Ideas and Opinions

Annals of Internal Medicine

Training for the 21st Century? Michael D. Stillman, MD


roposed in 2009, the “milestones” are specialty-specific observable behaviors meant to clarify the Accreditation Council on Graduate Medical Education’s (ACGME) 6 core competencies. These competencies—patient care, medical knowledge, professionalism, systems-based practice, practice-based learning, and interpersonal and communication skills— have been deemed essential to medical training and practice yet are difficult to evaluate objectively. Adoption of the more concrete milestones is intended to anchor curricular development, ease trainee remediation, and transform resident assessment from a “process” to a “competency-based” endeavor (1). The Next Accreditation System (NAS), an ACGMEmandated venture, was introduced in 2012 to move residency program accreditation from episodic evaluation toward continuous self-assessment and improvement (2). Under NAS, programs must submit biannual data confirming that each of their residents is progressing through the milestones and yearly reviews of “key performance measurements.” Well-performing programs will be subject to fewer site visits and program requirements, although it remains unclear which regulations will be loosened. Finally, internal medicine stakeholders, concerned with our trainees’ preparedness (or lack thereof) for 21stcentury practice (3), have identified a rapid shift toward outpatient care, an explosion of medical information, movement toward team-based patient management, and emerging obstacles in caring for resource-poor communities (4, 5) as tests for which our residents are ill-equipped. Many organizations have recommended improving outpatient education, prioritizing patient safety, standardizing learning objectives, and tailoring curricula to each trainee’s career aspirations, yet some have also ambitiously suggested significant undergraduate medical education reform (3). In reviewing proposals to reorganize our graduate medical education system, I cannot help but feel hopeful. Our trainees are sure to face logistic, technologic, and clinical challenges, and committees of solicitous and wellmeaning experts are toiling to ensure that they are adequately prepared. I am also unconvinced. Milestone-driven assessment may prove to be beneficial. Although largely untested, it could potentially ensure that residents acquire defined skill sets, allow educators to focus remediation efforts, and transition our evaluation system from a gestalt approach to one based on the demonstration of specific behaviors. Further, certain directives built into the milestones, including attention to patient safety and fostering collegiality, represent “cornerstone” values of our profession.

However, the milestones’ overemphasis on nondiagnostic aspects of medical practice is troubling. Various skills are essential to providing effective care, yet only 7 of the 22 sets of internal medicine milestones describe trainees’ clinical abilities and medical knowledge, whereas many others rate their ability to self-reflect, participate in quality improvement efforts and performance audits, provide cost-effective care, keep organized patient records, and advocate for “system improvement.” Although I hope my residents will keep pace with a rapidly changing health care system, I want them first and foremost to be superb clinicians, and the milestones seem to prioritize systems-based aspects of care at the expense of raw medical knowledge and diagnostic ability. In addition, nearly 30% of the milestones are specifically devoted to evaluation of our trainees’ professionalism, asking program directors to attest to our residents’ ability to appropriately interact with peers, assume responsibility for care, behave ethically, and communicate effectively and respectfully with patients and caregivers. Although being courteous and attentive in our practice is crucial—and those skills are critical to being a successful physician— dedicating fully one third of our evaluative efforts to ensuring proper behavior and attitudes seems excessive. The NAS is difficult to appraise, given that it has yet to be piloted in its entirety (2) and that so few people truly understand it. At last spring’s Association of Program Directors in Internal Medicine meeting, a progression of speakers addressed imminent program reforms, yet none detailed their mechanics or specific aims, and the literature offers little help. In attempting to validate NAS, one author predicts that it will produce clinicians who “develop the requisite management skills and approaches to systemsbased care” (6), whereas a second posits that NAS will enhance “the competence of future physicians in areas that are relevant to a well-performing, efficient, and costeffective health care system” (2). It is difficult to imagine restructuring our graduate medical education programs simply to enable physicians to more skillfully navigate our care organizations. Further, it is not at all clear that implementing NAS will meaningfully impact the U.S. public’s health, and addressing that ought to be our leading priority. A recent publication (7) comparing U.S. health with that of citizens from our peer nations revealed that we are twice as likely to be obese; rank highly in rates of cardiovascular disease, pulmonary disease, and diabetes mellitus; and have the highest overall mortality rate. Life expectancy in industrialized countries is rising, yet at a slower pace in

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Training for the 21st Century?

the United States than our sibling nations. We are an extraordinarily unhealthy people. Although the literature on NAS contains oblique references to its impact on patient care, it is unclear how physicians trained under this system will be better equipped to meet our patients’ needs. Will our young colleagues be more astute clinicians or more fully understand the basis of disease? Will they be skilled counselors who are better able to help patients choose healthy lifestyles? Will they grasp policy matters and succeed in engaging civic leaders and legislators in sensible and effective public health initiatives? We expect the next crop of physicians to be adaptable, but our primary concern ought to be for our patients’ well-being, and I question whether adopting the milestones and NAS will meaningfully change their lot. The stakeholders of the ACGME and internal medicine are reshaping our nation’s graduate medical education system with mandated, poorly understood, and untested evaluative programs that undervalue diagnostic skills, prioritize delivery systems, and fail to address our citizens’ dwindling health. I worry that medical educators are being asked to train young physicians not in the best traditions of our profession, but rather to simply melt into a dizzyingly complicated and capricious health care system. Current educational reform, I fear, will produce physicians for the 21st century—sensitive, technologically nimble, and quality-minded—with just those clinical skills necessary to have completed training and wholly unprepared to face our nation’s health care challenges. From University of Louisville School of Medicine, Louisville, Kentucky.

Ideas and Opinions

Disclosures: None. Forms can be viewed at /icmje/⫽M13-2358. Requests for Single Reprints: Michael D. Stillman, MD, Ambulatory

Care Building–Ambulatory Internal Medicine Clinic, 550 South Jackson Street, Louisville, KY 40202; e-mail, [email protected]. Author contributions are available at Ann Intern Med. 2014;160:800-801.

References 1. Green ML, Aagaard EM, Caverzagie KJ, Chick DA, Holmboe E, Kane G, et al. Charting the road to competence: developmental milestones for internal medicine residency training. J Grad Med Educ. 2009;1:5-20. [PMID: 21975701] 2. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and benefits. N Engl J Med. 2012;366:1051-6. [PMID: 22356262] 3. Weinberger SE, Smith LG, Collier VU; Education Committee of the American College of Physicians. Redesigning training for internal medicine. Ann Intern Med. 2006;144:927-32. [PMID: 16601254] 4. Fitzgibbons JP, Bordley DR, Berkowitz LR, Miller BW, Henderson MC; Association of Program Directors in Internal Medicine. Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine. Ann Intern Med. 2006;144:920-6. [PMID: 16785480] 5. Holmboe ES, Bowen JL, Green M, Gregg J, DiFrancesco L, Reynolds E, et al. Reforming internal medicine residency training. A report from the Society of General Internal Medicine’s task force for residency reform. J Gen Intern Med. 2005;20:1165-72. [PMID: 16423110] 6. Goroll AH, Sirio C, Duffy FD, LeBlond RF, Alguire P, Blackwell TA, et al; Residency Review Committee for Internal Medicine. A new model for accreditation of residency programs in internal medicine. Ann Intern Med. 2004;140: 902-9. [PMID: 15172905] 7. Woolf SH, Aron L, eds. U.S. Health in International Perspective: Shorter Lives, Poorer Health. Washington, DC: National Academies Pr; 2013.

3 June 2014 Annals of Internal Medicine Volume 160 • Number 11 801

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Annals of Internal Medicine Author Contributions: Conception and design: M.D. Stillman.

Drafting of the article: M.D. Stillman. Critical revision of the article for important intellectual content: M.D. Stillman. Final approval of the article: M.D. Stillman.

3 June 2014 Annals of Internal Medicine Volume 160 • Number 11

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Training for the 21st century?

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