Letters to the Editor
Letters to the Editor Teaching Health Centers: A Proven Solution for Primary Care Workforce Needs To the Editor: January 2014 marks the beginning of health insurance coverage for millions through the Affordable Care Act (ACA) Marketplace and Medicaid expansion. But will the newly insured have access to quality health care? The United States faces physician shortages, especially in primary care.1 These shortages are most pronounced in rural areas, yet most of the nation’s residency training (and with it, most of the $13 billion in annual federal GME subsidies)2 occurs in urban settings. In a step toward addressing these issues, ACA Section 5508: Increasing Teaching Capacity authorized and funded teaching health centers with $240 million over five years to address primary care shortages. Teaching health centers should be permanently funded and expanded to provide interprofessional training to meet the needs of underserved communities. Jolly et al1 report that residency slots in the United States increased 13.6% over the last 10 years in spite of the cap on federally funded positions. However, despite the overall increase in residency slots, 6.3% fewer medical school graduates chose primary care residencies. Because the decrease in those choosing primary care was leveling off from the prior year, the authors concluded that “the decline in interest in primary care careers may be ending.” Now is not the time for rosy primary care bromides. Had the number choosing primary care residencies grown at the same rate as the overall growth in residency slots in our teaching hospitals, the number of primary care residents would have also grown 13.6% from 8,624 in 2001 to 9,797 in 2010. The actual number in 2010 was 8,084—20% less than expected. Relaxing the residency cap, as some have suggested, would simply perpetuate producing too many subspecialist physicians in urban areas, and not enough primary care physicians anywhere. Teaching health centers complement the outstanding training in urban teaching hospitals with interprofessional health
Academic Medicine, Vol. 89, No. 1 / January 2014
professions training in outpatient, rural, primary care settings. Data suggest that this improves retention of medical resident graduates to practice in underserved and rural areas.3 Targeted residency expansion—to include interprofessional training with nursing, dental, and others—by expanding and permanently funding teaching health centers would build the communitybased training infrastructure, prioritize rural training, and extend the training pipeline to areas of need. States expanding Medicaid under the ACA should consider aligning the almost $4 billion per year in Medicaid GME funding to assure an adequate health workforce through innovations like teaching health centers. An all-payer funding approach would lessen the burden on Medicare and Medicaid and more equitably distribute graduates to rural and urban underserved areas. Disclosures: None reported. Daniel Derksen MD Professor, director, Center for Rural Health, and chair, Public Health Policy and Management Section, University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, Arizona; [email protected].
References 1 Jolly P, Erikson C, Garrison G. U.S. graduate medical education and physician specialty choice. Acad Med. 2013;88:468–474. 2 Voorhees KI, Prado-Gutierrez A, Epperly T, Dirkson D. A proposal for reform of the structure and financing of primary care graduate medical education. Fam Med. 2013;45:164–170. 3 Pacheco M, Weiss D, Vaillant K, Bachofer S, Garrett B, Dodson WH 3rd, et al. The impact on rural New Mexico of a family medicine residency. Acad Med. 2005;80:739–744.
Make Time for Teaching and Learning Procedural Skills To the Editor: We read the article by Dehmer et al1 with great interest, as it highlights important opinions of medical students regarding procedural skills competency in the United States. In the United Kingdom, competency with procedural skills can also vary greatly and can leave students unprepared for their hands-on roles as newly qualified doctors. Medical graduates in the United Kingdom are expected to be proficient
in a similar set of skills as those required in the United States. Junior doctors have traditionally provided instruction and supervision for students learning procedural skills, but current duty hours restrictions in the United Kingdom and the United States limit junior doctors’ availability to observe and offer feedback. Based on our experience as senior medical students at a modern medical school in the United Kingdom, we suggest ways for students to seek and receive the valuable feedback provided by junior doctors, even in an era of restricted duty hours. Newly qualified doctors can be more approachable than senior doctors, and they can have a practical and unique perspective on how students learn.2 However, one of the more significant restrictions faced by newly qualified doctors teaching students in the United Kingdom is the European Work Directive (2009), which limits junior doctors to an average of a 48-hour workweek.3 With limited time on the wards, junior doctors in the United Kingdom find less time to teach medical students. Therefore, students should actively seek to be supervised by junior doctors while performing procedural skills, such as venipuncture, intravenous cannulation, and arterial blood gases. Instead of searching for a junior doctor with a bit of free time at the last minute, students can ensure supervision by approaching junior doctors in advance to organize direct observation of procedural tasks. In spite of duty hours restrictions, there must be a shift to increase the time spent on teaching by newly qualified doctors, alongside teaching by more senior doctors. At our institution and at others in the United Kingdom, skill logbooks provide a semiformal method of assessment to garner and reinforce student learning. Logbooks require students to obtain signatures to verify they have independently performed practical procedures under direct observation. Planning ahead for observation of procedural tasks coupled with the use of skill logbooks with assessment completed by newly qualified doctors may increase students’ confidence and contribute to reaching desired competency levels in basic procedural skills.
7
Letters to the Editor Disclosures: None reported. Yashashwi Sinha Fourth-year medical student, School of Medicine, Keele University, Stoke-on-Trent, Staffordshire, United Kingdom; [email protected].
Mahdi Saleh Fourth-year medical student, School of Medicine, Keele University, Stoke-on-Trent, Staffordshire, United Kingdom.
Daniel Weinberg Fourth-year medical student, School of Medicine, Keele University, Stoke-on-Trent, Staffordshire, United Kingdom.
References 1 Dehmer JJ, Amos KD, Farrell TM, Meyer AA, Newton WP, Meyers MO. Competence and confidence with basic procedural skills: The experience and opinions of fourth-year medical students at a single institution. Acad Med. 2013;88:682–687. 2 Qureshi Z, Seah M, Ross M, Maxwell S. Centrally organised bedside teaching led by junior doctors. Clin Teach. 2013;10:141–145. 3 BMA. European Working Time Directive. 2011. http://bma.org.uk/practical-supportat-work/ewtd. Accessed September 20, 2013.
and designated RN teams for placement of IVs) have largely replaced interns as the team members responsible for these aspects of patient care. As such, Sinha and colleagues’ suggestion that medical students gain increased procedural experience through more dedicated time with interns or newly qualified doctors may not be valid in our system. The larger question remaining is whether or not broad procedural competence should be a reasonable expectation of all graduating medical students. We continue to believe, as Sinha and colleagues and the respondents to our survey do, that at least for a core set of procedures, this should be a goal. The devil, of course, is in the details of how to accomplish that, and while suggestions like the one from Sinha and colleagues are welcome, the answer unfortunately remains elusive. Disclosures: None reported. Jeffrey J. Dehmer, MD Fellow, Pediatric Surgery, Children’s Mercy, Kansas City, Missouri.
Michael O. Meyers, MD
In Reply to Sinha et al: We appreciate Sinha and colleagues’ thoughtful reply to our article. Clearly both in European and U.S. medical schools, the ongoing duty hours debate is affecting not just postgraduate education but also medical student education—an unintended consequence of these changes to be sure, but one with the potential to significantly impact all future doctors. The authors’ point about having logbooks and dedicated observation for procedural skills is well taken and supported by data in our study. We found that medical students reported the highest level of confidence in suturing. During our students’ surgical clerkship, dedicated time both for practice and formal testing of this skill is likely responsible for that finding, as we incorporate a formative OSCE into their experience. One challenge for other procedural skills, at least at our institution and at many others in the United States, is that the patient’s primary physician no longer performs many of these tasks. For example, other physicians (neurology/ neurosurgery for lumbar puncture, anesthesia for intubation) and ancillary staff (respiratory therapists for arterial puncture, phlebotomy for venipuncture,
8
Associate professor and program director, General Surgery Residency, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina; [email protected].
performance is analyzed in its consistent and variable aspects, DPT provides a particularly strong basis for teaching. Four-component instructional design,4 for example, is a research-based educational model related to DPT that provides highly detailed guidelines for the design of instruction and the teaching of clinical problem solving, among other topics. Learning tasks provide the backbone of learning and make an appeal on both System 1 and System 2 processing. Supportive information helps learners to perform and learn variable aspects of learning tasks and develops System 2 processing through reflection and cognitive feedback. Procedural information helps learners to perform and learn consistent aspects of learning tasks and develops System 1 processing through justin-time provision of “how-to” information and corrective feedback. Finally, part-task practice may help to reach full automaticity of selected System 1 aspects through repetitive practice. In contrast to teaching models based on cognitive continuum theory, this approach allows for the coordinated development of System 1 and System 2 processing in a process of complex learning. Disclosures: None reported. Jeroen J.G. van Merriënboer, PhD
Teaching Based on Thinking Fast and Slow To the Editor: I read Custers’1 criticism on dual processing theory (DPT) with interest. Yet, his conclusion that “a description of clinical problem solving as the result of two interacting systems […] gives few clues to […] what the best approach to teaching clinical problem solving will be”1(p5) is disputable and seems to rest on an oversimplification of DPT. In fact, real-life tasks such as medical diagnosis can never be classified as System 1 or System 2 because they contain both consistent aspects (System 1) and variable aspects (System 2). The great advantage of DPT is not that it creates a dichotomous classification for cognitive tasks but, rather, that it acknowledges that System 1 and System 2 processes occur and can be developed in parallel; expertise development is thus more than a sole transition from System 2 to System 1 processing on a cognitive continuum.2 Combined with a process of cognitive task analysis,3 in which real-life diagnostic task
Professor of learning and instruction, Maastricht University, Maastricht, The Netherlands; [email protected].
References 1 Custers EJFM. Medical education and cognitive continuum theory: An alternative perspective on medical problem solving and clinical reasoning. Acad Med. 2013;88:1–7. 2 Van Merriënboer JJG. Perspectives on problem solving and instruction. Comput Educ. 2013;64:153–160. 3 Van Merriënboer JJG. Training Complex Cognitive Skills. Englewood Cliffs, NJ: Educational Technology Publications; 1997. 4 Van Merriënboer JJG, Kirschner PA. Ten Steps to Complex Learning. 2nd rev ed. New York, NY: Routledge; 2013.
In Reply to van Merriënboer: First, I believe it should be kept in mind that neither dual process theories (DPTs) nor cognitive continuum theory (CCT) were specifically developed to provide guidelines for instructional design in an educational context. Neither are they learning theories. Rather, they focus on problem solving or decision making.
Academic Medicine, Vol. 89, No. 1 / January 2014
Letters to the Editor Teaching Health Centers: A Proven Solution for Primary Care Workforce Needs To the Editor: January 2014 marks the beginning of health insurance coverage for millions through the Affordable Care Act (ACA) Marketplace and Medicaid expansion. But will the newly insured have access to quality health care? The United States faces physician shortages, especially in primary care.1 These shortages are most pronounced in rural areas, yet most of the nation’s residency training (and with it, most of the $13 billion in annual federal GME subsidies)2 occurs in urban settings. In a step toward addressing these issues, ACA Section 5508: Increasing Teaching Capacity authorized and funded teaching health centers with $240 million over five years to address primary care shortages. Teaching health centers should be permanently funded and expanded to provide interprofessional training to meet the needs of underserved communities. Jolly et al1 report that residency slots in the United States increased 13.6% over the last 10 years in spite of the cap on federally funded positions. However, despite the overall increase in residency slots, 6.3% fewer medical school graduates chose primary care residencies. Because the decrease in those choosing primary care was leveling off from the prior year, the authors concluded that “the decline in interest in primary care careers may be ending.” Now is not the time for rosy primary care bromides. Had the number choosing primary care residencies grown at the same rate as the overall growth in residency slots in our teaching hospitals, the number of primary care residents would have also grown 13.6% from 8,624 in 2001 to 9,797 in 2010. The actual number in 2010 was 8,084—20% less than expected. Relaxing the residency cap, as some have suggested, would simply perpetuate producing too many subspecialist physicians in urban areas, and not enough primary care physicians anywhere. Teaching health centers complement the outstanding training in urban teaching hospitals with interprofessional health
Academic Medicine, Vol. 89, No. 1 / January 2014
professions training in outpatient, rural, primary care settings. Data suggest that this improves retention of medical resident graduates to practice in underserved and rural areas.3 Targeted residency expansion—to include interprofessional training with nursing, dental, and others—by expanding and permanently funding teaching health centers would build the communitybased training infrastructure, prioritize rural training, and extend the training pipeline to areas of need. States expanding Medicaid under the ACA should consider aligning the almost $4 billion per year in Medicaid GME funding to assure an adequate health workforce through innovations like teaching health centers. An all-payer funding approach would lessen the burden on Medicare and Medicaid and more equitably distribute graduates to rural and urban underserved areas. Disclosures: None reported. Daniel Derksen MD Professor, director, Center for Rural Health, and chair, Public Health Policy and Management Section, University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, Arizona; [email protected].
References 1 Jolly P, Erikson C, Garrison G. U.S. graduate medical education and physician specialty choice. Acad Med. 2013;88:468–474. 2 Voorhees KI, Prado-Gutierrez A, Epperly T, Dirkson D. A proposal for reform of the structure and financing of primary care graduate medical education. Fam Med. 2013;45:164–170. 3 Pacheco M, Weiss D, Vaillant K, Bachofer S, Garrett B, Dodson WH 3rd, et al. The impact on rural New Mexico of a family medicine residency. Acad Med. 2005;80:739–744.
Make Time for Teaching and Learning Procedural Skills To the Editor: We read the article by Dehmer et al1 with great interest, as it highlights important opinions of medical students regarding procedural skills competency in the United States. In the United Kingdom, competency with procedural skills can also vary greatly and can leave students unprepared for their hands-on roles as newly qualified doctors. Medical graduates in the United Kingdom are expected to be proficient
in a similar set of skills as those required in the United States. Junior doctors have traditionally provided instruction and supervision for students learning procedural skills, but current duty hours restrictions in the United Kingdom and the United States limit junior doctors’ availability to observe and offer feedback. Based on our experience as senior medical students at a modern medical school in the United Kingdom, we suggest ways for students to seek and receive the valuable feedback provided by junior doctors, even in an era of restricted duty hours. Newly qualified doctors can be more approachable than senior doctors, and they can have a practical and unique perspective on how students learn.2 However, one of the more significant restrictions faced by newly qualified doctors teaching students in the United Kingdom is the European Work Directive (2009), which limits junior doctors to an average of a 48-hour workweek.3 With limited time on the wards, junior doctors in the United Kingdom find less time to teach medical students. Therefore, students should actively seek to be supervised by junior doctors while performing procedural skills, such as venipuncture, intravenous cannulation, and arterial blood gases. Instead of searching for a junior doctor with a bit of free time at the last minute, students can ensure supervision by approaching junior doctors in advance to organize direct observation of procedural tasks. In spite of duty hours restrictions, there must be a shift to increase the time spent on teaching by newly qualified doctors, alongside teaching by more senior doctors. At our institution and at others in the United Kingdom, skill logbooks provide a semiformal method of assessment to garner and reinforce student learning. Logbooks require students to obtain signatures to verify they have independently performed practical procedures under direct observation. Planning ahead for observation of procedural tasks coupled with the use of skill logbooks with assessment completed by newly qualified doctors may increase students’ confidence and contribute to reaching desired competency levels in basic procedural skills.
7
Letters to the Editor Disclosures: None reported. Yashashwi Sinha Fourth-year medical student, School of Medicine, Keele University, Stoke-on-Trent, Staffordshire, United Kingdom; [email protected].
Mahdi Saleh Fourth-year medical student, School of Medicine, Keele University, Stoke-on-Trent, Staffordshire, United Kingdom.
Daniel Weinberg Fourth-year medical student, School of Medicine, Keele University, Stoke-on-Trent, Staffordshire, United Kingdom.
References 1 Dehmer JJ, Amos KD, Farrell TM, Meyer AA, Newton WP, Meyers MO. Competence and confidence with basic procedural skills: The experience and opinions of fourth-year medical students at a single institution. Acad Med. 2013;88:682–687. 2 Qureshi Z, Seah M, Ross M, Maxwell S. Centrally organised bedside teaching led by junior doctors. Clin Teach. 2013;10:141–145. 3 BMA. European Working Time Directive. 2011. http://bma.org.uk/practical-supportat-work/ewtd. Accessed September 20, 2013.
and designated RN teams for placement of IVs) have largely replaced interns as the team members responsible for these aspects of patient care. As such, Sinha and colleagues’ suggestion that medical students gain increased procedural experience through more dedicated time with interns or newly qualified doctors may not be valid in our system. The larger question remaining is whether or not broad procedural competence should be a reasonable expectation of all graduating medical students. We continue to believe, as Sinha and colleagues and the respondents to our survey do, that at least for a core set of procedures, this should be a goal. The devil, of course, is in the details of how to accomplish that, and while suggestions like the one from Sinha and colleagues are welcome, the answer unfortunately remains elusive. Disclosures: None reported. Jeffrey J. Dehmer, MD Fellow, Pediatric Surgery, Children’s Mercy, Kansas City, Missouri.
Michael O. Meyers, MD
In Reply to Sinha et al: We appreciate Sinha and colleagues’ thoughtful reply to our article. Clearly both in European and U.S. medical schools, the ongoing duty hours debate is affecting not just postgraduate education but also medical student education—an unintended consequence of these changes to be sure, but one with the potential to significantly impact all future doctors. The authors’ point about having logbooks and dedicated observation for procedural skills is well taken and supported by data in our study. We found that medical students reported the highest level of confidence in suturing. During our students’ surgical clerkship, dedicated time both for practice and formal testing of this skill is likely responsible for that finding, as we incorporate a formative OSCE into their experience. One challenge for other procedural skills, at least at our institution and at many others in the United States, is that the patient’s primary physician no longer performs many of these tasks. For example, other physicians (neurology/ neurosurgery for lumbar puncture, anesthesia for intubation) and ancillary staff (respiratory therapists for arterial puncture, phlebotomy for venipuncture,
8
Associate professor and program director, General Surgery Residency, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina; [email protected].
performance is analyzed in its consistent and variable aspects, DPT provides a particularly strong basis for teaching. Four-component instructional design,4 for example, is a research-based educational model related to DPT that provides highly detailed guidelines for the design of instruction and the teaching of clinical problem solving, among other topics. Learning tasks provide the backbone of learning and make an appeal on both System 1 and System 2 processing. Supportive information helps learners to perform and learn variable aspects of learning tasks and develops System 2 processing through reflection and cognitive feedback. Procedural information helps learners to perform and learn consistent aspects of learning tasks and develops System 1 processing through justin-time provision of “how-to” information and corrective feedback. Finally, part-task practice may help to reach full automaticity of selected System 1 aspects through repetitive practice. In contrast to teaching models based on cognitive continuum theory, this approach allows for the coordinated development of System 1 and System 2 processing in a process of complex learning. Disclosures: None reported. Jeroen J.G. van Merriënboer, PhD
Teaching Based on Thinking Fast and Slow To the Editor: I read Custers’1 criticism on dual processing theory (DPT) with interest. Yet, his conclusion that “a description of clinical problem solving as the result of two interacting systems […] gives few clues to […] what the best approach to teaching clinical problem solving will be”1(p5) is disputable and seems to rest on an oversimplification of DPT. In fact, real-life tasks such as medical diagnosis can never be classified as System 1 or System 2 because they contain both consistent aspects (System 1) and variable aspects (System 2). The great advantage of DPT is not that it creates a dichotomous classification for cognitive tasks but, rather, that it acknowledges that System 1 and System 2 processes occur and can be developed in parallel; expertise development is thus more than a sole transition from System 2 to System 1 processing on a cognitive continuum.2 Combined with a process of cognitive task analysis,3 in which real-life diagnostic task
Professor of learning and instruction, Maastricht University, Maastricht, The Netherlands; [email protected].
References 1 Custers EJFM. Medical education and cognitive continuum theory: An alternative perspective on medical problem solving and clinical reasoning. Acad Med. 2013;88:1–7. 2 Van Merriënboer JJG. Perspectives on problem solving and instruction. Comput Educ. 2013;64:153–160. 3 Van Merriënboer JJG. Training Complex Cognitive Skills. Englewood Cliffs, NJ: Educational Technology Publications; 1997. 4 Van Merriënboer JJG, Kirschner PA. Ten Steps to Complex Learning. 2nd rev ed. New York, NY: Routledge; 2013.
In Reply to van Merriënboer: First, I believe it should be kept in mind that neither dual process theories (DPTs) nor cognitive continuum theory (CCT) were specifically developed to provide guidelines for instructional design in an educational context. Neither are they learning theories. Rather, they focus on problem solving or decision making.
Academic Medicine, Vol. 89, No. 1 / January 2014
