great value."3 This statement is as true for housestaff as it is for medical students. I was the first chairman of the Committee on Clinical Competence of the American Board of Internal Medicine. After the oral examination was phased out, we instituted the hospital visit program and a series of program directors dinners. By these means, we trained, as best we could from a distance, the program directors to evaluate their residents in internal medicine. The clinical competence program in internal medicine has come a long way since its institution 15 years ago, but it still has a long way to go. As one who had made 48 visits to individual programs between 1978 and 1986, I saw the evaluations administered first-hand. Most were good and are getting better, but many also lacked intellectual rigor. I must be frank and state that the least effective clinical evaluation exercises were carried out in some of our major teaching hospitals where all residents were, ipso facto, considered clones of Osler. It is easier to evaluate residents in small training programs such as exist in your discipline. However, small size, in and of itself, does not assure thorough evaluation. It simply makes it easier. You still need a commit-
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ment to evaluation and a system to carry it out. The evaluation of young physicians is a professional responsibility that must be exercised by physicians, either in their role as faculty at the medical school as well as within the context of their specialty discipline as they certify residents completing their program. 4. Residency accreditation. The Association has a long history in calling for institutional or corporate responsibility in the accreditation of residency programs. This position is not based in an attempt to wrest authority from program directors. We advocate this because we believe that individual residency programs should be part of a coherent educational mission within a particular teaching hospital and its associated medical school. Each of us can cite from personal experience, I am sure, instances where a teaching hospital has had one or more residency training programs that were below the standards of the majority of the programs at that institution. What corporate responsibility in graduate medical education is about, is the obligation of all program directors as responsible educators to assure the quality of all of the hospital's educational programs. A difficult issue arises when Residency Review Committees mandate the size and nature of a residency or fellowship program even though that program is not appropriate for the hospital concerned. For example, a midwestern hospital located in a community replete with cardiologists objected to the Residency Review Committee's mandate to have a minimum number of fellows in cardiology despite the fact that the hospital requested a fellowship program half the size of that required by the Residency Review Committee. In my view, the rigidity on the part of Residency Review Committees in mandating the number or type of program is inappropriate. If the RRCs would work more closely with the host hospital and its medical school, the outcome might well be better for all concerned. 5. Working conditions. Earlier I alluded to the intense public and professional scrutiny that enveloped the debates about the working conditions of our residents. While much of the debate focused on the number of hours worked and the effect of resident fatigue on performance and patient care, a far more important issue, in my mind, is the need to assure that residents are appropriately supervised by faculty. There are still too many clinics, wards and operating rooms where the principle of graded housestaff responsibility is abused and where we have a serious problem with supervision of residents that should receive our immediate and personal attention. I hope that some of the same vigor that attended the debate over whether there should be a limitation of 80 working hours per
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week for residents will accompany the examination of residency supervision and will result ird implementation of needed improvements. It also seems clear that implementation of even the most modest proposals for limiting housestaff hours will require a number ofchanges in hospital operations that may include employing other health professionals to perform tasks now done by residents, expanding residency programs, a risky venture, in view of the likelihood that these residents may not be needed at the conclusion of their training, or eliminating residency programs in favor of employing staff physicians. Whatever means is chosen to implement changes in residency training and supervision, it will cost more. If new personnel are hired, the hospital will have to expend the funds for salaries and fringe benefits; if housestaff responsibilities are shifted to medical staff, more professional fees will be incurred. I cannot see it getting cheaper. One of the AAMC's recommendations is to implement whatever changes are made slowly, being sure to keep educational goals and maintenance of quality patient care clearly in mind. Bringing this off will require our best efforts as faculty members and educators, and as members of medical staffs. 6. Financing graduate medical education. For many years medicine enjoyed the luxury of having its educational costs routinely supported by patient care dollars. Not only were resident stipends and benefits an allowable cost, but so were supervising faculty and costs incurred in the educational process such as libraries and conference facilities. The changing patterns of reimbursement to a prospective payment system and discounted contracting have placed increasing emphasis on the cost of the service being purchased. Progressively fewer third party carriers whose insurance premiums have been rising at the rate of 25% a year, and employers who have been responsible for paying most of these premiums, will tolerate the degree of cost shifting that was in vogue in the past, and almost all insurance carriers are looking for prospective, fixed or discounted reimbursement plans or are offering preferred provider contracts. To this price competitive environment, we must add a growing reluctance on the part of third party payers to pay for educational costs with any part of their service dollar. Even when a teaching hospital can compete on an economic basis, it will find itself challenged to subtract out the strictly educational costs from its service contracts. The federal government has already begun to set limits on the circumstances in which it will cover the costs associated with residency programs, and there is reason to believe that this trend will continue to be the principal source of support for graduate medical education, I can
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foresee the time where we will have to look to sources other than patient care revenues for substantial sums to support graduate medical education. We recognize that, in the future, additional funding might be needed from state and local governments, special purpose federal programs, and private organizations. 7. Autonomy of specialty boards. This country certifies to the competence of the physicians who have completed graduate training through an elaborate mechanism of specialty certification. There are 21 primary specialty boards exemplified by the broad disciplines of internal medicine, surgery, obstetrics and gynecology, pediatrics, and a number of the surgical specialties. A number of primary boards also issue certificates of special or added competence in one or several subspecialties. Each certifying board is autonomous and generally self-perpetuating. Although the board certification system assures a generally high standard of quality, it is not, in my view, trouble free. Nowadays its major ailment is a disease I have termed "certifimania. "4 Certifimania is the tendency to issue more and more certificates of special or added competence. At any one time there may be a dozen such certificates under consideration. Recent ones have varied from electrophysiology under the jurisdiction of the subspecialty Board of Cardiology and its parent, the American Board of Internal Medicine, to transfusion medicine, proposed by hematology and internal medicine, to orthopedic trauma. A recent specialty certification sponsored by the American Board of Preventive Medicine is certification of special competence in hyperbaric medicine. The proliferation of these certificates makes one wonder what a primary or subspecialty certificate really means. I remain convinced that certifimania is unnecessary. For example, if a certified hematologist does not know how to give transfusions, what does he know? Does it really make sense to add yet a third tier to a specialty such as hematology? Likewise, one may question that if an orthopedic surgeon does not know how to take care of trauma, what does the initial certificate mean? Another form of indoor sport engaged in by the boards is to add a year to the basic period of specialty training. A number of years ago a brouhaha ensued when the American Board of Pathology lengthened its training requirements from 3 to 4 years. A few years ago, the American Board of Anesthesiology followed suit, and most recently, the American Board of Pediatrics has proposed adding a year of research to the requirements in each of its subspecialties. In fact, in these pediatric subspecialties, better than a year and a half is supposed to be spent in research and less than half the time in specialized clinical training. The economic implications of these added certificates or more pro-
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tracted periods for certification should not be ignored. Usually an added certificate means a fellowship of at least one and sometimes two years of additional training. Who will pay for this training? A related economic issue is that the mere possession of such a certificate may lead to higher fees in the subspecialties in which these certificates are issued. Increasing the number of certificates results in a progressively greater emphasis on specialization, subspecialization and sub-subspecialization, while the need, as recognized by most authorities in health care, is for more broadly-trained physicians who can take care of the entire patient rather than a small part of his anatomy and physiology. There is no question that advances in knowledge and, particularly, advances in technology, have made specialization necessary, but aren't we carrying it too far? It is not difficult for a specialty board to ask for and eventually issue certificates of added or special competence. All that is required is for the board to give 180 days notice, to have a forum of interested parties organized by the ABMS before its Committee on Certification (COCERT), and, if that committee does not find adversely, to implement its new certification program. If a new area of competence is proposed, the proposal must be approved by the American Board of Medical Specialties, but the last and final word is the board making the proposal. In effect, the ABMS cannot veto a proposal to issue a certificate of special competence. If a specialty board simply changes the duration of training, but does not add a new area of training, it does not require ABMS approval at all. The members of ABMS are naturally hesitant to disapprove a proposal made by one of their sister boards lest that board recall at some future date what another board has done to them previously. It is this system that has led some of us to call for increased accountability by the boards. The major reason is that the boards are making decisions about training requirements that require longer and more expensive training that others have to pay for. The payors in this instance are the teaching hospitals and, in some instances, the medical schools. Although organizations representing them, or the hospitals and schools themselves may make a statement to a forum considering a change in board requirements, to my knowledge, once a board has given notice to issue a certificate of special competence, it has, in the final analysis, not been rebuffed. I must say, in all fairness, that while the boards may prevail eventually, it is encouraging that their petitions are being subjected to greater scrutiny. Despite these encouraging signs, a system that is not subject to impartial scrutiny by others is fundamentally flawed. In my view, a peer review process, akin to what is invoked for research or training grants,
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should be instituted by the boards. I would suggest that such a process should result in greater restraint, and certainly will improve accountability. 8. Manpower distribution. Many have thought that a graduate medical education system that has been skewed to an overproduction of specialists and subspecialists at the expense of generalists would eventually right itself through market forces. In my view, market forces are not coping with the problem. The reasons why the market is unlikely to control residency training have been summarized nicely by Whitcomb and Caswell.5 These authors contend, and I agree with them, that the market structure for residency training is imperfect at best. Medical students are generally unaware of practice opportunities, both in terms of geography and specialties. Medical students also fail to analyze correctly and carefully the cost of their education, the debt they have accumulated, the risk that they take in pursuing a particular specialty and the financial return that practice of a particular specialty is likely to bring. The system with its matching program for graduate medical education tends to emphasize the buying power of the hospitals and training programs, rather than those of the trainee. This is particularly true in popular and highly competitive specialties such as ophthalmology. Perhaps most important in career choice is the extraordinary influence of the faculty in promoting specialization and subspecialization as opposed to primary care training. On the supply side the market forces are even weaker. There is virtually no link between practice opportunities in a community or a region and the training positions in the academic medical centers located in those regions. The number of residency positions is usually determined by the desire of hospitals - particularly when hospital directors are told that more residents will make the hospital more money - desire of the medical staff, and most particularly, the desires of program directors, chairmen, and even deans. I have been pointing out for a decade the excessive influence of these groups on training opportunities much to the detriment of our health care system. The other fact that makes the supply side inefficient is that until recently the cost of the training could be passed on without question to third party payers irrespective of the need for this training. Last, but by no means least, in many specialties, there has been an almost implacable tendency for program directors to ignore signals from the market place. These signals all seem to say, enough; we do not need any more specialists and subspecialists at the rate at which you are training them.
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There are many reasons why the system of graduate medical education needs reform. Unless we devise some reforms that are perceived not to be self-serving, we will almost certainly bring down upon us draconian measures by government that will not enable us to preserve our system of graduate medical education. If that comes to pass, we will have no one to blame but ourselves. I would like to see the discussions within the academic community not degenerate into arguments about whether it is the teaching hospital or the medical school that has the responsibility for implementing changes in graduate medical education. On the contrary, we need to work together to implement these changes. After all, it is not them and us, it is us and us, and we must get the individuals on specialty boards, on Residency Review Committees, in the ABMS and on the ACGME to look at issues in graduate medical education not from a narrow parochial point of view. On the contrary, they must work together to see to it that the educational enterprise, whether at the student, resident or fellow level, will reach the potential of which it is capable and for which we all strive. REFERENCES
1. Petersdorf RG, Bentley JD: Residents' hours and supervision. Acad Med 1989; 64:175181. 2. Ebert RH, Ginzberg E: The reform of medical education. Health Aff (Suppl) 1988; 7:5-38. 3. Stemmler EJ: Promoting improved evaluation of students during clinical education: A complex management task. J Med Educ 1986; 61:75-81. 4. Petersdorf RG: The President's Column. Acad Med 1990; 65:96. 5. Whitcomb ME, Caswell J: Sounding board: The market structure of residency training. N Engl J Med 1986; 314:710-712.
