Residency Education: Where We’ve Come From and Where We Need to Go
January 13th, 2023
Guest Blog by
Debra Weinstein, M.D.
Executive Vice Dean for Academic Affairs, Medical School
Chief Academic Officer, Michigan Medicine
A new calendar year always prompts both looking back and looking forward. This mindset has led me to reflect about graduate medical education (GME), which had been my principal focus for many years and is one of Michigan Medicine’s outstanding gems. Our GME residency and fellowship programs retain many of our outstanding students, lure other top medical school grads to U-M, and provide a pipeline of talented and dedicated physicians to the faculty.
It’s interesting how quickly health care delivery is being transformed. Physician training is also undergoing fundamental change, albeit more slowly. Some aspects of GME have been significantly strengthened, while others remain ripe for innovation.
GME has always relied on experiential training (“learn by doing”). When I trained, the underlying assumption was that each resident would see and learn everything we needed through immersion in patient care, so a curriculum seemed unnecessary. Our assignments to various inpatient services reflected patient care needs, rather than an education plan. Supervision and assessment were informal: “see one, do one, teach one.” Residency graduation was largely based on completing the required number of years for each specialty without raising serious concerns.
Today’s residency programs are strengthened by curricula focused on achieving defined core competencies. Work hours are regulated, which is even more essential amid today’s higher patient acuity and focus on efficiency. Supervision and assessment are more explicit and deliberate, though both represent works-in-progress. In addition, residency programs are moving toward holistic selection processes – along with a focus on diversity, equity and inclusion – to improve education and health care.
Yet, nationally, the overall approach to GME remains time-based, inpatient-focused, limited in opportunities to individualize according to a resident’s learning needs or career goals. Several factors have constrained innovation: inadequate funding for medical education research; historic de-valuing of education scholarship in promotions processes; a web of regulations and requirements perpetuating current processes; ongoing reliance on trainees to provide care; lack of a mechanism to coordinate GME research across institutions; and no standard or shared data infrastructure. But a window of opportunity is opening…
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The time is now. Growing interest and expanded training opportunities in medical education research have built quite a bench of innovative investigators across the U.S. Promotion criteria have evolved to better recognize contributions in this domain. National organizations such as AAMC, ACGME and NRMP are increasingly sharing the data they collect. While overall funding remains insufficient, national funding opportunities for medical education research have begun to emerge. Successful application of “continuous quality improvement” in healthcare lays a path for medical education.
The place is here. Michigan Medicine is distinctly well-positioned to lead in this area. First, our residency programs are recognized as among the very best. It is worth noting (without understanding or endorsing Doximity’s residency rankings), that 13 of our programs are among the top 10 nationally and 6 more among the top 20. We can afford to take the risks that come with innovation, and we can’t become complacent in the face of success.
Second, we can leverage a remarkable track record and continued momentum. These include the former Department of Medical Education’s legacy and ongoing contributions from its Chair, Larry Gruppen, PhD; the Department of Learning Health Sciences’ education opportunities and depth of scholars, led by Chair Charles Friedman, PhD; and the success of the Society for Improving Medical Professional Learning (SIMPL) consortium, developed by Michigan Medicine’s Brian George, MD, MA.
UMMS was one of the original members of the American Medical Association’s “Change Med Ed” consortium, and successfully implemented a new medical school curriculum model under the direction of Raj Mangrulkar and Seetha Monrad. The AMA subsequently funded large grants as part of its “Reimagining Residency” effort, including a pilot of competency-based, time-variable GME that I had initiated and led before coming to U-M — in which some UM residency programs are considering participating.
Third, our people are our greatest strength. We have amazing faculty, as well as residents, fellows, and medical/masters/PhD students – the next gen clinician-teachers-scholars, to propose and evaluate new ideas. We also benefit from strong GME leadership. Associate Dean for GME Sybil Biermann brings experience as a UM Residency Director and an important national role as chair-elect of the AAMC’s Group on Resident Affairs. Assistant Dean Scott Gitlin, and our GME Program Directors, are dedicated to ensuring training at UM is outstanding – as a launching pad to diverse career opportunities here and elsewhere. Probably most important are our shared ambitions, spirit of inquiry, and itch to innovate.
Moving forward, together. Just as we make clinical decisions based on empiric evidence, we should do the same in education. UMMS/Michigan Medicine has a number of internally-funded grants and innovation programs aimed to inspire idea generation and facilitate initial exploration, such as those through RISE and GME. Over the next year we will highlight and seek to expand such opportunities, leveraging the strength of our GME programs and the energy and vision of RISE.
In addition, this month we are launching a work group to plan for a Michigan Medicine data infrastructure that facilitates evidence-based approaches to medical education, initially focusing on GME
Optimizing GME will help us maintain our strength across each of the missions and will advance our ultimate goal of improving health.
We invite you to share your input on this topic in the discussion box below.
Thanks for these important reflections about the kinds of meaningful patient experiences that are essential to learning – I couldn’t agree more. Other educational elements complement these experience but most certainly don’t replace the central pillar of learning through supervised patient care.
The goal should be to move toward competency based residencies as pioneered in Toronto and continued/initiated by Dr. Benjamin Alman, Chair of Orthopaedic Surgery at Duke. The central role of which would be played by simulation based out of the Simulation Center.
Thank you! I completely agree that competency-based training is the appropriate framework for medical education. Kudos to Ron Hirschl, MD, who has been advancing this approach in pediatric surgery training here and with collaborators at other institutions. Based on pilots at Toronto and elsewhere, I had worked with colleagues in Boston to design a model for piloting competence-based time-variable GME across specialties. This was funded through the AMA’s “Reimagining Residency” initiative. There is an opportunity for Michigan Medicine residencies to get involved and I hope that some will choose to pursue this.
I also agree that Simulation is a key resource for both training and assessment, and we are fortunate to have an outstanding sim center led by Jim Cooke, MD, Professor of Family Medicine and Learning Health Sciences.
I look forward to seeing the specific ideas, but be very careful not to create a generation of “Medical Tourist”. They have toured medicine but have not had depth of experience (i.e. like living and working in a foreign land). The less direct patient experiences they have, the less learning, less joy, and less humanity they will experience. One must experience successes and some difficulties during training (this could be due bad patient outcome, their own failings, or even being mistreated by someone) which can lead to growth in handling these complex situations which they will face after training. It has to be real experience. I will be dismissed as old school. well, I am all for now technologies to help in training, tools to measure a resident’s progress, more data, understanding competency, training surgical residents like elite athletes, creating a positive-supportive learning environment, etc. Yes I trained a long time ago. It remains one of the hardest things I have done in my life, but also brought me the greatest depth of relationships, learning, and joy in my career. At the end of my training, I was a confident, independent, surgeon well prepared to face the challenges of clinical and academic practice. Is that our product today? I hope so. Good luck