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AAMC Reporter: March 2007
A Word from the President:
"GME: Trained on the Future"
In my February column, I asked "What Flexner would
really think?" about undergraduate medical education
(UGME) today, and addressed that question by reflecting
upon the transformation of UGME in the 30 years
since I graduated from medical school. Turning to
graduate medical education (GME), Abraham Flexner
lived in a time when GME largely meant preparing
doctors for general practice. The topic was not even
discussed in his 1910 report.
If Flexner looked at GME today, I imagine he would be
overwhelmed by the sheer number of residency programs
(8,403 and counting!) and the proliferation of
specialties and sub-specialties. I also imagine he would
value the emphasis on learning in the resident experience;
e.g., learning objectives for each rotation, educational
methods and assessment tools developed by
professional educators, and the use of current cases
as the basis for developing multiple competencies.
These and other innovations stem from an emerging
consensus that resident education should be more
closely aligned with society's expectations of doctors
and a health care system that is growing increasingly
complex. The Accreditation Council for Graduate
Medical Education (ACGME), with adoption of the
six core competencies in 2001, gave formal shape to this
thinking and set the stage for many of the improvements
we are seeing today in GME as well as patient care.
Meeting society's needs and expectations—With the
U.S. population over age 65 projected to reach 71 million
by 2030, and medical advances extending the lives
of those with chronic disease, chronic care has become
an increasingly important component of health care
delivery. To improve residency training in this area,
the AAMC established the Academic Chronic Care
Collaborative (ACCC) in 2005. Through this initiative,
residents at 22 medical schools and teaching hospitals
are working in interdisciplinary teams to care for
patients with asthma, diabetes, congestive heart failure,
and chronic obstructive pulmonary disease.
But even as our population ages and becomes more
diverse, one expectation remains the same—patients
want doctors with whom they can talk and who will listen
to them. In many institutions, residents are often
directly observed or taped as they interact with real or
standardized patients, and are provided feedback for
improvement. Additionally, many GME programs are
tackling complex matters such as obtaining informed
consent from patients (or their family members) from a
wide range of cultural backgrounds, thereby building on
UGME's increasing emphasis on communications skills
and cultural competency training.
Preparing new doctors for the "real world"—Providing
safe, reliable, high-quality care in a complex environment
requires comprehensive training in the prevention
of medical errors and the ability to interface with complex
systems. A 2003 AAMC report, Patient Safety and
Graduate Medical Education, called upon GME programs
to place increased emphasis on patient safety in
their curricula and suggested ways to link patient safety
to the six ACGME core competencies (e.g., requiring
resident participation in multidisciplinary sentinel event
and root cause analysis).
As a community, we are extraordinarily fortunate to
provide residents with access to the nation's premier
training ground for patient safety and quality improvement
through our longstanding association with the
Veterans Administration (VA). The VA directly funds a
significant number of the 103,106 residency positions
nationwide. Through our academic affiliations with
130 Veterans Health Administration medical facilities,
31,000 residents receive training annually, which means
they learn firsthand about new developments in patient
safety and learn to use a sophisticated electronic health
record that has become integral to veterans' care.
Being a doctor today also requires the ability to interact
with health care systems and know some fundamental
concepts in law, accounting, and public policy. In
Flexner's time, it would have been outside the realm
of medical practice to know, as today's residents do,
the legal basis for reporting suspected cases of domestic
abuse, understand administrative and billing procedures,
or explain privacy guidelines such as those related
to Health Insurance Portability and Accountability
Act (HIPAA).
Training for a lifetime of learning and improvement—We have taken several important steps to reaffirm that
residents are, first and foremost, learners. My distinguished
predecessor as AAMC president, Jordan J.
Cohen, M.D., referred to this as "honoring the 'E' in
GME." These steps include capping resident duty hours
at 80 hours weekly and developing The Compact Between
Resident Physicians and Their Teachers that "re-energizes"
GME's commitment to education. Even more
importantly, we are working to instill in young doctors
the principle that learning and self-improvement are
continuous processes throughout a medical career.
Residents are being trained to self-assess and improve
their practice behavior through practice-based learning
and improvement (PBLI). Among the approaches being
explored and developed are portfolio entry, development
of learning plans, and the use of quality improvement
knowledge application tools.
Cultivating future leaders—Ensuring that residency
training helps nurture young doctors for leadership
positions is another focus of today's GME. For example,
in the VA National Quality Scholars Fellowship Program,
physician scholars learn about the scientific underpinnings
behind quality improvement while training to
participate in the "redesign" of health care, and in the
Dartmouth-Hitchcock Leadership Preventive Medicine
Residency, residents learn in depth about outcomes
measurement and becoming leaders of change
and improvement.
Clearly, GME has become the crucial bridge connecting
UGME to clinical practice. I think Flexner would be
duly impressed by this, and submit that it is time to
build other bridges that might truly integrate the
entire medical education continuum. In my next
column, I will talk about how we might do just that.
Darrell G. Kirch, M.D.,
AAMC President
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