CHICAGO—The ingredients required to make a rheumatologist have changed from the early years of the last century to now and are moving toward further transformation in the millennial-influenced future, according to Calvin Brown, MD, keynote speaker at the ACR’s 2019 Program Directors Conference.
Dr. Brown, who trains medical students at Northwestern University Feinberg School of Medicine in Chicago, began his presentation with a nod to his grandfather, an ophthalmologist in the 1940s, who during his medical career, became chief of staff of Detroit’s most prominent hospital at the time. The first revolution in medical education was brewing around 1910 when his grandfather, A.O. Brown, attended medical school, he said.
Historical Starting Point
In those early years, anyone wanting to attend medical school to become a doctor was required to have a high school education. But no one really checked, noted Dr. Brown. These schools existed to make money by training doctors, he added.
Then the American Medical Association (AMA) commissioned Abraham Flexner to visit all 155 medical schools in the country and write a report on his findings. His recommendations on reforms and adherence to scientific protocols helped transform medicine into a respected profession, said Dr. Brown.
Greater accountability emerged after 1928, when the AMA published a list of approved residencies in the country and followed up in 1940 with a report from the Commission on Graduate Medical Education. More rules and regulations came along in 1970, when accreditation of internships and residencies began.
“Doctors regulating doctors is where this whole process started,” he said.
List of Core Competencies
The Accreditation Council for Graduate Medical Education (ACGME), charged with evaluating medical residency programs, adopted the competencies in 1999 and has established milestones of behavioral markers for a candidate to be deemed competent. The familiar list of core competencies of accountability covers half a dozen categories, some more clearly named than others, said Dr. Brown.
Patient care and medical knowledge, for example, are descriptors of core competencies better understood than systems-based practice, he said. Other competencies include practice-based learning and improvement, interpersonal and communication skills and professionalism.
“Part of our problem, unfortunately, is we have some pretty obscure, unclear language around the competencies,” said Dr. Brown.
“So we do have a problem in the future,” he said. “Part of it is simply terminology.”
Rheumatology trainees are steeped like tea during a required 24-month, time-oriented process to develop the necessary competency to become a doctor in their chosen specialty.
Brew for 24 Months
Rheumatology trainees are steeped like tea during a required 24-month, time-oriented process to develop the necessary competency to become a doctor in their chosen specialty, said Dr. Brown. “It must be 24 months. That’s what it takes to make a rheumatologist. Period, end of story,” he said.
Referring to it as the tea bag model, Dr. Brown said this ACGME-specified span for training rheumatology graduates is not a good fit for some would-be doctors. Some fellows become competent sooner than that, while others require more time, he said.
“So we still have some great problems even in the present—some of them that come from our very own governing and accrediting bodies themselves,” said Dr. Brown.
Entrustable Professional Activity
Turning to future possibilities, Dr. Brown discussed the work of Olle ten Cate, PhD, from the University of Amsterdam, The Netherlands. He is a professor and scholar of medical education who said to show competence we should define what the work is, said Dr. Brown.
“So Olle put forth … the concept of entrustable professional activities (EPAs)—a list of things that an individual needs to do to be competent,” he said. An example would be how we approach the work of an airline pilot, said Dr. Brown. We know pilots are competent to take off, fly and land a plane even if something goes wrong.
“Competencies can be reflected in activities,” said Dr. Brown. “In the future, … if we define our fellows as being competent not in terms of the competencies but in terms of being able to perform these activities, we will have a better model that will be independent of time.”
There are 14 EPAs in rheumatology developed to be understood without “a long-winded explanation,” said Dr. Brown. Use of EPAs is, perhaps, a way to move from the tea bag model to one that focuses on fulfilling competencies independently, he said.
“I hope our education in the future becomes more centered on evaluating entrustable professional activities,” said Dr. Brown.
Recent literature indicates that milestones to measure achievement as mandated by ACGME are popular with the current population of millennial medical students. Early research also suggests that milestones are beginning to be accepted, lead to overall improvement of knowledge and skills, and correlate highly with annual evaluation summaries, according to Dr. Brown.
Work is underway to improve current milestones to render them simpler and more straightforward. “So progress continues,” he said.
Dr. Brown concluded with a reminder of another important aspect of training new doctors. Noting that students learn best from teachers they love, he encouraged the audience to always keep the importance of relationships with student fellows at the center of education and training.
“Do not forget your humanity and the care that we have for our students and the love that we express,” said Dr. Brown. “We can talk about competencies. We can talk about milestones. We can’t forget love and don’t forget the love in what it is that you do.”
Catherine Kolonko is a medical writer based in Oregon.