Viewpoint: Strengthening the 'E' in GME

VOLUME 10, NUMBER 10

JORDAN J. COHEN, M.D., PRESIDENT

JULY 2001

Viewpoint: Strengthening the 'E' in GME

By David Leach, M.D.

By David Leach, M.D.
Executive Director Accreditation Council for Graduate Medical Education

In 1998, AAMC President Jordan J. Cohen, M.D., challenged academic medicine to address public concerns about the adequacy of residency training by honoring the "e" in graduate medical education (GME). Three years later, there are signs that the medical education community has risen to his challenge and even that innovative models more suited to the emerging world are sprouting. And yet several vexing threats persist. So, how is it going?

It has never been more apparent that graduate medical education is part of the larger health care system. Residents' education is inexorably tied to the atmosphere in which they work and the greater health care environment. The issue of resident work hours illuminates this point clearly and provides an example of Dr. Cohen's concerns. The Accreditation Council for Graduate Medical Education (ACGME) does and will cite programs in violation of work-hour requirements. However, work-hour violations are a symptom, and symptom management alone won't work. Causal patterns underlying the violations can be detected and addressed. They include:

Inadequate resources. Teaching hospitals are not adequately funded. Support staff have been reduced, and residents frequently fill in the gap. Residents, many of whom are idealistic and loath to ignore a problem, transport patients, draw blood, and go to pharmacies when no one else will. Sometimes these behaviors become routine.

More work to do and less time to do it in. Patients are sicker. They are older and more apt to have multiple failing systems and require greater technologic support for diagnosis and treatment. At the same time, shorter stays in the hospital have heightened the activity on the day of and following admission. More must be done in a shorter interval, but oftentimes resident duties have not been redesigned to reflect these changes.

Safety. At present the resident serves as a safety net when the system fails. Idealistic and intelligent residents are hesitant to trust the system and therefore shoulder heavy burdens. Safety should be designed into health care. A good system makes it easy to do the right thing and hard to do the wrong thing.

Work force issues. Shortages of well-trained, highly competent nurses and other health professionals directly affect residents' quality of life. This is more than a resource issue; it is perhaps our most serious problem.

Truly fixing the causes behind excessive resident work-hours will require thoughtful, innovative approaches to improving patient care. But as we in academic medicine work to craft such solutions, we must ensure that residents are well trained and treated despite the challenges facing our nation's teaching hospitals. For their part, residency review committees (RRCs) are now more aggressive, requiring institutions to define what they are doing in response to work-hour citations and shortening review cycles and taking action against violators. There are signs of progress: Between 1999 and 2000, the frequency of work-hour and related violations fell in most disciplines, including from 30 percent of programs reviewed to 10 percent in internal medicine, from 19 percent to 5 percent in obstetrics-gynecology, and from 29 percent to 10 percent in orthopedic surgery.

As encouraging as these trends are, the problem is far from resolved. Some disciplines still have frequent citations. For example, the general surgery RRC cited 36 percent of programs in 1999 for work-hour and related violations and 35 percent of programs in 2000. Others appear to have met the requirements in ways that may compromise the educational components of the program. As a result, resident experience and/or didactics may be limited. In summary, evidence suggests that in many cases institutions are curbing excessive reliance on residents for service, however, progress is slow and by no means uniform.

But cracking down on excessive resident work-hours isn't the only means by which the ACGME is working to ensure the "e" in GME is emphasized. The ACGME Outcome Initiative assesses and works to improve educational outcomes. Such outcomes measures can define actual education and focus limited resources, whereas process and structure measures capture only the potential of programs to educate. The six general competencies adopted by both ACGME and the American Board of Medical Specialties - patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice - provide a way to organize measurements of educational effectiveness.

Many institutions and educators are taking the lead in this initiative, the first phase of which - Forming the Initial Response - begins this academic year. Both RRCs and institutions are developing and implementing dependable means of assessing learning in these domains. Direct observation of clinical skills; peer, professional associate, and even patient observations about communication skills and professionalism; cognitive testing; and portfolio assessment are a few of the methods being used.

In short, the academic world is responding to Dr. Cohen's challenge by both strengthening education and containing service abuses. The problems are daunting, we have a long way to go, but perhaps we are at the end of the beginning of what needs to be done.