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From: The Rheumatologist, August 2013

Rheum with a View: How Should We Train Rheumatology Fellows?

by Richard S. Panush, MD

Rheum with a View
The ACGME's Next Accreditation System aims to improve the way we train physicians—but will it have the desired effect?
Richard S. Panush, MD
Richard S. Panush, MD

“I didn’t say it was good for you,” the king replied. “I said there was nothing like it.”
—Lewis Carroll, Through the Looking Glass

Education is an admirable thing, but it is well to remember from time to time that nothing that is worth learning can be taught.
—Oscar Wilde

How should we train rheumatology fellows today for tomorrow? As the “new” rheumatology fellowship program director at the University of Southern California (it’s interesting doing this again, having had this role much earlier in my career), I’ve been thinking a lot about the NAS. For those who may not know, this is the acronym for the “Next Accreditation System” now being implemented by the Accreditation Council for Graduate Medical Education (ACGME), which has regulatory authority for all residency and fellowship training programs.1-4 This affects us all. Certainly there is the immediate impact on training programs. Directives about our education and training, and practice, whether from the ACGME or others, are now our reality; we have long ago lost any hope of the public trusting us to meet their expectations without regulation. However, there is some opportunity for us to decide collectively how we are going to respond, such as we still can, to certain regulatory mandates as we implement them for rheumatology training. How we do so will profoundly influence the education and training of future rheumatologists, ultimately reflecting and defining our societal responsibilities as physicians—who we are and how we practice.

Let me present a short exposition of salient aspects of the NAS, followed by my thoughts about how rheumatology might approach this.

The NAS: A Very Brief Summary

The intent of the ACGME is admirable. It is to change the paradigm of training and its regulation. To be less prescriptive. To have fewer standards and standards revisions. To reduce the burden on programs. To continuously monitor outcomes and other predictive measures. To hold sponsoring institutions responsible for ongoing oversight of educational and clinical systems. To promote curricular innovation. To be constructive and supportive.

The ultimate goal is for self-study/self-regulation—for training programs to critically analyze and improve their learning environments and outcomes. This will be predicated on several essential elements. These will include having the appropriate and necessary quantitative data (metrics). There would be a culture of quality improvement, program improvement, performance improvement, and assuring safe care. Outcomes assessments (by and for patients, faculty, residents, and fellows) will be implicit. Competencies will be defined and documented. Educational/professional milestones will be developed and utilized. Entrustable professional activities will be enumerated. There will be new institutional responsibilities and accountabilities (Clinical Learning Environment Review program).

Care will be safe, high quality, and humanistic. It will reflect the highest professional values, including self-effacement, appreciating medicine’s inherent fundamental ethical core, and its public responsibility and accountability. It will be based on information-technology literacy, involving patients in their own care, and the use of health information technology to improve outcomes for individuals and populations. Residents and/or fellows will be trained to have the knowledge and skills essential to function as experts. They will be team oriented. They will have leadership skills. They will perform critical self-analysis. They will measure what they do. They will optimally manage transitions of care. They will communicate excellently and professionally. They will engage in continued study. They will practice medicine in a manner conducive to delivery of high-value, cost-effective, cost-conscious, safe, timely, efficient, equitable, patient-centered, ethical, and humanistic care. This will be expected by society. Graduate medical education (GME) will be a critical, if not key, influence in training doctors with these skills requisite for tomorrow’s physicians.1-4

Personal Comments and Thoughts

Whew. That’s a lot, summarized as best and as concisely as I can, and without describing all the attendant infrastructure, particular expectations, new processes and requirements, and annual reporting. Doesn’t it sound good? I laud colleagues at the ACGME, many of whom I have come to know and respect over the years, for their vision. It reflects many of my values and perceptions for contemporary medicine. But I have concerns here. I have been intimately involved with education and training of students, residents, and fellows during my entire career. I do it because it’s important, worthwhile, satisfying, “generative,” and fun. I worry that the NAS will not necessarily be these.

Emperor Joseph II said to Mozart, after hearing “The Abduction from the Seraglio,” which he had commissioned, “there are simply too many notes … just cut a few and it will be perfect.” I worry that accreditation will still be too complex, that preoccupation with details will impede realization of the overall goals, that new processes are substituted for old, not lessened—that there are too many notes. I worry that the NAS will be expensive and burdensome, probably more than the “old” system; that’s what my colleagues in medicine—where it has already begun—tell me. I worry that academic medicine will (continue to) invest enormous time and effort with this, more than I would wish. I worry that regulatory agencies aren’t the best agents for change; regulators regulate. I worry that regulatory concerns will predominate over aspirational outcomes. Some will worry about incentives to perpetuate the GME regulatory enterprise. I worry that one of the changes predicted for the future of medicine—“plasticity” of regulatory authorities—isn’t apparent here.5 I worry that, just as there is finally recognition of the need to minimize excessive costs in healthcare, so too should there be attention to reducing and streamlining medical and postgraduate medical education and training.6

I wonder if perhaps the NAS should be accompanied by more effort to curtail the huge costs of GME. I wonder, too, about the experimental basis of the mandated educational changes; perhaps I’m missing something, but I don’t see the scientific basis upon which to transform GME, despite the noble thoughts; pivotal elements (aspects of this are still evolving and being developed) were said to have been tested successfully in the Educational Innovation Project in internal medicine, but I, as a participant, didn’t perceive or experience it in that manner (and I don’t think my view of this is unique).1 I worry, too, that we have seen that other mandated and costly educational experiments failed to achieve the expected outcomes.7

How Should We Train Rheumatology Fellows?

So what should rheumatology do regarding the NAS? Permit me a brief reflection on formative experiences when I was a Duke resident in the era of Dr. Stead; these influence my thinking about how I hope rheumatology approaches this. Eugene A. Stead, Jr., MD, chair of Duke’s Department of Medicine during mid-20th century, was arguably the preeminent figure in American medicine in that century, with/after William Osler, MD.8 He was imaginative, innovative, creative, provocative, charismatic, brilliant, different, prophetic, and prescient. A few years ago, I had occasion to think about the future of medicine, and consulted Dr. Stead.9 It wasn’t complicated for him. “Change it,” he said (personal communication/conversation, September 3, 2004). “Don’t teach what we’re going to forget. Simplify the system. Eliminate all the formal teaching that has become so entrenched and is now unnecessary with ready availability of information stores. Let people learn by ‘apprenticeships’ with master clinicians. Assure quality and mastery by examination, direct observation of how they care for patients. How else? Then let them practice what they learned and what they are able. The resulting healthcare will be widely accessible, available, and affordable.”

I suspect he would not embrace the NAS. His view would ask if the astute clinician, particularly in rheumatology, needs a plethora of numbers, images, and tests to recognize a lupus flare, diagnose soft-tissue rheumatism, deal with uncomplicated chronic low back pain, or manage osteoarthritis. To assess trainees? Yes, it’s good to have a menu of tests, of evaluations or “instruments,” but could not the expert observer know if, when, and how to use them? And will not much of this change as our perceptions of and expectations for care and training change?

Generations of physicians did and still do fine just learning the right stuff from the right people in the right way at the right time in the right environment, and they learned how to keep learning and changing. Could not those responsible for training programs (who must be deemed experts) make valid assessments and judgments without a proliferation of definitions and details? I understand that Dr. Stead’s notions are fanciful today, but I believe some of his thinking remains valid.

Our imperative today is to make the NAS work. As a division chief and department chair for 35 years, I confronted the problems of struggling to reconcile our education and training to contemporary practice. I appreciate that we live and work in an environment of omnipresent regulation. While I, and others, might have wished otherwise, it is now our reality and we must deal with it.

Assuring quality and appropriate education and training, and patient care, are indeed important. I accept that we are expected to do better, as interpreted and promulgated for society by the ACGME. How should rheumatology respond to this imperative? I think we can yet do this reasonably well. Calvin Brown, Jr., our liaison to the ACGME, American Board of Internal Medicine, and internal medicine subspecialties dialogue about the NAS, reminded me that Mozart’s reply to the emperor was, “Which [notes] did you have in mind, majesty?” We must make music. The challenge is to select which notes are important, pick the tune, make it pleasing, keep it harmonious, find one that is satisfying for both the orchestra and audience, and recognize that we won’t all share the same tastes. We should, I think, be careful about too many details, or definitions, however appealing or seductive. Less is sometimes more. We should, I think, be skeptical about prescriptions and processes insensitive to change. We should, I think, espouse enduring principles. We must assure that medical education can be fun, and an attractive and rewarding career path.

I’ve expressed my admiration for the hopes of the NAS, despite concerns about its implementation. There exists now at least some opportunity for self-determination. I want us to successfully retain the best of our traditions and values and adapt them for the future. Dr. Stead’s perspective is relevant. We should, I think, resist the impulse to necessarily add more “stuff,” such as we can, adopt as principle-based and elemental an approach as possible, keep this uncomplicated, empower program directors’ judgments insofar as practicable, and develop curricula, measures, definitions, competencies, milestones, entrustable professional activities, outcomes, and the corresponding tools that are simple and enduring, coming together melodiously—without cacophony—as good (maybe even great) music. If anyone can do this, we rheumatologists will.

It has been willed where will and power are one.
—Dante Alighieri

Make everything as simple as possible but not simpler.
—Albert Einstein


Dr. Panush is professor of medicine, division of rheumatology, department of medicine, Keck School of Medicine, University of Southern California in Los Angeles.

References

  1. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and benefits. N Engl J Med. 2012;366:1051-1056.
  2. Accreditation Council for Graduate Medical Education. Frequently asked questions about the next accreditation system. Updated December 2012. Available at www.acgme-nas.org/assets/pdf/NASFAQs.pdf. Accessed July 12, 2013.
  3. Vasilias J (Executive Director, Review Committee for Internal Medicine, Accreditation Council For Graduate Medical Education, Chicago, IL): Personal communication/conversation, May 23, 2012.
  4. Criscione-Schreiber LG, Bolster MB, Jonas BL, O’Rourke KS. Competency based goals, objective, and linked evaluations for rheumatology training programs: A standardized template of learning activities from the Carolinas fellows collaborative (CFC). Arthritis Care Res. 2013;65:846-853.
  5. Kohane IS, Drazen JM, Campion EW. A glimpse of the next 100 years in medicine. New Engl J Med. 2012;367:2538-2539.
  6. Emanuel EJ, Fuchs VR. Shortening medical training by 30%. JAMA. 2012;307:1143-1144.
  7. Goiten L, Ludmerer KM. Resident workload—let’s treat the disease, not just the symptom. JAMA Intern Med. 2013;173:655-656.
  8. Ludmerer KM. Time To Heal. American Medical Education from the Turn of the Century to the Era of Managed Care. New York, N.Y.: Oxford; 1999.
  9. Panush RS. “Introduction, Chapter 8, Miscellaneous Topics.” In: Panush RS, ed: Yearbook of Rheumatology, Arthritis and Musculoskeletal Disease. Mosby-Yearbook; 2006:277-307.

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