- Email: [email protected]
Internal Medicine Residency Redesign: Proposal of the Internal Medicine Working Group
REVIEW
Internal Medicine Residency Redesign: Proposal of the Internal Medicine Working Group Ralph I. Horwitz, MD,a Jerome P. Kassirer, MD,b Eric S. Holmboe, MD,c Holly J. Humphrey, MD,d Abraham Verghese, MD,e Carol Croft, MD,f Minjung Kwok, MPH,e Joseph Loscalzo, MDg a
GlaxoSmithKline, King of Prussia, Pa; bTufts University; cAmerican Board of Internal Medicine, Philadelphia, Pa; dUniversity of Chicago, Ill; eStanford University, Palo Alto, Calif; fUniversity of Texas Southwestern, Dallas; gBrigham and Women’s Hospital, Boston, Mass.
ABSTRACT Concerned with the quality of internal medicine training, many leaders in the field assembled to assess the state of the residency, evaluate the decline in interest in the specialty, and create a framework for invigorating the discipline. Although many external factors are responsible, we also found ourselves culpable: allowing senior role models to opt out of important training activities, ignoring a progressive atrophy of bedside skills, and focusing on lock-step curricula, lectures, and compiled diagnostic and therapeutic strategies. The group affirmed its commitment to a vision of internal medicine rooted in science and learned with mentors at the bedside. Key factors for new emphasis include patient-centered small group teaching, greater incorporation of clinical epidemiology and health services research, and better schedule control for trainees. Because previous proposals were weakened by lack of evidence, we propose to organize the Cooperative Educational Studies Group, a pool of training programs that will collect a common data set describing their programs, design interventions to be tested rigorously in multimethodological approaches, and at the same time produce knowledge about high-quality practice. © 2011 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2011) 124, 806-812 KEYWORDS: Clinical examination; Internal medicine; Medical education
The pace of change in internal medicine resident education is accelerating. Many of the recent changes have been intended to mitigate features of the residency experience believed to be related to unacceptably high rates of medical errors and the associated need for quality improvement. Concerned that resident fatigue may be a greater risk to patient safety than frequent patient hand-offs, considerable attention has been directed to work hours and time spent in the hospital. Similarly, fueled by the belief that many medical errors could be prevented by better adoption of enFunding: Josiah Macy, Jr, Foundation; California HealthCare Foundation; and a gift from an anonymous fund of the San Antonio Area Foundation. Conflict of Interest: Eric Holmboe is employed by the American Board of Internal Medicine. None of the other authors have any conflicts of interest associated with the work presented in this manuscript. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Ralph I. Horwitz, MD, GlaxoSmithKline, 709 Swedeland Road, King of Prussia, PA 19406. E-mail address: [email protected]
0002-9343/$ -see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2011.03.007
hancements in the system of medical care, regulators have required a greater emphasis on systems-based care in the residency curriculum. Unfortunately, the relentless process of reform and regulatory oversight in resident education has rarely been based on rigorous evidence that measures the impact of educational reform on objective measures of resident performance. Regrettably, internal medicine has not required similar standards of evidence to guide educational interventions that it preaches are required to adopt new diagnostic and therapeutic interventions. We believe that this inattention to rigorous evidence by which to guide the design of resident education has weakened internal medicine training, has given undue weight to opinions of authorities external to the practice of internal medicine, and has the potential to create an internal medicine workforce that is unprepared for the contemporary practice of medicine. We firmly believe that the field of internal medicine must adopt an attitude of continual improvement in training that can only be achieved with a renewed dedication to rigorous, evidence-based
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ment dominate. The information gained by the history and change. What is at stake is much too great to be subject to justification based on long-standing tradition or the assumpthe physical examination also has gradually become viewed tion of face validity. as being of little value when compared with the insights To assess the status of internal medicine and to propose offered by these imaging and other studies. The decreased new solutions, we assembled 30 internal medicine leaders, emphasis on the skilled history and physical examination including chairs of medicine, prothat embody the values of the craft gram directors, and officers of the of internal medicine and the loss American Board of Internal Medof these skills mean that an essenCLINICAL SIGNIFICANCE icine. We summarize many of tial bond between physician and their concerns in this review. The patient fails to form because a rit● The internal medicine residency has begroup averred that the richness ual of great import has been come insufficient to accommodate the and intellectual challenges of inshortchanged. public’s expectations, which include ternal medicine have never been Participants believed that the service as healers, morality and integgreater; yet, interest in the internal change in the duration and quality rity, transparency, accountability, and medicine residency has progresof physician time at the bedside guaranteed competence. sively declined. In part, this outhas not been lost on the patient. come is a consequence of inflexiPatients have often commented on ● Internal medicine residency should be ble regulations, but, in part, it also how care seems fractured, replete redesigned to emphasize bedside learncan be attributed to our failure to with hand-offs, with little clarity ing, effectiveness and efficiency in preserve those elements that creas to who is in charge. The brevity medical care, and issues of fatigue durate excitement and to incorporate and lack of skill that characterize ing training. new features that contribute to the the physical examination contrib● To foster these goals, we propose develallure of our discipline. Dissatisute to the patients’ sense that they faction with internal medicine as a are of less consequence than the oping a Cooperative Study Group among career has grown, driven in part by diagnostic images that exist of training programs. opportunities in other specialties, them. increasing emphasis on “lifestyle” Many of these changes are the issues, and reimbursement sysunintended consequences of politems that create income inequities among physician groups, cies that were enacted to improve the care of patients and favoring procedure-oriented specialties. Although students the efficiency of our hospitals and clinics. The growing are largely satisfied with their internal medicine clerkships, emphasis on practice guidelines and the demands for shorter only 2% plan a career in primary care internal medicine and lengths of hospital stay led to 2 contradictory impulses: only 20% claim their core clerkship favorably influenced greater focus on standardization of medical care and, at the them toward a career in internal medicine. Factors that same time, greater tolerance for overuse and misuse of dissuade them include the hectic pace of training, excessive medical tests and procedures. Concurrently, new requirepaperwork and charting, debt levels, the differential reimments for quality improvement, curriculum reporting, data entry, work on “team leadership,” discharge planning meetbursement of generalists and specialists, lifestyle issues, and ings, work hours reporting, and other paperwork detract the overall attractiveness of other specialties.1 The experienced leaders in our symposium voiced many from the direct encounter with patients; the short lengths of concerns that we summarize in this review. Participants stay reduce the opportunity for residents to follow patients agreed that many of the attributes of internal medicine that as their clinical course changes. formerly drew students into the discipline are now in decline. Diagnostics has been largely expunged from resiEXTERNAL FORCES dents’ learning purview as patients often arrive on the hospital wards from the emergency department with diagnoses Graduate medical education is experiencing unprecedented in hand. In the clinics, many patients have already been attention and pressure for reform from policy makers in thoroughly evaluated before residents see them, and clinic Washington, DC. Heightened attention from several key assignments often compete with ward responsibilities. Indipublic constituencies, specifically the Medicare Payment vidual clinical judgment has been devalued. Expediency has Advisory Commission (MedPAC), the Institute of Meditrumped clinical reasoning in diagnostic testing and treatcine, and the Congress, signals the urgent need for internal ment decisions, as armies of specialists are called in to medicine to accelerate efforts at educational reform. The facilitate patient throughput. As single issues dominate a 2008 Institute of Medicine report was critical of efforts to clinical encounter, a holistic assessment of patients that enforce duty hours regulations and of the quality and level includes their social and emotional well-being often goes of supervision provided to trainees.2 This past year, Medlacking. Although all these issues are germane to many PAC also weighed in, raising concern that Graduate Mediother disciplines, they are particularly relevant to internal cal Education training programs are not adequately preparmedicine where cognitive aspects of diagnosis and manageing future physicians to care for an aging population, and
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they opined that Medicare is not getting an appropriate return on its 9 billion dollar investment in Graduate Medical Education. The June 2009 MedPAC report concluded that training programs are not adequately preparing future physicians in the competencies of teamwork, diagnostic reasoning around expensive technology, systems-based practice, health information technology, and quality improvement3 (MedPAC report [chapter 1], available at: www.medpac.gov). The June 2010 MedPAC report again emphasized the need for more attention to these competencies and recommended changes to Graduate Medical Education financing policies to accelerate change. In late 2010, the Accreditation Council for Graduate Medical Education responded to this increasing pressure for change by further restricting work hours in hospital for interns. Regardless of the shape that health care reform ultimately takes, it seems likely that pressure will continue to come from constituencies such as the Center for Medicare and Medicaid Services, MedPAC, Institute of Medicine, and others to accelerate the reform of training that would produce a workforce more in line with the needs of an aging and increasingly diverse population. Current internal medicine training formats are clearly limited in this regard.
RECENT REFORM EFFORTS Most residency reform proposals continue to promote 3 years of training. All proposals recommend more emphasis on ambulatory training, but not in the usual clinics; instead, these proposals recommend training in unspecified “innovative” environments with advanced technology. All prefer more longitudinal ambulatory time, unfettered by inpatient responsibilities. To focus on education over “service,” proposals suggest adding hospitalists, creating nonteaching services, diverting more patient care to nurse practitioners and physician assistants, and providing residents assistance with scheduling and discharge planning. They recommend more lectures, workshops, and directed readings. Other features include programs to develop leaders and promote mastery in practice management. New aspects of training also would include patientcentered care, continuous quality improvement, error prevention, informatics, team-based care, systems-based practice, practice-based learning, cost-effective care, efficient care, culturally sensitive care, evidence-based care, and, in some cases, social activism. Promoting professionalism is a major feature of all programs. Many of these aspects are embodied in the 6 Accreditation Council for Graduate Medical Education/American Board of Medical Specialties competencies.4-9 Unfortunately, these proposals are unlikely to reverse the trend away from internal medicine. They do not emphasize the fundamental joy of internal medicine residency training, namely, acquiring new knowledge and sharpening clinical judgment based on one patient encounter after another, in conjunction with adequate time and opportunity for accessing and analyzing specific patient and disease information. None address the loss of the intellectual identity and rigor of
the internal medicine residency. There also is little discussion of the role of bedside “hands-on” medicine. Little explicit consideration is paid to reengaging senior faculty members, who argue that clinical duties, especially teaching students and residents on the wards, distract them from other activities. Indeed, senior faculty balk at their direct involvement because of the fundamental shift in what is required of the attending physician, a change mandated more by a focus on the administrative aspects of medical care rather than on the educational needs of the residents and clinical care needs of patients. There is little doubt that senior faculty bring rich perspectives that shed light on the history of a disease or its management, along with personal narratives that illustrate the richness of our field. Although many of the new aspects described above (patient-centered care, continuous quality improvement, teambased care, systems-based practice, practice-based learning) have potential benefit in improving patient care, a growing list of prescriptive requirements fragments both the training of residents and the care of patients. In addition, they keep residents away from the bedside, and from searching the medical literature, and thus detract from the key learning experience and joy of the patient interaction. As new approaches substitute other direct caregivers for physicians, students and physicians may be removed further from direct encounters with patients. Repeated performance assessments also can be burdensome. To its credit, the Internal Medicine Residency Review Committee has recognized the limitations of these prescriptive approaches to program evaluation and reduced the process-focused accreditation requirements in the most recent iteration of their regulations.10 In sum, it is at least arguable that the existing structure and proposed new features have made residency training more tedious, more regimented, and, consequently, less attractive.
COLLOQUIUM ON RESIDENCY REDESIGN At the recent Colloquium on Internal Medicine Residency Redesign, in which the authors of this article participated, a broad consensus emerged that internal medicine education has lost its focus and eroded its quality. Many participants voiced the worries considered above. They acknowledged the disappearance of senior clinicians and physician-investigators from the training experience; the altered roles of attendings that diminish the essential educational opportunity for house staff to function with increasing independence over time; and the lack of “control” by residents, both in managing their patients and in structuring their schedules. Participants affirmed their commitment to a vision of internal medicine rooted in our traditions, but made current by our embrace of contemporary medical science and clinical practice. All agreed that internal medicine must be learned at the bedside from one patient after another, aided by the right mentors. Of all medicine’s specialties, internal medicine has been most rigorously science-based, both in the generation of new knowledge and in its applications to
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clinical care. Any expression of our educational goals would necessarily require that we instill in our trainees a curiosity for new knowledge, a facility with critical analytic reasoning, and a shared commitment that ensures that internal medicine remains at the innovative edge of practice improvement. It is remarkable but important that internal medicine has managed to pursue 2 contradictory realities simultaneously: the reality that its trainees will have career diversity that is greater than any other medical specialty and the reality that clinical excellence is a non-negotiable demand of our training programs, regardless of whether an internist will work at the bench or computer as a physicianinvestigator, at the bedside or in the office as a clinician, or in government or foundations as a leader in policy or administration. Colloquium participants thus emphasized a parsimonious set of themes that could form the basis for redesigning the residency experience, all of which have at their core the ability to test their impact on the outcomes of resident education.
SOME KEY ISSUES In considering the decline in interest in internal medicine, we have contemplated a number of key issues. Given that internal medicine has been the leading discipline in the development of clinical epidemiology, decision sciences, health services, and cost-effectiveness research, why is it that we have failed to enrich the intellectual substrate of the discipline, made our training exciting, and made these fields of scholarship a compelling part of medical practice? Why have we settled instead for formulaic guidelines? What can we do to accommodate greater flexibility in training program design? How can we reinstitute a sense of empowerment to residents, keep them at the bedside, reduce didactic sessions, eliminate rotations that lack intellectual stimulation, and reengage senior clinicians and clinician-scientists in residency training? What can be done to accommodate the strong interest of medical residents in international health rotations? Could block outpatient (subspecialty) experience suffice for longitudinal ambulatory training? How can we promote and enhance the research experience during training? What can be done in training programs about a lack of attention to the cost of care of the individual patient? And how can we ensure that internal medicine trains physicians who become masters of, not slaves to, technologies that have the potential to both help and harm our patients?
A NEED FOR CHANGE As established members of the academic medicine community, we have had many years of experience with and commitment to the postgraduate education of residents in internal medicine. We recognize the adverse impact produced by these mounting challenges to the professional education of our residents and are concerned that our responses to these challenges thus far have largely been reactive rather than proactive. As a result, the educational environment we have created for our professional progeny falls far short of what
809 is necessary to meet the goals of an effective residency education. We believe that without significant, rational restructuring of the residency program, based primarily on evidence from rigorously designed studies, we will slowly create a generation of internists who have not experienced fully the joy of the profession in all of its dimensions, and, thus, can no longer pass on to their students what we have come to cherish about the profession. Put briefly, we are running the risk of eating our seed corn. We must prevent this irresponsible act of professional desperation and, thus, want to propose an approach in principle to the design of internal medicine residency programs of the future. To do so, we first present the phenotype of the ideal internist. The social contract that governs the profession of medicine creates several public expectations of us as physicians, included among which are altruistic service as healers, morality and integrity, transparency, accountability, promotion of the public good, and guaranteed competence.11,12 We guarantee professional competence, in part, by establishing and overseeing training programs and their assessment. Although the environmental context and the constraints within which we train internists may change, that we ultimately produce competent practitioners remains a firm obligation. Unfortunately, in our recent efforts to react to a changing regulatory and learning environment, we run the risk of failing to meet this key tenet of our social contract. For this reason, the guiding principle in the following plan of attack must be our professional obligation to the terms of the social contract of medicine. Owing to the dynamics of change in the practice and learning environments, the social contract that guides the expectations and obligations of internists and the public, by definition, must respond dynamically: Although its fundamental tenets are invariant, the means by which they are followed must be proactively adapted to constantly changing conditions. Put simply, the social contract of medicine must be continually renewed and refreshed to assure that it is valued and apposite. Sadly, 100 years after the Flexner report, little data from well-designed studies are available to guide the design of residency education in medicine broadly, or internal medicine particularly. We are left to draw analogy from adult learning theory and the research and experience of other fields of education. Acknowledging this research, we now know, for example, that lectures are not an adequate format for learning the knowledge of medicine. Internal medicine training programs are too dependent on large group learning formats. We must return to an emphasis on small group, problem-based learning that supports the education of our residents more effectively. Much research in education and cognitive sciences has emphasized that knowledge is a prerequisite for expertise. Knowledge acquisition cannot be abandoned to the availability of computer-based information sites. Evidence also exists that experiential learning remains at the core of successful professional practice. Finally, and perhaps most important, efficient learning in high-stress environments requires that our trainees have a greater sense of control over their environment and their
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practices. Each of these principles should guide the development of strategies to reform internal medicine residency education.13,14
SOME THEMES FOR RESIDENCY REDESIGN 1) Knowledge as a prerequisite for expertise: It is certainly true that knowledge has never been more democratic. The web has made it easier than ever before to locate information and especially to find the evidence that guides clinical decisions. Yet, it also is true that numerous studies have demonstrated the link between knowledge and expertise. In medicine, the care of patients demands that the practitioner has up-to-date knowledge that is effectively integrated and readily applied to clinical care. Even today, most residency programs rely heavily on lectures and seminars to convey information. Small group formats with problem-based learning approaches remain infrequent, despite their demonstrated effectiveness.15 Unfortunately, experiential, bedside learning, which has always been central to education in medicine, is now often conflated with “service”: Learning while doing with the patient at the center of the experience and the physician at the bedside needs to be acknowledged again as a core value in the training of physicians.16,17 2) Effectiveness and efficiency in medical care: Clinical practice guidelines have become ready substitutes for the rigorous and parsimonious practice of medicine.18 Internal medicine developed the fields of clinical epidemiology, health services’ research, and decision analysis. Regrettably, despite the academic success of these endeavors, internists have rarely succeeded in linking research in these fields to clinical education. This failure is especially ironic as genomic, “personalized” medicine emerges as a new focus of research-based practice. Now, more than ever, internal medicine must embrace a new commitment to relying less on rules and more on integrating evidence into practice and to achieving greater clinical efficiencies in our healthcare system. 3) “High demand/high control” setting for residents: Fatigue and stress have become recognized as adversities that impair both the quality of care and of resident education. Lacking more specific evidence on the effects of sleep loss on clinical performance, and uncertain of the causes of stress in the residency, well-intentioned regulators have relied on surrogate evidence to guide the design of resident schedules. Data from sleep studies have been used to justify decisions about the total number of hours a resident can work each week and have guided the number of hours that can be worked before sleep is required. We are all familiar with the unintended consequences of these narrow policies: the hazardous “hand-offs” of patients; the frequent, misleading comments from residents who do not want to report hours “violations”; and the increased stress created in the hour or 2 before residents need to leave the hospital. Most
academicians understand how residents are caught between the consequences to their programs if they report the hours violations and their responsibility to their patients, but we should not “cover up the issue” or make excuses for the problem other than the unintended consequences of these narrow policies.
PROPOSAL: FORMATION OF A COOPERATIVE STUDY GROUP We propose the formation of a formal mechanism for refreshing a fundamental tenet of the social contract of internal medicine, that is, to ensure the competency of its internists. We base our proposal on 2 assumptions—that the qualities of the ideal internist are time-invariant and that the context in which we train internists will continually change and constrain the means by which we strive to achieve the ideal. To meet this challenge of maintaining a high standard in the face of changing constraints, we suggest that the time has come to create a national cooperative studies program in educational research modeled after the successful Veterans Affairs program testing the effectiveness of medicines and procedures. The purpose of this program would be to conduct cooperative trials of training approaches that would test the efficacy of any major changes in training program structure before they are recommended for regulatory implementation. As evidence-based practitioners, we recognize that training program structure and its many configurations imposed from within a program or by outside agencies have not been based on irrefutable proof; rather, they have been predicated on longstanding tradition, analogy to other training environments, or face validity. We do not feel at all sanguine about program structures and their implementation imposed without evidence for their efficacy because so very much is at stake, primarily the need to produce a competent internist, at the very least, and the ideal internist, at best. In the following section, we outline the strategies that could be used to develop the evidence base for reinvigorating internal medicine training.
Cooperative Educational Studies Group We propose a Cooperative Educational Studies Group composed of a consortium of willing programs that reflect the full spectrum of internal medicine training programs. Each institution would collect a standardized data set that creates a common collection of information describing their programs, residents, and faculty. Among the initial data set to be assembled would be elements that describe operational characteristics of the medical service; allocation of educational time and activities; and patient, resident, and faculty satisfaction with clinical care and work environment. Perhaps most important are the specific interventions that would be tested in multimethodological approaches to the evaluation of current performance and the assessment of change. Some of the earliest interventions could focus on the content of internal medicine training, the formats for learning, the role of attending physicians, and the resident control
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over their schedules and management of patients. The Education Innovations Project sponsored by the Internal Medicine Residency Review Committee and the Accreditation Council for Graduate Medical Education encourage innovation on residency education. The University of Cincinnati has worked under this initiative to evaluate a 14-month “long block” approach for ambulatory training.19 An example of a future intervention might be an examination of the impact of a set of technique-dependent clinical skills (Stanford 25) that emphasize the importance of the clinical examination for both enhanced care efficiency and a stronger bond between doctor and patient (see website at http:// medicine.stanford.edu/education/stanford25overview.html for further details).20 Further examination of the impact of “intensive-teaching units” as tested at Brigham and Women’s Hospital might be another.21 Few issues have proven more intractable than the tension between the high stress our residents feel in their training and the lack of control they have in carrying out their responsibilities. Although this is a complex problem, one approach to greater resident control involves the full geographic localization of patients on medical services. The University of Pennsylvania Internal Medicine Residency Program has evolved an innovative strategy to achieve localization through collaboration of the hospital, the department of internal medicine, and the department of emergency medicine. Their approach might be a third example of an intervention that needs to be tested in a consortium of hospitals that have struggled to replicate their success. Finally, we should emphasize the multi-methodological approach to the conduct of this research. Qualitative studies are needed to create a comprehensive set of themes through focus groups, surveys, and observational studies. Educational trials will be required that have clearly defined interventions, well-circumscribed and reproducible end points, and sufficient sample size to detect meaningful differences. Most important, participating programs will need to be committed to longitudinal research and practice that ensure incremental improvements over time. Some of the changes we test can be rapidly assessed for benefits; most will require years of evaluation and a ready flexibility that can accommodate and address new interventions as they evolve. There should be no constraint on the range of potential changes that could be tested in the Cooperative Educational Studies Group. Assumptions about the impact of decreased work hours on resident performance might be assessed against the effects of increased control by residents over their work schedules. Strategies to improve the skills of residents in the clinical examination, including reintroducing oral examinations in some programs, could be assessed for its impact on the use of expensive medical tests and procedures. Requirements for public service might be tested for its effects on career choices and attitudes toward professionalism. These are just a few possible strategies that would help to point a new direction for training programs and reinvigorate internal medicine education.
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CONCLUSIONS Having developed the background and guiding principles for this approach to restructuring training programs rationally, it will be necessary to develop the questions and hypotheses, the outcome metrics that would be used, and the trials designed to test them in existing training programs. Such study designs will require broad discussions with all interested parties, from training program directors to regulatory agencies to credentialing bodies. We believe that only by establishing such a formal mechanism of educational research will we be able to meet our obligations to society, regardless of the nature or magnitude of changes within our practice and learning environments.
ACKNOWLEDGMENTS The authors acknowledge the intellectual contributions of many internal medicine leaders who participated in an invited conference that initiated this project. They included Osman Akhtar, Joseph Alpert, Michele Barry, Carol Bates, David W. Bates, Jay Bhattacharya, William Bremner, Troyen Brennan, David Coleman, Mark Cullen, Jack Ende, Faith T. Fitzgerald, Terry Fulmer, Mark Henderson, Harry Hollander, Joel Katz, Talmadge E. King, Richard Kopelman, Eric B. Larson, Kenneth M. Ludmerer, Jeanette Mladenovic, Asghar Rastegar, Paul Rothman, Richard Shannon, Kelley Skeff, Lawrence Smith, and Jimmy Stewart.
References 1. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students’ career choices regarding internal medicine. JAMA. 2008;300:1154-1164. 2. Ulmer C, Wolman DM, Johns MME, eds. Resident Duty Hours: Enhancing Sleep, Supervision and Safety. Institute of Medicine. Washington, DC: The National Academies Press; 2008. 3. Medicare Payment Advisory Commission. Report to the Congress: Improving Incentives in the Medicine Program. Available at: http:// www.medpac.gov. Accessed June 2009. 4. Schroeder SA, Sox HC. Internal medicine training: putt or get off the green. Ann Intern Med. 2006;144:938-939. 5. Fitzgibbons JP, Bordley DR, Berkowitz LR, et al. Redesigning residency education in Internal Medicine: a position paper from the Association of Program Directors in Internal Medicine. Ann Intern Med. 2006;144:920-926. 6. Larson EB. Health care system chaos should spur innovation: summary of a report of the Society of General Internal Medicine Task Force on the Domain of Internal Medicine. Ann Intern Med. 2004; 140:639-643. 7. Ludmerer KM, Johns MM. Reforming graduate medical education. JAMA. 2005;294:1083-1087. 8. Weinberger SE, Smith LG, Collier VU. Redesigning training for internal medicine. Ann Intern Med. 2006;144:927-932. 9. Huddle TS, Heudebert GR. Internal medicine training in the 21st century. Acad Med. 2008;83:910-915. 10. The Residency Review Committee for Internal Medicine, Program requirements. July 2009. 11. Starr P. The Social Transformation of American Medicine. New York: Basic Books; 1984. 12. Cruess SR, Cruess RL. Professionalism: a contract between medicine and society. CMAJ. 2000;162:668-669. 13. Kaufman DH. ABC of learning and teaching in medicine: applying educational theory in practice. BMJ. 2003;326:213-216.
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14. Colliver JA. Effectiveness of problem-based learning curricula: research and theory. Acad Med. 2000;75:259-266. 15. Kassirer JP. Teaching clinical reasoning: case-based and coached. Acad Med. 2010;85:1118-1124. 16. Van Merriënboer JJG, Sweller J. Cognitive load theory and complex learning: recent developments and future directions. Educ Psychol Rev. 2005;17:147-177. 17. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79(10 Suppl.):S70-S81.
18. Kassirer JP. Does instant access to compiled information undermine clinical cognition? Lancet. 2010;376:1510-1511. 19. Warm EJ, Schauer DP, Diers T, et al. The ambulatory long-block: an accreditation council for graduate medical education (ACGME) educational innovations project (EIP). J Gen Intern Med. 2008;23:921-926. 20. Verghese A, Horwitz RI. In praise of the physical examination. BMJ. 2009;339:b5448. 21. McMahon GT, Katz JT, Thorndike ME, Levy BD, Loscalzo J. Evaluation of a redesign initiative in an internal medicine residency. N Engl J Med. 2010;362:1304-1311.
Internal Medicine Residency Redesign: Proposal of the Internal Medicine Working Group Ralph I. Horwitz, MD,a Jerome P. Kassirer, MD,b Eric S. Holmboe, MD,c Holly J. Humphrey, MD,d Abraham Verghese, MD,e Carol Croft, MD,f Minjung Kwok, MPH,e Joseph Loscalzo, MDg a
GlaxoSmithKline, King of Prussia, Pa; bTufts University; cAmerican Board of Internal Medicine, Philadelphia, Pa; dUniversity of Chicago, Ill; eStanford University, Palo Alto, Calif; fUniversity of Texas Southwestern, Dallas; gBrigham and Women’s Hospital, Boston, Mass.
ABSTRACT Concerned with the quality of internal medicine training, many leaders in the field assembled to assess the state of the residency, evaluate the decline in interest in the specialty, and create a framework for invigorating the discipline. Although many external factors are responsible, we also found ourselves culpable: allowing senior role models to opt out of important training activities, ignoring a progressive atrophy of bedside skills, and focusing on lock-step curricula, lectures, and compiled diagnostic and therapeutic strategies. The group affirmed its commitment to a vision of internal medicine rooted in science and learned with mentors at the bedside. Key factors for new emphasis include patient-centered small group teaching, greater incorporation of clinical epidemiology and health services research, and better schedule control for trainees. Because previous proposals were weakened by lack of evidence, we propose to organize the Cooperative Educational Studies Group, a pool of training programs that will collect a common data set describing their programs, design interventions to be tested rigorously in multimethodological approaches, and at the same time produce knowledge about high-quality practice. © 2011 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2011) 124, 806-812 KEYWORDS: Clinical examination; Internal medicine; Medical education
The pace of change in internal medicine resident education is accelerating. Many of the recent changes have been intended to mitigate features of the residency experience believed to be related to unacceptably high rates of medical errors and the associated need for quality improvement. Concerned that resident fatigue may be a greater risk to patient safety than frequent patient hand-offs, considerable attention has been directed to work hours and time spent in the hospital. Similarly, fueled by the belief that many medical errors could be prevented by better adoption of enFunding: Josiah Macy, Jr, Foundation; California HealthCare Foundation; and a gift from an anonymous fund of the San Antonio Area Foundation. Conflict of Interest: Eric Holmboe is employed by the American Board of Internal Medicine. None of the other authors have any conflicts of interest associated with the work presented in this manuscript. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Ralph I. Horwitz, MD, GlaxoSmithKline, 709 Swedeland Road, King of Prussia, PA 19406. E-mail address: [email protected]
0002-9343/$ -see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2011.03.007
hancements in the system of medical care, regulators have required a greater emphasis on systems-based care in the residency curriculum. Unfortunately, the relentless process of reform and regulatory oversight in resident education has rarely been based on rigorous evidence that measures the impact of educational reform on objective measures of resident performance. Regrettably, internal medicine has not required similar standards of evidence to guide educational interventions that it preaches are required to adopt new diagnostic and therapeutic interventions. We believe that this inattention to rigorous evidence by which to guide the design of resident education has weakened internal medicine training, has given undue weight to opinions of authorities external to the practice of internal medicine, and has the potential to create an internal medicine workforce that is unprepared for the contemporary practice of medicine. We firmly believe that the field of internal medicine must adopt an attitude of continual improvement in training that can only be achieved with a renewed dedication to rigorous, evidence-based
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ment dominate. The information gained by the history and change. What is at stake is much too great to be subject to justification based on long-standing tradition or the assumpthe physical examination also has gradually become viewed tion of face validity. as being of little value when compared with the insights To assess the status of internal medicine and to propose offered by these imaging and other studies. The decreased new solutions, we assembled 30 internal medicine leaders, emphasis on the skilled history and physical examination including chairs of medicine, prothat embody the values of the craft gram directors, and officers of the of internal medicine and the loss American Board of Internal Medof these skills mean that an essenCLINICAL SIGNIFICANCE icine. We summarize many of tial bond between physician and their concerns in this review. The patient fails to form because a rit● The internal medicine residency has begroup averred that the richness ual of great import has been come insufficient to accommodate the and intellectual challenges of inshortchanged. public’s expectations, which include ternal medicine have never been Participants believed that the service as healers, morality and integgreater; yet, interest in the internal change in the duration and quality rity, transparency, accountability, and medicine residency has progresof physician time at the bedside guaranteed competence. sively declined. In part, this outhas not been lost on the patient. come is a consequence of inflexiPatients have often commented on ● Internal medicine residency should be ble regulations, but, in part, it also how care seems fractured, replete redesigned to emphasize bedside learncan be attributed to our failure to with hand-offs, with little clarity ing, effectiveness and efficiency in preserve those elements that creas to who is in charge. The brevity medical care, and issues of fatigue durate excitement and to incorporate and lack of skill that characterize ing training. new features that contribute to the the physical examination contrib● To foster these goals, we propose develallure of our discipline. Dissatisute to the patients’ sense that they faction with internal medicine as a are of less consequence than the oping a Cooperative Study Group among career has grown, driven in part by diagnostic images that exist of training programs. opportunities in other specialties, them. increasing emphasis on “lifestyle” Many of these changes are the issues, and reimbursement sysunintended consequences of politems that create income inequities among physician groups, cies that were enacted to improve the care of patients and favoring procedure-oriented specialties. Although students the efficiency of our hospitals and clinics. The growing are largely satisfied with their internal medicine clerkships, emphasis on practice guidelines and the demands for shorter only 2% plan a career in primary care internal medicine and lengths of hospital stay led to 2 contradictory impulses: only 20% claim their core clerkship favorably influenced greater focus on standardization of medical care and, at the them toward a career in internal medicine. Factors that same time, greater tolerance for overuse and misuse of dissuade them include the hectic pace of training, excessive medical tests and procedures. Concurrently, new requirepaperwork and charting, debt levels, the differential reimments for quality improvement, curriculum reporting, data entry, work on “team leadership,” discharge planning meetbursement of generalists and specialists, lifestyle issues, and ings, work hours reporting, and other paperwork detract the overall attractiveness of other specialties.1 The experienced leaders in our symposium voiced many from the direct encounter with patients; the short lengths of concerns that we summarize in this review. Participants stay reduce the opportunity for residents to follow patients agreed that many of the attributes of internal medicine that as their clinical course changes. formerly drew students into the discipline are now in decline. Diagnostics has been largely expunged from resiEXTERNAL FORCES dents’ learning purview as patients often arrive on the hospital wards from the emergency department with diagnoses Graduate medical education is experiencing unprecedented in hand. In the clinics, many patients have already been attention and pressure for reform from policy makers in thoroughly evaluated before residents see them, and clinic Washington, DC. Heightened attention from several key assignments often compete with ward responsibilities. Indipublic constituencies, specifically the Medicare Payment vidual clinical judgment has been devalued. Expediency has Advisory Commission (MedPAC), the Institute of Meditrumped clinical reasoning in diagnostic testing and treatcine, and the Congress, signals the urgent need for internal ment decisions, as armies of specialists are called in to medicine to accelerate efforts at educational reform. The facilitate patient throughput. As single issues dominate a 2008 Institute of Medicine report was critical of efforts to clinical encounter, a holistic assessment of patients that enforce duty hours regulations and of the quality and level includes their social and emotional well-being often goes of supervision provided to trainees.2 This past year, Medlacking. Although all these issues are germane to many PAC also weighed in, raising concern that Graduate Mediother disciplines, they are particularly relevant to internal cal Education training programs are not adequately preparmedicine where cognitive aspects of diagnosis and manageing future physicians to care for an aging population, and
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they opined that Medicare is not getting an appropriate return on its 9 billion dollar investment in Graduate Medical Education. The June 2009 MedPAC report concluded that training programs are not adequately preparing future physicians in the competencies of teamwork, diagnostic reasoning around expensive technology, systems-based practice, health information technology, and quality improvement3 (MedPAC report [chapter 1], available at: www.medpac.gov). The June 2010 MedPAC report again emphasized the need for more attention to these competencies and recommended changes to Graduate Medical Education financing policies to accelerate change. In late 2010, the Accreditation Council for Graduate Medical Education responded to this increasing pressure for change by further restricting work hours in hospital for interns. Regardless of the shape that health care reform ultimately takes, it seems likely that pressure will continue to come from constituencies such as the Center for Medicare and Medicaid Services, MedPAC, Institute of Medicine, and others to accelerate the reform of training that would produce a workforce more in line with the needs of an aging and increasingly diverse population. Current internal medicine training formats are clearly limited in this regard.
RECENT REFORM EFFORTS Most residency reform proposals continue to promote 3 years of training. All proposals recommend more emphasis on ambulatory training, but not in the usual clinics; instead, these proposals recommend training in unspecified “innovative” environments with advanced technology. All prefer more longitudinal ambulatory time, unfettered by inpatient responsibilities. To focus on education over “service,” proposals suggest adding hospitalists, creating nonteaching services, diverting more patient care to nurse practitioners and physician assistants, and providing residents assistance with scheduling and discharge planning. They recommend more lectures, workshops, and directed readings. Other features include programs to develop leaders and promote mastery in practice management. New aspects of training also would include patientcentered care, continuous quality improvement, error prevention, informatics, team-based care, systems-based practice, practice-based learning, cost-effective care, efficient care, culturally sensitive care, evidence-based care, and, in some cases, social activism. Promoting professionalism is a major feature of all programs. Many of these aspects are embodied in the 6 Accreditation Council for Graduate Medical Education/American Board of Medical Specialties competencies.4-9 Unfortunately, these proposals are unlikely to reverse the trend away from internal medicine. They do not emphasize the fundamental joy of internal medicine residency training, namely, acquiring new knowledge and sharpening clinical judgment based on one patient encounter after another, in conjunction with adequate time and opportunity for accessing and analyzing specific patient and disease information. None address the loss of the intellectual identity and rigor of
the internal medicine residency. There also is little discussion of the role of bedside “hands-on” medicine. Little explicit consideration is paid to reengaging senior faculty members, who argue that clinical duties, especially teaching students and residents on the wards, distract them from other activities. Indeed, senior faculty balk at their direct involvement because of the fundamental shift in what is required of the attending physician, a change mandated more by a focus on the administrative aspects of medical care rather than on the educational needs of the residents and clinical care needs of patients. There is little doubt that senior faculty bring rich perspectives that shed light on the history of a disease or its management, along with personal narratives that illustrate the richness of our field. Although many of the new aspects described above (patient-centered care, continuous quality improvement, teambased care, systems-based practice, practice-based learning) have potential benefit in improving patient care, a growing list of prescriptive requirements fragments both the training of residents and the care of patients. In addition, they keep residents away from the bedside, and from searching the medical literature, and thus detract from the key learning experience and joy of the patient interaction. As new approaches substitute other direct caregivers for physicians, students and physicians may be removed further from direct encounters with patients. Repeated performance assessments also can be burdensome. To its credit, the Internal Medicine Residency Review Committee has recognized the limitations of these prescriptive approaches to program evaluation and reduced the process-focused accreditation requirements in the most recent iteration of their regulations.10 In sum, it is at least arguable that the existing structure and proposed new features have made residency training more tedious, more regimented, and, consequently, less attractive.
COLLOQUIUM ON RESIDENCY REDESIGN At the recent Colloquium on Internal Medicine Residency Redesign, in which the authors of this article participated, a broad consensus emerged that internal medicine education has lost its focus and eroded its quality. Many participants voiced the worries considered above. They acknowledged the disappearance of senior clinicians and physician-investigators from the training experience; the altered roles of attendings that diminish the essential educational opportunity for house staff to function with increasing independence over time; and the lack of “control” by residents, both in managing their patients and in structuring their schedules. Participants affirmed their commitment to a vision of internal medicine rooted in our traditions, but made current by our embrace of contemporary medical science and clinical practice. All agreed that internal medicine must be learned at the bedside from one patient after another, aided by the right mentors. Of all medicine’s specialties, internal medicine has been most rigorously science-based, both in the generation of new knowledge and in its applications to
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clinical care. Any expression of our educational goals would necessarily require that we instill in our trainees a curiosity for new knowledge, a facility with critical analytic reasoning, and a shared commitment that ensures that internal medicine remains at the innovative edge of practice improvement. It is remarkable but important that internal medicine has managed to pursue 2 contradictory realities simultaneously: the reality that its trainees will have career diversity that is greater than any other medical specialty and the reality that clinical excellence is a non-negotiable demand of our training programs, regardless of whether an internist will work at the bench or computer as a physicianinvestigator, at the bedside or in the office as a clinician, or in government or foundations as a leader in policy or administration. Colloquium participants thus emphasized a parsimonious set of themes that could form the basis for redesigning the residency experience, all of which have at their core the ability to test their impact on the outcomes of resident education.
SOME KEY ISSUES In considering the decline in interest in internal medicine, we have contemplated a number of key issues. Given that internal medicine has been the leading discipline in the development of clinical epidemiology, decision sciences, health services, and cost-effectiveness research, why is it that we have failed to enrich the intellectual substrate of the discipline, made our training exciting, and made these fields of scholarship a compelling part of medical practice? Why have we settled instead for formulaic guidelines? What can we do to accommodate greater flexibility in training program design? How can we reinstitute a sense of empowerment to residents, keep them at the bedside, reduce didactic sessions, eliminate rotations that lack intellectual stimulation, and reengage senior clinicians and clinician-scientists in residency training? What can be done to accommodate the strong interest of medical residents in international health rotations? Could block outpatient (subspecialty) experience suffice for longitudinal ambulatory training? How can we promote and enhance the research experience during training? What can be done in training programs about a lack of attention to the cost of care of the individual patient? And how can we ensure that internal medicine trains physicians who become masters of, not slaves to, technologies that have the potential to both help and harm our patients?
A NEED FOR CHANGE As established members of the academic medicine community, we have had many years of experience with and commitment to the postgraduate education of residents in internal medicine. We recognize the adverse impact produced by these mounting challenges to the professional education of our residents and are concerned that our responses to these challenges thus far have largely been reactive rather than proactive. As a result, the educational environment we have created for our professional progeny falls far short of what
809 is necessary to meet the goals of an effective residency education. We believe that without significant, rational restructuring of the residency program, based primarily on evidence from rigorously designed studies, we will slowly create a generation of internists who have not experienced fully the joy of the profession in all of its dimensions, and, thus, can no longer pass on to their students what we have come to cherish about the profession. Put briefly, we are running the risk of eating our seed corn. We must prevent this irresponsible act of professional desperation and, thus, want to propose an approach in principle to the design of internal medicine residency programs of the future. To do so, we first present the phenotype of the ideal internist. The social contract that governs the profession of medicine creates several public expectations of us as physicians, included among which are altruistic service as healers, morality and integrity, transparency, accountability, promotion of the public good, and guaranteed competence.11,12 We guarantee professional competence, in part, by establishing and overseeing training programs and their assessment. Although the environmental context and the constraints within which we train internists may change, that we ultimately produce competent practitioners remains a firm obligation. Unfortunately, in our recent efforts to react to a changing regulatory and learning environment, we run the risk of failing to meet this key tenet of our social contract. For this reason, the guiding principle in the following plan of attack must be our professional obligation to the terms of the social contract of medicine. Owing to the dynamics of change in the practice and learning environments, the social contract that guides the expectations and obligations of internists and the public, by definition, must respond dynamically: Although its fundamental tenets are invariant, the means by which they are followed must be proactively adapted to constantly changing conditions. Put simply, the social contract of medicine must be continually renewed and refreshed to assure that it is valued and apposite. Sadly, 100 years after the Flexner report, little data from well-designed studies are available to guide the design of residency education in medicine broadly, or internal medicine particularly. We are left to draw analogy from adult learning theory and the research and experience of other fields of education. Acknowledging this research, we now know, for example, that lectures are not an adequate format for learning the knowledge of medicine. Internal medicine training programs are too dependent on large group learning formats. We must return to an emphasis on small group, problem-based learning that supports the education of our residents more effectively. Much research in education and cognitive sciences has emphasized that knowledge is a prerequisite for expertise. Knowledge acquisition cannot be abandoned to the availability of computer-based information sites. Evidence also exists that experiential learning remains at the core of successful professional practice. Finally, and perhaps most important, efficient learning in high-stress environments requires that our trainees have a greater sense of control over their environment and their
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practices. Each of these principles should guide the development of strategies to reform internal medicine residency education.13,14
SOME THEMES FOR RESIDENCY REDESIGN 1) Knowledge as a prerequisite for expertise: It is certainly true that knowledge has never been more democratic. The web has made it easier than ever before to locate information and especially to find the evidence that guides clinical decisions. Yet, it also is true that numerous studies have demonstrated the link between knowledge and expertise. In medicine, the care of patients demands that the practitioner has up-to-date knowledge that is effectively integrated and readily applied to clinical care. Even today, most residency programs rely heavily on lectures and seminars to convey information. Small group formats with problem-based learning approaches remain infrequent, despite their demonstrated effectiveness.15 Unfortunately, experiential, bedside learning, which has always been central to education in medicine, is now often conflated with “service”: Learning while doing with the patient at the center of the experience and the physician at the bedside needs to be acknowledged again as a core value in the training of physicians.16,17 2) Effectiveness and efficiency in medical care: Clinical practice guidelines have become ready substitutes for the rigorous and parsimonious practice of medicine.18 Internal medicine developed the fields of clinical epidemiology, health services’ research, and decision analysis. Regrettably, despite the academic success of these endeavors, internists have rarely succeeded in linking research in these fields to clinical education. This failure is especially ironic as genomic, “personalized” medicine emerges as a new focus of research-based practice. Now, more than ever, internal medicine must embrace a new commitment to relying less on rules and more on integrating evidence into practice and to achieving greater clinical efficiencies in our healthcare system. 3) “High demand/high control” setting for residents: Fatigue and stress have become recognized as adversities that impair both the quality of care and of resident education. Lacking more specific evidence on the effects of sleep loss on clinical performance, and uncertain of the causes of stress in the residency, well-intentioned regulators have relied on surrogate evidence to guide the design of resident schedules. Data from sleep studies have been used to justify decisions about the total number of hours a resident can work each week and have guided the number of hours that can be worked before sleep is required. We are all familiar with the unintended consequences of these narrow policies: the hazardous “hand-offs” of patients; the frequent, misleading comments from residents who do not want to report hours “violations”; and the increased stress created in the hour or 2 before residents need to leave the hospital. Most
academicians understand how residents are caught between the consequences to their programs if they report the hours violations and their responsibility to their patients, but we should not “cover up the issue” or make excuses for the problem other than the unintended consequences of these narrow policies.
PROPOSAL: FORMATION OF A COOPERATIVE STUDY GROUP We propose the formation of a formal mechanism for refreshing a fundamental tenet of the social contract of internal medicine, that is, to ensure the competency of its internists. We base our proposal on 2 assumptions—that the qualities of the ideal internist are time-invariant and that the context in which we train internists will continually change and constrain the means by which we strive to achieve the ideal. To meet this challenge of maintaining a high standard in the face of changing constraints, we suggest that the time has come to create a national cooperative studies program in educational research modeled after the successful Veterans Affairs program testing the effectiveness of medicines and procedures. The purpose of this program would be to conduct cooperative trials of training approaches that would test the efficacy of any major changes in training program structure before they are recommended for regulatory implementation. As evidence-based practitioners, we recognize that training program structure and its many configurations imposed from within a program or by outside agencies have not been based on irrefutable proof; rather, they have been predicated on longstanding tradition, analogy to other training environments, or face validity. We do not feel at all sanguine about program structures and their implementation imposed without evidence for their efficacy because so very much is at stake, primarily the need to produce a competent internist, at the very least, and the ideal internist, at best. In the following section, we outline the strategies that could be used to develop the evidence base for reinvigorating internal medicine training.
Cooperative Educational Studies Group We propose a Cooperative Educational Studies Group composed of a consortium of willing programs that reflect the full spectrum of internal medicine training programs. Each institution would collect a standardized data set that creates a common collection of information describing their programs, residents, and faculty. Among the initial data set to be assembled would be elements that describe operational characteristics of the medical service; allocation of educational time and activities; and patient, resident, and faculty satisfaction with clinical care and work environment. Perhaps most important are the specific interventions that would be tested in multimethodological approaches to the evaluation of current performance and the assessment of change. Some of the earliest interventions could focus on the content of internal medicine training, the formats for learning, the role of attending physicians, and the resident control
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over their schedules and management of patients. The Education Innovations Project sponsored by the Internal Medicine Residency Review Committee and the Accreditation Council for Graduate Medical Education encourage innovation on residency education. The University of Cincinnati has worked under this initiative to evaluate a 14-month “long block” approach for ambulatory training.19 An example of a future intervention might be an examination of the impact of a set of technique-dependent clinical skills (Stanford 25) that emphasize the importance of the clinical examination for both enhanced care efficiency and a stronger bond between doctor and patient (see website at http:// medicine.stanford.edu/education/stanford25overview.html for further details).20 Further examination of the impact of “intensive-teaching units” as tested at Brigham and Women’s Hospital might be another.21 Few issues have proven more intractable than the tension between the high stress our residents feel in their training and the lack of control they have in carrying out their responsibilities. Although this is a complex problem, one approach to greater resident control involves the full geographic localization of patients on medical services. The University of Pennsylvania Internal Medicine Residency Program has evolved an innovative strategy to achieve localization through collaboration of the hospital, the department of internal medicine, and the department of emergency medicine. Their approach might be a third example of an intervention that needs to be tested in a consortium of hospitals that have struggled to replicate their success. Finally, we should emphasize the multi-methodological approach to the conduct of this research. Qualitative studies are needed to create a comprehensive set of themes through focus groups, surveys, and observational studies. Educational trials will be required that have clearly defined interventions, well-circumscribed and reproducible end points, and sufficient sample size to detect meaningful differences. Most important, participating programs will need to be committed to longitudinal research and practice that ensure incremental improvements over time. Some of the changes we test can be rapidly assessed for benefits; most will require years of evaluation and a ready flexibility that can accommodate and address new interventions as they evolve. There should be no constraint on the range of potential changes that could be tested in the Cooperative Educational Studies Group. Assumptions about the impact of decreased work hours on resident performance might be assessed against the effects of increased control by residents over their work schedules. Strategies to improve the skills of residents in the clinical examination, including reintroducing oral examinations in some programs, could be assessed for its impact on the use of expensive medical tests and procedures. Requirements for public service might be tested for its effects on career choices and attitudes toward professionalism. These are just a few possible strategies that would help to point a new direction for training programs and reinvigorate internal medicine education.
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CONCLUSIONS Having developed the background and guiding principles for this approach to restructuring training programs rationally, it will be necessary to develop the questions and hypotheses, the outcome metrics that would be used, and the trials designed to test them in existing training programs. Such study designs will require broad discussions with all interested parties, from training program directors to regulatory agencies to credentialing bodies. We believe that only by establishing such a formal mechanism of educational research will we be able to meet our obligations to society, regardless of the nature or magnitude of changes within our practice and learning environments.
ACKNOWLEDGMENTS The authors acknowledge the intellectual contributions of many internal medicine leaders who participated in an invited conference that initiated this project. They included Osman Akhtar, Joseph Alpert, Michele Barry, Carol Bates, David W. Bates, Jay Bhattacharya, William Bremner, Troyen Brennan, David Coleman, Mark Cullen, Jack Ende, Faith T. Fitzgerald, Terry Fulmer, Mark Henderson, Harry Hollander, Joel Katz, Talmadge E. King, Richard Kopelman, Eric B. Larson, Kenneth M. Ludmerer, Jeanette Mladenovic, Asghar Rastegar, Paul Rothman, Richard Shannon, Kelley Skeff, Lawrence Smith, and Jimmy Stewart.
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18. Kassirer JP. Does instant access to compiled information undermine clinical cognition? Lancet. 2010;376:1510-1511. 19. Warm EJ, Schauer DP, Diers T, et al. The ambulatory long-block: an accreditation council for graduate medical education (ACGME) educational innovations project (EIP). J Gen Intern Med. 2008;23:921-926. 20. Verghese A, Horwitz RI. In praise of the physical examination. BMJ. 2009;339:b5448. 21. McMahon GT, Katz JT, Thorndike ME, Levy BD, Loscalzo J. Evaluation of a redesign initiative in an internal medicine residency. N Engl J Med. 2010;362:1304-1311.