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|Title:||A Vision for Graduate Medical Education|
|Abstract:||When I started my residency years ago, there was no orientation. On that first day the new interns arrived from all parts of the country, all men, some dressed formally in jackets and ties, others in scrubs. We received our patient lists from the tired departing interns, who smiled knowingly about what we were soon to experience. We each met our new resident and faculty attendings, and in my case, I immediately started getting called to work up new patients. One was a patient with leukemia, another had end-stage liver disease, a third had chronic lung disease with an infection. I was on call my first day and would end up in the hospital for 36 hours, picking up several more patients, visiting the intensive care unit to manage a sign-out patient from another team who had developed a fever, and going to the emergency department to assist in the evaluation of a patient who was vomiting blood. I remember these patients as vividly as if I had seen them yesterday. I left the hospital the next day in a daze, exhausted and exhilarated at the flood of stories, people, and experiences I had encountered. I remember thinking that if I could survive the crushing workload, I would learn more in the coming year than I had ever learned in my life. In fact, that first week I calculated that I spent 126 hours in the hospital. The pager, which initially had been a mark of distinction and pride demonstrating my new status as a doctor, quickly became a persistent and dreaded enemy, interrupting patient conversations, lunch breaks, or educational conferences, even hounding me in the bathroom. The pages often led to questions from nurses that I could not answer and reminded me of how much I had to learn. At the same time, I felt motivated to overcome the gaps in my knowledge by the enormous trust of my faculty supervisor, the other residents, and especially the patients, who imagined I knew far more than I did. The experience of residency has changed since those days. Gone are the 100-hour workweeks and the limited on-site supervision by faculty. Educational conferences have become more organized, and the learning time is now more protected from interruptions. Evaluation has expanded beyond medical knowledge and patient care to encompass a variety of outcomes that residents should demonstrate. Simulation has provided an alternative venue for exposure to unusual or difficult cases and has augmented procedural learning and evaluation. Faculty now have become more involved in the care of the residents’ patients, writing notes to document their involvement and generating bills that provide substantial income for academic departments. The residents have also changed; there are more women—now the majority in some specialties—and there is greater diversity of race, ethnicity, and class. There are also other providers to share the workload, such as nurse practitioners, physician assistants, pharmacists, and paramedics. Concerns about patient safety, quality improvement, cost of care, and the educational environment have resulted in broadening expectations for residents’ education. With all of the improvements in graduate medical education (GME), why has it been the subject of numerous studies and reports over the past four years, two sponsored by the Macy Foundation,1,2 one from the Institute of Medicine (IOM),3 and another from a consortium of organizations in Canada?4 What are the problems that have led to concerns? Is there a crisis in GME and, if so, what is its cause and what can we do about it? This month’s special GME issue of Academic Medicine provides some answers to these questions. But first, it is instructive to briefly describe the recent expert reports published about GME. The Macy Foundation sponsored two conferences of GME leaders in 2010 and 2011. The first conference,1 chaired by Michael M.E. Johns, MD, recommended a comprehensive review of GME finance and governance by the IOM as well as reexamination of accreditation policies to facilitate GME redesign, the funding of innovation, and an initial expansion of 3,000 entry-level positions and other changes based upon estimates of the future workforce. The second conference,2 chaired by Debra Weinstein, MD, emphasized public accountability of GME, changes in training to anticipate delivery system reform, changes in the curriculum and the learning environment, reexamination of the duration of training and transitions along the continuum of medical education, greater integration of the clinical educational environment with the educational objectives, increased flexibility to allow for innovation, and investment|
|Appears in Collections:||Academic Medicine 2015|
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