AAMC Reporter: January 2005

A Word from the President: "Reassert the 'E' in GME"

I'm not big on New Year's resolutions, but there is one thing I'd like to resolve this year. And that's the debate about the fundamental nature of residency training: Are residents primarily students who perform some useful services as an inherent part of their education, or are they primarily employees who happen to learn something in the course of doing a job?

Now, when I was a medicine resident 40+ years ago... (I hate to do this to you, but it's important to remember how we got to where we are)... there was no such debate. Or, more accurately, there was no need for such a debate. We certainly performed a lot of services, being on call every other night and every other weekend. But there was plenty of time for education -- including leisurely rounds twice a day, conferences, library searches, lengthy discussions with consultants, mini lectures and seminars with students.

As an example of the pace of hospital activities at that time, patients with routine, uncomplicated myocardial infarctions were kept in the hospital for three solid weeks! And they rarely required more attention than a daily greeting and a blood pressure check. Uncomplicated lobar pneumonia, acute asthma attacks, even acute gouty arthritis were common admitting diagnoses to the medical service. There were no ICUs, few ventilators, no dialysis machines, not even central lines to place. Life seemed pretty hectic to us at the time, but in retrospect, we had it relatively easy.

By contrast, today's resident lives in a different world with a more frenzied pace. Patients who get admitted are a lot sicker; there are more of them; they stay in the hospital for a shorter time; they require more procedures; and the technologies involved in their care are infinitely more complex than anything we had to deal with. And yet, the structure of residency training has changed hardly at all -- even with the long overdue restrictions on duty hours. Is it any wonder that the service demands being placed on residents today -- and the high stress levels they experience as a consequence -- have led many to wonder just what's driving the show? Is it the residents' need for an education or is it their faculty's need for a helping hand?

There's more at stake here than a philosophical debate. We've already seen too many examples of how the perception of residents as employees has threatened to undermine the core purpose of graduate medical education (GME) as well as the critical role of program faculty. We may not agree with that perception, but it is real.

In 1999, the National Labor Relations Board reviewed residents' "working conditions" and reversed its earlier finding that residents were primarily students. As a result, housestaff in private institutions can now join labor unions. The Jung litigation, alleging an antitrust conspiracy involving the Match, was premised in part on the theory that a resident is simply another kind of "employee." The IRS has recently ruled that residents' stipends are subject to FICA payments like any other "wages." And Rep. John Conyers, Jr. (D-Mich.) and Sen. Jon Corzine (D-N.J.) have filed bills in Congress that would legislate the "work hours" of residents.

More worrisome still: If residents continue to perceive themselves solely as employees, a perception fostered by their large service demands, the predictable consequences are increased cynicism and an undermining of professionalism. Unless we do something to halt this slide down the slippery slope from teacher/learner to employer/employee, not only will our residents fail to receive an optimal education, but our claim to be deserving of public trust will also be compromised.

Which brings me back to my New Year's resolution. In an effort to put a halt to the slide down that slope, I have resolved to promote a new compact between residents in training and their teachers. I have just finished a draft version of the compact and will distribute it widely for comment and revision. It is based on three core tenets of residency training:

• excellence in medical education
• highest quality and safe patient care
• respect for residents' well-being

The compact lays out a set of specific commitments for faculty and a complementary set of commitments for residents, all targeted at maintaining the fundamental focus of GME on education and professional development.

Once the compact has been vetted and modified as needed, I intend to solicit the endorsement of all of the stakeholder organizations concerned about graduate medical education. After that, it will be up to institutional sponsors of GME and individual program faculty to consider adapting the compact for local use as an affirmation of their and their residents' responsibilities as members of a learning community.

My hope for the New Year is that this compact will not only help resolve the student/employee debate but will also remind residents and their teachers that their interaction with one another is the medium through which the profession inculcates its ethical values.

Jordan J. Cohen, M.D.
AAMC President

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