- Email: [email protected]
Experience with flexibility in an academic residency program
780
Jaffe
greater flexibility also might be beneficial if individuals are to be prepared for productive, academic research careers. Many of the current obstetric-gynecologic leaders in reproductive research pursued training programs that would be proscribed by current guidelines of the subspecialty boards. Thus, while many spent 1 or 2 years in a laboratory either abroad or in a basic science department in the United States, these are not components of "approved" programs of the current subspecialty disciplines. Furthermore, extensive clinical requirements, for example, the need for reproductive endocrinologists to train in tubal microsurgery and in vitro fertilization, and the large amounts of time in clinical pursuits mandated in fetal and maternal medicine and oncology mitigate against obtaining the requisite training to pursue an independent, productive, and competitive research-oriented career-and the discipline sorely needs this facet of the specialty better represented. Although I was not personally involved, the activity of this Society of which I have been most supportive and proud has been the creation ofthe Kennedy-Dannreuther fellowships. They furnish tangible evidence of the Society's commitment to training investigators in the reproductive sciences. To maximize these opportunities, the greatest possible program flexibility needs to be encouraged and facilitated.
Experience with flexibility in an academic residency program Charles H. Hendricks, M.D. Chapel Hill, North Carolina
During my tenure as Director of the Residency Program in Obstetrics and Gynecology at the University of North Carolina at Chapel Hill, from 1968 through 1980, seven principles served as guidelines. All of these principles are important, but the first two were absolutely critical in our residency management during those years: 1. The residency exists primarily to serve the developmental needs of the resident and not the service needs of the hospital where he is being trained. From the Department of Obstetrics and Gynecology, University of North Carolina School of Medicine. Presented at the Fourth Annual Meeting of the American Gynecological and Obstetrical Society, Hot Springs, Virginia, September 4-7, 1985. Reprint requests: Charles H. Hendricks, M.D., Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, 214 MacNider Building 202H, Chapel Hill, NC 27514.
April, 1986 Am J Obstet Gynecol
2. Education is not neatly confined within the white picket fence of any institution nor tidily contained within a classical school year. The University should be thought of as a universal idea rather than as an institution. The strategy of utilizing the University should allow for rearranging the boundaries of time and geography where such adaptations can aid in the development of a single individual's career. 3. A residency should be considered to be a vital, demanding, prolonged postgraduate academic experience. Treating a residency training program as a trade school program demeans both the resident and the residency. 4. Ideally, residency experiences should be designed to help the person reach toward his highest aspirations for his own development. It is unrealistic to design a residency program to produce only academicians or only practitioners. Having high aspirations for a fulltime academic career is no more worthy than having high aspirations for a successful career in private practice. S. The individualization of resident care is just as important as the individualization of patient care. 6. Both the resident and the residency benefit by having some input by the resident, in the design of his own learning program. 7. It is manifestly impossible for the resident to "learn" obstetrics and gynecology during a 4-year period. Rather than "learning" the field, the resident should be learning intellectual inquiry and disciplined study methods that will qualify him as a life-long student in his chosen field. Only in this way can he hope to avoid boredom, obsolescence, and professional decay.
Strategies The residents were selected through the usual selection mechanisms except for those who joined the program at an irregular time. We made provision for accepting as early starters, and therefore early finishers, those individuals who had completed their medical school requirements for the M.D. degree sooner than their fellows had done. During 12 of the years under study here, the resident applicants were encouraged to have some input into their own curriculum, designed to advance their personal goals. Their elective programs were determined partly by their requests and partly by suggestions offered by the faculty. There was no requirement that any resident would have to perform any research. We did take care, however, to provide opportunities for research, which we enthusiastically aided and abetted. If one applies seriously and logically all of the precepts listed above, it is perfectly apparent that there
Volume 154 Number 4
Flexibility in academic obstetric-gynecologic residencies
Table I. Graduates of the University of North Carolina residency program by years, 1970-1982*
Table II. Types of electives chosen by graduates of residency program
Year
1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982
No. of graduates
4 3 2 2 4 5 5 5 3 6
4 5 5
*Mean number of graduates per year, 1970-1974: 3.0. Mean number of graduates per year, 1975-1982: 4.8. will not necessarily be the same number of residents within the home hospital training department at any one time. There will be a great deal of coming and going of residents as they go from one assignment or elective to another in pursuit of the individual 4-year plan. Our training program needed to make allowances for the fact that the training was not even necessarily continuous. For example, when two of our residents dropped out after 2 years to work at the Centers for Disease Control, they returned to finish their final 2 years at the University of North Carolina. Three others joined the program at the second-year level. The total number of graduates did not vary widely from year to year, since some residents transferred quite early to other activities. Altogether, 65 physicians entered the training program. Of these, II (17%) departed for other activities; only one of these was with our program more than a single year. Two entered required military service; after completing the military requirement, one of these went into family medicine, while the other completed the obstetrics and gynecology residency in another program. After no more than I year in our program, one resident left for further training in each of the following specialties: pathology, psychiatry, radiology, radiation therapy, ophthalmology, anesthesiology, pediatrics, and family practice. One resident departed after 2 years to enter the Public Health School. The planned number of residents during most of the years was five per year (Table I). Actually, with one exception, in only one year was that number exceeded: in that year, there were six graduates. It should be noted, however, that in the year just preceding and the year just following that year, the actual number of graduates were only three and four, respectively.
On campus
Research Oncology Extra clinical Surgical specialties Maternal/fetal medicine, including genetics and ultrasound Endocrinology Pathology Anesthesiology Other Total Percent
8 4 I
Off campus
2 6 8
3 5
3
6
I
5
5
I
I 6
6
34 45.3%
4 41 54.7%
781
Total 10 10
9 9 8 6 6 5 12 75
In general, we abided by the guideline that our residents would have 3 years of categorical rotations but not necessarily serve those rotations in any required identical order. This left 12 months for elective experiences. The elective experiences were expected to be worthy of a graduate study level, to be challenging, and also to be building blocks for the long-range growth of the individual. In the preparation of our report on the residents' experiences, the resident graduates were surveyed. During the inclusive years 1970 to 1982, 53 residents completed our program. An additional one who finished a year later is included because he had been away for 2 years at the Centers for Disease Control and thus was a late finisher. The graduates were asked to react to their residency experiences in the light of what they have learned since they have left the residency. They were also asked to describe their current activities, their curricula vitae, and their future plans. Of the 54, 45 (83.3%) responded. The following report draws heavily on their replies and perceptions. Stresses in a flexible system
Of the 54 graduates the great majority indicated their approval of the flexibility features. However, a minority of graduates were critical of the elective system for various reasons. One said he had regrets at having failed to sign up for any electives. One expressed criticism of the program for having failed to apply pressure on him to seek elective experiences. * One superb and stalwart graduate said that he had no opportunity to sign up for electives because he was too busy carrying major patient care clinical loads, which
*My own recollection is that a large proportion of the residents were reluctant to sign up for any elective that they feared would dilute their categorical-type training experience!
782 Hendricks
April, 1986 Am J Obstet Gynecol
Table III. Off-campus training sites for electives within the United States Training site
Area of study
Atlanta-Cullen Richardson Gynecologic surgery Bowman Gray Anesthesia Case Western Reserve Anesthesia Columbia Pathology Duke Endocrinology George Washington Surgery Jefferson Endocrinology Mayo Gynecologic surgery Texas/Southwestern Maternal/fetal medicine University of California Urology (Los Angeles) Sloan-Kettering Oncology Centers for Disease Control Total
No. of residents
2 2 2 I 2 I I
2 I I 3 2 20
indeed he was. Two believed the electives were not evenly distributed. Several found the frequent coming and going of residents and the variability of the size of the resident staff on duty at anyone time to be unsettling. One graduate provided the following insightful commentary on what a flexible program meant to him. "I believe UNC's graduates are able to consider alternatives to diagnosis and treatment because we had time and were encouraged to discuss problems rather than follow a 'cookbook' .... It remains imperative that UNC continue to choose residents that can handle this pressure of being more independent than residents of other programs .... The flexibility of our program is an excellent concept as long as residents or at least the majority of them are able to handle the stress and anxiety of accepting the responsibility that comes with flexibility." Some positive feelings
Here are excerpts from other graduates' reports: "The flexibility of the program at UNC allowed and encouraged me to function as an adult. My assessment is that many residency programs currently treat residents as children, rather than 26 + -year-old individuals who have a good idea about what they need and want in order to grow personally and professionally. 1 would suspect that you will receive an argument against a flexible residency program-the statement that this sort of program would only work for a certain small segment and subset of the total group of GYN residents. While this may to some extent be true, 1 think the encouragement of self-motivation, assessment of character needs, and goals coupled with the guidance when needed from attendings within the basic structure of residency is the optimal situation." " ... the program at UNC provided me with in-
valuable academic contacts and started academic habits ... " "The ease with which alternative educational activities blended with the program, the flexibility both with regard to internal and extramural scheduling, and the sincere (not just lip service) support and encouragement to broaden educational experience were unmatched by any program I interviewed at or have seen since. It still remains an ideal goal for programs 1 am involved with now." "While I believe that the flexibility which you built into the program was exceedingly important, at least equally important in my mind was your strong support of the residents as they sought to take advantage of the opportunities you helped to create." " ... the residency experience was more weighted to postgraduate education and less to technical training than other programs with which I am familiar. Nonetheless, I gained a good basic experience in clinical obstetrics and gynecology, such as surgical techniques and endocrinology, which has enabled me to continue my evolution as a specialist in infertility treatment, and which allows me to apply the skills in preventive medicine and epidemiology which I have also continued to pursue since the residency years." "I am aware and will always be grateful that you squeezed me in after your five first-year slots were filled (to my chagrin!) .... The experience was freewheeling and intellectually exciting. You assembled a critical mass of superb people!" Elective activities
Overall, the residents described 75 elective experiences that were meaningful to them. Thirty-four of these (45%) were electives undertaken on the campus of the University of North Carolina, and 41 (55 %) were taken off campus (Table II). A wide latitude was provided. Most commonly, the electives chosen tended to be grouped within a relatively few areas. Over half of the experiences described focused on five areas. Ten residents had one or more oncology electives. Ten had research electives, nine had surgical specialty electives, and nine had extra handson clinical electives. Eight chose electives relative to maternal and fetal medicine, including ultrasound, genetics, and neonatology. The remainder of the 75 electives varied widely in content and objective. 1 will cite five unique electives: (1) A resident joined the Division of Medical Education for 3 months, as preparation for a career in academic medicine. (2) A resident established a university sex education course, which attracted wide interest and imitation. (3) Another resident established our departmental colposcopy clinic. (4) The same resident computerized our oncology records, a most demanding task but most produc-
Flexibility in academic obstetric-gynecologic residencies
Volume 154 Number 4
Into Practice
t
Into Full Time Academics t
67%
33%
Table IV. Off-campus foreign elective sites No. of
Foreign elective site
residents
Jamaica-Project Hope Stockholm-Karolinska Oslo-Norwegian Radium Hospital London-University College Hospital London-King's College Hospital Vienna Israel
4 3
1 1
2 Fig. 1. Percentage of the graduates who went directly into private practice and those who entered full-time academic departments.
1
1 13
Total
Table V. Memberships and certification of graduates of residency program
Listed in Directory, American College of Obstetricians and Gynecologists Diplomates of American Board of Obstetrics and Gynecology*
783
n
%
51154
94.4
51154
94.4
Always in Practice
t
67%
Moved from Academic into Practice
t
14% 19%
t
*Two more ready to take Board examinations for the first time after required waiting period.
tive in his future career. (5) Another resident undertook a heavy reading and study course during her 10week maternity leave. This resulted in an article describing her own physical and emotional response to the pregnancy and delivery process. Publication of that article in turn led to multiple invitations for this graduate to participate extensively with women's education. There were 20 elective experiences conducted at 12 off-campus sites in the United States (Table III). These included service at nine medical schools. Also included were three Galloway Oncology Fellowships at SloanKettering, two 2-year stints away from the residency at the Centers for Disease Control, and two gynecologic surgical rotations in Atlanta. Thirteen of our residents elected to do clerkships abroad (Table IV). Four of these were served at the University of West Indies in Kingston, Jamaica, as part of our Departmental participation in Project Hope. Three electives were served in London (one at University College Hospital and two at King's College Hospital), three at the Karolinska Institute in Stockholm, and one each in Vienna and Israel. It appeared that prolonged furloughs or other absences from our campus did not deter the development of careers-in fact, it was quite the contrary with the Centers for Disease Control. Two of our residents had 2-year furloughs to work there, and a third joined our program at the completion of his 2-year appointment there. In each case the Centers for Disease Control proved to be an exceptionally stimulating and productive environmental influence. The resident who spent a year in Sweden learned research techniques that have helped his academic career.
Always in Academic Medicine Fig. 2. Percentage of those graduates who went directly into practice, those who left academic departments to enter private practice, and those who have remained in full-time academic departments.
Outcomes of a flexible program It is difficult to quantitate precisely the effect that flexibility and versatility in educational endeavor have on the final product, the graduate of such a residency program. As a general indication of overall results, I have elected to report on the following: membership and certification, a description of activities since leaving the residency and their relationships to medical school teaching programs, and evidence of scholarly activities as indicated by publications listed on curricula vitae. Membership and certification. Of our 54 graduates, 51 are listed in the most recent directory of the American College of Obstetricians and Gynecologists. Fiftyone are Diplomates of The American Board of Obstetrics and Gynecology, with two more waiting to take Board examinations for the first time as soon as they are permitted to do so (Table V). Four of our residents used elective opportunities in partial fulfillment of the Board requirements for specialties other than obstetrics and gynecology (Table VI). One resident had a 5-month elective in obstetric anesthesiology. At the completion of his formal residency, he achieved additional experience and ultimately became a Diplomate of The American Board of Anesthesiology. A second resident, having already served an internship in internal medicine, chose to use his 12
784
Hendricks
Practice in North Carolina 50%
April. 1986 Am J Obstet Gynecol
Practice Full Elsewhere Time 31%
119 %1
Fig. 3. Location of graduates in private practice or in full-time academic medicine. One-half of the graduates are now in practice in North Carolina.
None
Part Time
Total, All Groups
Always Full Time Full Time, then Into Practice Always in Practice
Full Time
44
~
41%
41%
119%1 I
mean
1.2
~ 34.6
61.3
17.3
Fig. 5. Publications listed by graduates according to current professional activity. Of the 934 total listed publications, 613 appeared on the curricula vitae of the 10 full-time academicians.
59% Fig. 4. Nearly three-fifths of the graduates now hold full-time or clinical teaching appointments. months of electives entirely for internal medicine rotations, thus completing the formal training requirements that ultimately allowed him to become a Diplomate of The American Board of Internal Medicine. A third resident, having interned and then served a year of residency elsewhere that was followed by 2 years at the Centers for Disease Control, joined our program as a second-year resident for the final 3 years of his training experience. For his elective work he chose to obtain a Master of Public Health degree in our Public Health School, which ultimately helped him become a Diplomate of The American Board of Public Health and Preventive Medicine. A fourth resident also achieved a M.P.H. degree during his residency and was also able to become a Diplomate of the American Board of Public Health and Preventive Medicine. Activities after leaving the residency. Of the 54 graduates, 36 (67%) went directly into private practice, while 18 (33%) went into full-time academic careers (Fig. 1). Of these, 16 were in medical school academic programs and two became permanent officers at the Centers for Disease Control, a career which, in my opinion, represents the equivalent of full-time academic activity. With the passage of time, eight of those originally in full-time academic medicine moved from academic careers to full-time practice, leaving only 10 now in fulltime academic careers (Fig. 2). Where are they now? At present, 27 (50%) of the graduates of the program are in full-time private practice in North Carolina (Fig. 3). The primary mandate and mission of our training program was to produce well-trained specialists to serve the State, and it appears
Table VI. Certification by a Board in addition to certification by the American Board of Obstetrics and Gynecology Additional Board certification
Public health and preventive medicine Anesthesiology Internal medicine Total Percent
No. of residents
2 1 1 4 7.4%
that this mandate has been well fulfilled. Seventeen (31 %) are in private practice elsewhere, while 10 (19%) are still in full-time academic medicine. It is a matter of interest to note the current relationship between our 54 graduates and their teaching activities at various medical schools (Fig. 4). As mentioned, 10 are full-time staff members, but in addition to this, 22 (41 %) hold part-time appointments for medical student and/or resident training in association with various medical schools across the country.* Thus 59% are currently performing teaching obligations in one of 12 medical schools. Four schools are in North Carolina: Bowman-Gray School of Medicine, Duke University, East Carolina University, and the University of North Carolina. The medical schools outside North Carolina are University of Arizona, Emory University, Hershey Medical Center, University of Mississippi, University of Nevada, Ohio State University, University of Oklahoma, and University of Oregon. Publications. The publications to date as listed on
*The two Centers for Disease Control officers also have clinical appointments but are listed with the academic fulltime quota and are not counted in the part-time teaching group.
Flexibility in academic obstetric-gynecologic residencies
Volume 154 Number 4
785
Table VII. Publications listed on curricula vitae of the 54 graduates No. of publications
Always in private practice
Over 100 51-100 26-50 6-25 1-5 None
8 26
Total
26
Full-time academic, then private practice
I I
the curriculum vitaes submitted by the various graduates are shown in Table VII. With very few exceptions, all items submitted are listed, including abstracts, papers in journals, chapters, books, and a scattering of articles appearing in non-peer reviewed publications. The 36 residents who have always been in private practice list a total of 44 publications or a mean of 1.2 publications per graduate. The individuals who started out in full-time academic careers but then went into full-time practice have published a total of 277 articles, a mean of 34.6 per graduate. The 10 individuals always in full-time academic medicine list a total of 613 publications, a mean of 61 per full-time graduate (Fig. 5). In conclusion, it should be stated that a program as flexible as ours was during the decade of the 1970s would not be applicable to most other American training programs. There may be some features of our approach, however, that might find limited usefulness in the 1980s.
Response on the need for flexibility in academic obstetric-gynecologic residencies James A. Merrill, M.D. Seattle, Washington It is appropriate that the American Gynecological and Obstetrical Society be concerned with resident education in our discipline and that emphasis be on the production of individuals who will further education and research. This is not the first time such an issue has been addressed here. In 1953 the American Gynecological Society appointed a committee to study the problem of recruitment of academic personnel for the
From The American Board of Obstetrics and Gynecology. Presented at the Fourth Annual Meeting of the American Gynecological and Obstetrical Society, Hot Springs, Virginia, September 4-7, 1985. Reprint requests: James A. Merrill, M.D., The American Board of Obstetrics and Gynecology, Inc., 4507 University Way N.E., Suite 204, Seattle, WA 98105.
Always full-time academic
Total
4 I
I 6 I I I
2 7 3 6 10
8
10
54
I I I
specialty of obstetrics and gynecology. The work of that committee lead to the publication in 1961 of a report entitled "The Recruitment of Talent for a Medical Specialty." Many of the observations and recommendations in that report remain valid in 1985, 25 years later. Although the recent American Gynecological and Obstetrical Society committees have addressed many of the same issues included in the earlier report, they have concentrated their interests on graduate medical education and preparation for academic careers. The American Gynecological and Obstetrical Society committee has stated "... If we are to develop different tracks for those preparing themselves for academic careers, the policies of The American Board of Obstetrics and Gynecology and the Residency Review Committee must be adjusted to accommodate them." This morning's symposium is a discussion of that opinion. Many years ago the program director of a prestigious residency program proposed that graduates of his program should be certified by the Board without the necessity of examination. He reasoned that his program was at least 2 years longer than standard residency programs and that residents were selected because of their talent and interest in academic medicine. Unfortunately, that same year, graduates from that program failed the oral Board examination. Whatever its other policies, the Board has always maintained that individuals in academic positions should be at least as competent and preferably more competent than others and that their education should be at least as comprehensive and preferably more comprehensive than others. Certainly, there can be no quarrel with providing outstanding house officers with the opportunity to develop skills beyond those needed in practice, but there may be argument about developing other skills instead of those needed in practice. Let us look at Board policy and see where it needs to be adjusted to accommodate academic programs. The second American Gynecological and Obstetrical Society committee has arbitrarily defined an academic program as one with the capability of preparing house officers to practice as specialist/consultant obstetrician/ gynecologists. This essentially is what the Board seeks to evaluate in every candidate for certification. The
Jaffe
greater flexibility also might be beneficial if individuals are to be prepared for productive, academic research careers. Many of the current obstetric-gynecologic leaders in reproductive research pursued training programs that would be proscribed by current guidelines of the subspecialty boards. Thus, while many spent 1 or 2 years in a laboratory either abroad or in a basic science department in the United States, these are not components of "approved" programs of the current subspecialty disciplines. Furthermore, extensive clinical requirements, for example, the need for reproductive endocrinologists to train in tubal microsurgery and in vitro fertilization, and the large amounts of time in clinical pursuits mandated in fetal and maternal medicine and oncology mitigate against obtaining the requisite training to pursue an independent, productive, and competitive research-oriented career-and the discipline sorely needs this facet of the specialty better represented. Although I was not personally involved, the activity of this Society of which I have been most supportive and proud has been the creation ofthe Kennedy-Dannreuther fellowships. They furnish tangible evidence of the Society's commitment to training investigators in the reproductive sciences. To maximize these opportunities, the greatest possible program flexibility needs to be encouraged and facilitated.
Experience with flexibility in an academic residency program Charles H. Hendricks, M.D. Chapel Hill, North Carolina
During my tenure as Director of the Residency Program in Obstetrics and Gynecology at the University of North Carolina at Chapel Hill, from 1968 through 1980, seven principles served as guidelines. All of these principles are important, but the first two were absolutely critical in our residency management during those years: 1. The residency exists primarily to serve the developmental needs of the resident and not the service needs of the hospital where he is being trained. From the Department of Obstetrics and Gynecology, University of North Carolina School of Medicine. Presented at the Fourth Annual Meeting of the American Gynecological and Obstetrical Society, Hot Springs, Virginia, September 4-7, 1985. Reprint requests: Charles H. Hendricks, M.D., Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, 214 MacNider Building 202H, Chapel Hill, NC 27514.
April, 1986 Am J Obstet Gynecol
2. Education is not neatly confined within the white picket fence of any institution nor tidily contained within a classical school year. The University should be thought of as a universal idea rather than as an institution. The strategy of utilizing the University should allow for rearranging the boundaries of time and geography where such adaptations can aid in the development of a single individual's career. 3. A residency should be considered to be a vital, demanding, prolonged postgraduate academic experience. Treating a residency training program as a trade school program demeans both the resident and the residency. 4. Ideally, residency experiences should be designed to help the person reach toward his highest aspirations for his own development. It is unrealistic to design a residency program to produce only academicians or only practitioners. Having high aspirations for a fulltime academic career is no more worthy than having high aspirations for a successful career in private practice. S. The individualization of resident care is just as important as the individualization of patient care. 6. Both the resident and the residency benefit by having some input by the resident, in the design of his own learning program. 7. It is manifestly impossible for the resident to "learn" obstetrics and gynecology during a 4-year period. Rather than "learning" the field, the resident should be learning intellectual inquiry and disciplined study methods that will qualify him as a life-long student in his chosen field. Only in this way can he hope to avoid boredom, obsolescence, and professional decay.
Strategies The residents were selected through the usual selection mechanisms except for those who joined the program at an irregular time. We made provision for accepting as early starters, and therefore early finishers, those individuals who had completed their medical school requirements for the M.D. degree sooner than their fellows had done. During 12 of the years under study here, the resident applicants were encouraged to have some input into their own curriculum, designed to advance their personal goals. Their elective programs were determined partly by their requests and partly by suggestions offered by the faculty. There was no requirement that any resident would have to perform any research. We did take care, however, to provide opportunities for research, which we enthusiastically aided and abetted. If one applies seriously and logically all of the precepts listed above, it is perfectly apparent that there
Volume 154 Number 4
Flexibility in academic obstetric-gynecologic residencies
Table I. Graduates of the University of North Carolina residency program by years, 1970-1982*
Table II. Types of electives chosen by graduates of residency program
Year
1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982
No. of graduates
4 3 2 2 4 5 5 5 3 6
4 5 5
*Mean number of graduates per year, 1970-1974: 3.0. Mean number of graduates per year, 1975-1982: 4.8. will not necessarily be the same number of residents within the home hospital training department at any one time. There will be a great deal of coming and going of residents as they go from one assignment or elective to another in pursuit of the individual 4-year plan. Our training program needed to make allowances for the fact that the training was not even necessarily continuous. For example, when two of our residents dropped out after 2 years to work at the Centers for Disease Control, they returned to finish their final 2 years at the University of North Carolina. Three others joined the program at the second-year level. The total number of graduates did not vary widely from year to year, since some residents transferred quite early to other activities. Altogether, 65 physicians entered the training program. Of these, II (17%) departed for other activities; only one of these was with our program more than a single year. Two entered required military service; after completing the military requirement, one of these went into family medicine, while the other completed the obstetrics and gynecology residency in another program. After no more than I year in our program, one resident left for further training in each of the following specialties: pathology, psychiatry, radiology, radiation therapy, ophthalmology, anesthesiology, pediatrics, and family practice. One resident departed after 2 years to enter the Public Health School. The planned number of residents during most of the years was five per year (Table I). Actually, with one exception, in only one year was that number exceeded: in that year, there were six graduates. It should be noted, however, that in the year just preceding and the year just following that year, the actual number of graduates were only three and four, respectively.
On campus
Research Oncology Extra clinical Surgical specialties Maternal/fetal medicine, including genetics and ultrasound Endocrinology Pathology Anesthesiology Other Total Percent
8 4 I
Off campus
2 6 8
3 5
3
6
I
5
5
I
I 6
6
34 45.3%
4 41 54.7%
781
Total 10 10
9 9 8 6 6 5 12 75
In general, we abided by the guideline that our residents would have 3 years of categorical rotations but not necessarily serve those rotations in any required identical order. This left 12 months for elective experiences. The elective experiences were expected to be worthy of a graduate study level, to be challenging, and also to be building blocks for the long-range growth of the individual. In the preparation of our report on the residents' experiences, the resident graduates were surveyed. During the inclusive years 1970 to 1982, 53 residents completed our program. An additional one who finished a year later is included because he had been away for 2 years at the Centers for Disease Control and thus was a late finisher. The graduates were asked to react to their residency experiences in the light of what they have learned since they have left the residency. They were also asked to describe their current activities, their curricula vitae, and their future plans. Of the 54, 45 (83.3%) responded. The following report draws heavily on their replies and perceptions. Stresses in a flexible system
Of the 54 graduates the great majority indicated their approval of the flexibility features. However, a minority of graduates were critical of the elective system for various reasons. One said he had regrets at having failed to sign up for any electives. One expressed criticism of the program for having failed to apply pressure on him to seek elective experiences. * One superb and stalwart graduate said that he had no opportunity to sign up for electives because he was too busy carrying major patient care clinical loads, which
*My own recollection is that a large proportion of the residents were reluctant to sign up for any elective that they feared would dilute their categorical-type training experience!
782 Hendricks
April, 1986 Am J Obstet Gynecol
Table III. Off-campus training sites for electives within the United States Training site
Area of study
Atlanta-Cullen Richardson Gynecologic surgery Bowman Gray Anesthesia Case Western Reserve Anesthesia Columbia Pathology Duke Endocrinology George Washington Surgery Jefferson Endocrinology Mayo Gynecologic surgery Texas/Southwestern Maternal/fetal medicine University of California Urology (Los Angeles) Sloan-Kettering Oncology Centers for Disease Control Total
No. of residents
2 2 2 I 2 I I
2 I I 3 2 20
indeed he was. Two believed the electives were not evenly distributed. Several found the frequent coming and going of residents and the variability of the size of the resident staff on duty at anyone time to be unsettling. One graduate provided the following insightful commentary on what a flexible program meant to him. "I believe UNC's graduates are able to consider alternatives to diagnosis and treatment because we had time and were encouraged to discuss problems rather than follow a 'cookbook' .... It remains imperative that UNC continue to choose residents that can handle this pressure of being more independent than residents of other programs .... The flexibility of our program is an excellent concept as long as residents or at least the majority of them are able to handle the stress and anxiety of accepting the responsibility that comes with flexibility." Some positive feelings
Here are excerpts from other graduates' reports: "The flexibility of the program at UNC allowed and encouraged me to function as an adult. My assessment is that many residency programs currently treat residents as children, rather than 26 + -year-old individuals who have a good idea about what they need and want in order to grow personally and professionally. 1 would suspect that you will receive an argument against a flexible residency program-the statement that this sort of program would only work for a certain small segment and subset of the total group of GYN residents. While this may to some extent be true, 1 think the encouragement of self-motivation, assessment of character needs, and goals coupled with the guidance when needed from attendings within the basic structure of residency is the optimal situation." " ... the program at UNC provided me with in-
valuable academic contacts and started academic habits ... " "The ease with which alternative educational activities blended with the program, the flexibility both with regard to internal and extramural scheduling, and the sincere (not just lip service) support and encouragement to broaden educational experience were unmatched by any program I interviewed at or have seen since. It still remains an ideal goal for programs 1 am involved with now." "While I believe that the flexibility which you built into the program was exceedingly important, at least equally important in my mind was your strong support of the residents as they sought to take advantage of the opportunities you helped to create." " ... the residency experience was more weighted to postgraduate education and less to technical training than other programs with which I am familiar. Nonetheless, I gained a good basic experience in clinical obstetrics and gynecology, such as surgical techniques and endocrinology, which has enabled me to continue my evolution as a specialist in infertility treatment, and which allows me to apply the skills in preventive medicine and epidemiology which I have also continued to pursue since the residency years." "I am aware and will always be grateful that you squeezed me in after your five first-year slots were filled (to my chagrin!) .... The experience was freewheeling and intellectually exciting. You assembled a critical mass of superb people!" Elective activities
Overall, the residents described 75 elective experiences that were meaningful to them. Thirty-four of these (45%) were electives undertaken on the campus of the University of North Carolina, and 41 (55 %) were taken off campus (Table II). A wide latitude was provided. Most commonly, the electives chosen tended to be grouped within a relatively few areas. Over half of the experiences described focused on five areas. Ten residents had one or more oncology electives. Ten had research electives, nine had surgical specialty electives, and nine had extra handson clinical electives. Eight chose electives relative to maternal and fetal medicine, including ultrasound, genetics, and neonatology. The remainder of the 75 electives varied widely in content and objective. 1 will cite five unique electives: (1) A resident joined the Division of Medical Education for 3 months, as preparation for a career in academic medicine. (2) A resident established a university sex education course, which attracted wide interest and imitation. (3) Another resident established our departmental colposcopy clinic. (4) The same resident computerized our oncology records, a most demanding task but most produc-
Flexibility in academic obstetric-gynecologic residencies
Volume 154 Number 4
Into Practice
t
Into Full Time Academics t
67%
33%
Table IV. Off-campus foreign elective sites No. of
Foreign elective site
residents
Jamaica-Project Hope Stockholm-Karolinska Oslo-Norwegian Radium Hospital London-University College Hospital London-King's College Hospital Vienna Israel
4 3
1 1
2 Fig. 1. Percentage of the graduates who went directly into private practice and those who entered full-time academic departments.
1
1 13
Total
Table V. Memberships and certification of graduates of residency program
Listed in Directory, American College of Obstetricians and Gynecologists Diplomates of American Board of Obstetrics and Gynecology*
783
n
%
51154
94.4
51154
94.4
Always in Practice
t
67%
Moved from Academic into Practice
t
14% 19%
t
*Two more ready to take Board examinations for the first time after required waiting period.
tive in his future career. (5) Another resident undertook a heavy reading and study course during her 10week maternity leave. This resulted in an article describing her own physical and emotional response to the pregnancy and delivery process. Publication of that article in turn led to multiple invitations for this graduate to participate extensively with women's education. There were 20 elective experiences conducted at 12 off-campus sites in the United States (Table III). These included service at nine medical schools. Also included were three Galloway Oncology Fellowships at SloanKettering, two 2-year stints away from the residency at the Centers for Disease Control, and two gynecologic surgical rotations in Atlanta. Thirteen of our residents elected to do clerkships abroad (Table IV). Four of these were served at the University of West Indies in Kingston, Jamaica, as part of our Departmental participation in Project Hope. Three electives were served in London (one at University College Hospital and two at King's College Hospital), three at the Karolinska Institute in Stockholm, and one each in Vienna and Israel. It appeared that prolonged furloughs or other absences from our campus did not deter the development of careers-in fact, it was quite the contrary with the Centers for Disease Control. Two of our residents had 2-year furloughs to work there, and a third joined our program at the completion of his 2-year appointment there. In each case the Centers for Disease Control proved to be an exceptionally stimulating and productive environmental influence. The resident who spent a year in Sweden learned research techniques that have helped his academic career.
Always in Academic Medicine Fig. 2. Percentage of those graduates who went directly into practice, those who left academic departments to enter private practice, and those who have remained in full-time academic departments.
Outcomes of a flexible program It is difficult to quantitate precisely the effect that flexibility and versatility in educational endeavor have on the final product, the graduate of such a residency program. As a general indication of overall results, I have elected to report on the following: membership and certification, a description of activities since leaving the residency and their relationships to medical school teaching programs, and evidence of scholarly activities as indicated by publications listed on curricula vitae. Membership and certification. Of our 54 graduates, 51 are listed in the most recent directory of the American College of Obstetricians and Gynecologists. Fiftyone are Diplomates of The American Board of Obstetrics and Gynecology, with two more waiting to take Board examinations for the first time as soon as they are permitted to do so (Table V). Four of our residents used elective opportunities in partial fulfillment of the Board requirements for specialties other than obstetrics and gynecology (Table VI). One resident had a 5-month elective in obstetric anesthesiology. At the completion of his formal residency, he achieved additional experience and ultimately became a Diplomate of The American Board of Anesthesiology. A second resident, having already served an internship in internal medicine, chose to use his 12
784
Hendricks
Practice in North Carolina 50%
April. 1986 Am J Obstet Gynecol
Practice Full Elsewhere Time 31%
119 %1
Fig. 3. Location of graduates in private practice or in full-time academic medicine. One-half of the graduates are now in practice in North Carolina.
None
Part Time
Total, All Groups
Always Full Time Full Time, then Into Practice Always in Practice
Full Time
44
~
41%
41%
119%1 I
mean
1.2
~ 34.6
61.3
17.3
Fig. 5. Publications listed by graduates according to current professional activity. Of the 934 total listed publications, 613 appeared on the curricula vitae of the 10 full-time academicians.
59% Fig. 4. Nearly three-fifths of the graduates now hold full-time or clinical teaching appointments. months of electives entirely for internal medicine rotations, thus completing the formal training requirements that ultimately allowed him to become a Diplomate of The American Board of Internal Medicine. A third resident, having interned and then served a year of residency elsewhere that was followed by 2 years at the Centers for Disease Control, joined our program as a second-year resident for the final 3 years of his training experience. For his elective work he chose to obtain a Master of Public Health degree in our Public Health School, which ultimately helped him become a Diplomate of The American Board of Public Health and Preventive Medicine. A fourth resident also achieved a M.P.H. degree during his residency and was also able to become a Diplomate of the American Board of Public Health and Preventive Medicine. Activities after leaving the residency. Of the 54 graduates, 36 (67%) went directly into private practice, while 18 (33%) went into full-time academic careers (Fig. 1). Of these, 16 were in medical school academic programs and two became permanent officers at the Centers for Disease Control, a career which, in my opinion, represents the equivalent of full-time academic activity. With the passage of time, eight of those originally in full-time academic medicine moved from academic careers to full-time practice, leaving only 10 now in fulltime academic careers (Fig. 2). Where are they now? At present, 27 (50%) of the graduates of the program are in full-time private practice in North Carolina (Fig. 3). The primary mandate and mission of our training program was to produce well-trained specialists to serve the State, and it appears
Table VI. Certification by a Board in addition to certification by the American Board of Obstetrics and Gynecology Additional Board certification
Public health and preventive medicine Anesthesiology Internal medicine Total Percent
No. of residents
2 1 1 4 7.4%
that this mandate has been well fulfilled. Seventeen (31 %) are in private practice elsewhere, while 10 (19%) are still in full-time academic medicine. It is a matter of interest to note the current relationship between our 54 graduates and their teaching activities at various medical schools (Fig. 4). As mentioned, 10 are full-time staff members, but in addition to this, 22 (41 %) hold part-time appointments for medical student and/or resident training in association with various medical schools across the country.* Thus 59% are currently performing teaching obligations in one of 12 medical schools. Four schools are in North Carolina: Bowman-Gray School of Medicine, Duke University, East Carolina University, and the University of North Carolina. The medical schools outside North Carolina are University of Arizona, Emory University, Hershey Medical Center, University of Mississippi, University of Nevada, Ohio State University, University of Oklahoma, and University of Oregon. Publications. The publications to date as listed on
*The two Centers for Disease Control officers also have clinical appointments but are listed with the academic fulltime quota and are not counted in the part-time teaching group.
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785
Table VII. Publications listed on curricula vitae of the 54 graduates No. of publications
Always in private practice
Over 100 51-100 26-50 6-25 1-5 None
8 26
Total
26
Full-time academic, then private practice
I I
the curriculum vitaes submitted by the various graduates are shown in Table VII. With very few exceptions, all items submitted are listed, including abstracts, papers in journals, chapters, books, and a scattering of articles appearing in non-peer reviewed publications. The 36 residents who have always been in private practice list a total of 44 publications or a mean of 1.2 publications per graduate. The individuals who started out in full-time academic careers but then went into full-time practice have published a total of 277 articles, a mean of 34.6 per graduate. The 10 individuals always in full-time academic medicine list a total of 613 publications, a mean of 61 per full-time graduate (Fig. 5). In conclusion, it should be stated that a program as flexible as ours was during the decade of the 1970s would not be applicable to most other American training programs. There may be some features of our approach, however, that might find limited usefulness in the 1980s.
Response on the need for flexibility in academic obstetric-gynecologic residencies James A. Merrill, M.D. Seattle, Washington It is appropriate that the American Gynecological and Obstetrical Society be concerned with resident education in our discipline and that emphasis be on the production of individuals who will further education and research. This is not the first time such an issue has been addressed here. In 1953 the American Gynecological Society appointed a committee to study the problem of recruitment of academic personnel for the
From The American Board of Obstetrics and Gynecology. Presented at the Fourth Annual Meeting of the American Gynecological and Obstetrical Society, Hot Springs, Virginia, September 4-7, 1985. Reprint requests: James A. Merrill, M.D., The American Board of Obstetrics and Gynecology, Inc., 4507 University Way N.E., Suite 204, Seattle, WA 98105.
Always full-time academic
Total
4 I
I 6 I I I
2 7 3 6 10
8
10
54
I I I
specialty of obstetrics and gynecology. The work of that committee lead to the publication in 1961 of a report entitled "The Recruitment of Talent for a Medical Specialty." Many of the observations and recommendations in that report remain valid in 1985, 25 years later. Although the recent American Gynecological and Obstetrical Society committees have addressed many of the same issues included in the earlier report, they have concentrated their interests on graduate medical education and preparation for academic careers. The American Gynecological and Obstetrical Society committee has stated "... If we are to develop different tracks for those preparing themselves for academic careers, the policies of The American Board of Obstetrics and Gynecology and the Residency Review Committee must be adjusted to accommodate them." This morning's symposium is a discussion of that opinion. Many years ago the program director of a prestigious residency program proposed that graduates of his program should be certified by the Board without the necessity of examination. He reasoned that his program was at least 2 years longer than standard residency programs and that residents were selected because of their talent and interest in academic medicine. Unfortunately, that same year, graduates from that program failed the oral Board examination. Whatever its other policies, the Board has always maintained that individuals in academic positions should be at least as competent and preferably more competent than others and that their education should be at least as comprehensive and preferably more comprehensive than others. Certainly, there can be no quarrel with providing outstanding house officers with the opportunity to develop skills beyond those needed in practice, but there may be argument about developing other skills instead of those needed in practice. Let us look at Board policy and see where it needs to be adjusted to accommodate academic programs. The second American Gynecological and Obstetrical Society committee has arbitrarily defined an academic program as one with the capability of preparing house officers to practice as specialist/consultant obstetrician/ gynecologists. This essentially is what the Board seeks to evaluate in every candidate for certification. The