Reflections on Residency Training: 1991 ARTHUR H. RUBENSTEIN, MD* WITH MEDICALSCIENCEAND PRACTICE changing so rapidly, many have asked w h e t h e r the residency curriculum is satisfactory or w h e t h e r changes should be made. To try to answer this difficult question, I decided to follow my scientific instincts. I reviewed the literature, searching for studies in which physicians in practice were surveyed about the quality and adequacy of their original training programs. There have b e e n several such studies, a particularly excellent example of w h i c h has been published recently by Nelson and colleagues. 1 AS part of their survey of 532 graduates in internal medicine, they analyzed a subset of 121 general internists w h o had c o m p l e t e d their training after 1970. Although virtually all respondents assessed their inpatient training as adequate, only 42% were fully satisfied with their outpatient experience. They were particularly critical about their limited involvement in continuity of care, and their lack of opportunity for independent decision making. Furthermore, they thought that many allied areas such as office dermatology, gynecology, nutrition, medical orthopedics, and drug and alcohol abuse were important to their practice and necessitated additional training. Kern, Parrino, and Korst, 2 from Boston University, came to similar conclusions. The graduates of that program rated history taking, problem definition, physical examination, and interpersonal skills of the greatest importance and needing additional emphasis. They also believed that more time should be devoted to geriatrics, psychiatry, ethics, patient education, and practice management. Kantor and Griner's 3 survey in 1981 indicated that only 31% of the graduates of the medical residency program of Strong Memorial Hospital between 1960 and 1975 judged their ambulatory e x p e r i e n c e to have been adequate, and almost 80% responded that they w o u l d have liked more training in ophthalmology, gynecology, orthopedics, otolaryngology, and dermatology. Several other interesting reviews and surveys dealing with this issue have b e e n published, including excellent analyses by L i n n e t al., 4 Mandel et al., s Martin et al., 6 McPhee et al., 7 and Reuben et al. s Again, there was remarkable consistency in the importance that practicing physicians placed on history taking, physical examination, interpersonal
"LowellT. Coggeshall Distinguished ServiceProfessorof Medical Sciencesand Chairman, Department of Medicine, The University of Chicago, Chicago, Illinois. Presented at the Symposiumto Honor John Benson, Philadelphia, Pennsylvania,June 12, 1991. Address correspondence and reprint requests to Dr. Rubenstein, Department of Medicine, University of Chicago, 5841 South MarylandAvenue, Chicago, IL 60637.
skills, and the need for additional ambulatory care rotations. Although there are legitimate, acknowledged criticisms of these studies, 6 including the rates of the responses, which were sometimes quite low, the fact that they were based on subjective, self-reported perceptions and might have b e e n influenced by other experiences in the years since residency, and the heterogenous composition of the respondents, I believe that the consistency of the findings merits careful consideration. Of course, retrospective surveys can indicate only deficiencies or successes in the preparation of graduates for practicing in the past or the present health care system. What about training physicians for the future? Our challenge is thus to predict th e structure and organization of medicine in the years ahead and to anticipate the role that internists will and should play. Tarlov, my mentor during his chairmanship of the Department of Medicine at The University of Chicago, has summarized his views o f the important determinants of health and the potential points of productive interventions in a n u m b e r of outstanding papers dealing with this topic. 9 Numerous books, scholarly manuscripts, journals, conference proceedings, symposia, newspaper and magazine articles, and so on also bear on it. Some that I have found particularly informative include: Doctoring America: The Last 100 Years a n d the Next 100 Years, 1opublished under the aegis of The Johns Hopkins University Society of Scholars; The Task o f M e d i c i n e - - D i a l o g u e at Wickenburg, edited by Kerr White 11 and published u n d e r the auspices of The Henry J. Kaiser Family Foundation; Vertical Integration in Health Care: Implications f o r Medical Education a n d Practice, a symposium sponsored by the American Hospital Association, the American Medical Association, and the Association o f American Medical Collegest2; the 1985 and 1987 Summer Conference Reports published by the ABIM13; the January 1, 1991, Annals o f Internal Medicinel~; and the May 15, 1991, JAMA. 15 Despite this tremendous diversity of sources, there are certain central themes and critical issues that are repeatedly emphasized and agreed u p o n by almost every commentator. These include the needs for cost containment, access to care (without increased cost), and maintaining or enhancing quality of care (at the same or r e d u c e d cost). Other important and often interrelated issues that are stressed include the aging of the population, oversupply of physicians and their maldistribution, increasing numbers of specialists with too few generalists, costly malpractice litigation, excess use of expensive t e c h n o l o g y and laboratory test-
217
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ing, inadequate attention to behavioral modification and prevention, and a reimbursement system that favors technical dexterity rather than cognitive skills. With specific regard to my topic, the adequacy of internal medicine residency training programs to meet the challenges that medicine faces, I agree with Dr. Thier's 16 conclusion that an analysis of this future supports the results of surveys of recently graduated general internists, namely, that w e need more preventive services delivered in " m o r e ambulatory, communitybased settings . . . . [That] The medical sciences [should] be defined more broadly to include skills in behavioral science and thinking about probabilities, populations, and prevention [that] Reimbursement [should] pay for those services that most effectively improve the health o f the public as opposed to those that have less or little utility but can more easily be d o c u m e n t e d . " ~6 Based on these past surveys and predictions regarding the organization of medical care in the future, remarkable unanimity has emerged among various experts as to the changes in internal medicine graduate training programs that w o u l d be desirable. These have b e e n detailed in a n u m b e r of excellent articles published during the past five years. Schroeder and colleagues tr and Perkoff, Is in their seminal papers published in 1986, pointed out that internal medicine residencies had undergone only modest changes in their organization despite dramatic changes in their major teaching site, the inpatient setting. They stressed the decline in length of stay of inpatients, the increasing acuity of their illnesses leading to the more frequent use o f intensive care units and coronary care units, the shift of diagnostic decision making to ambulatory care settings, the emphasis on admissions for invasive and surgical procedures, and the corresponding underrepresentation within the hospital of patients with certain illnesses, w h o c o m m o n l y present to general internists for their care in ambulatory settings. Their logical response to this situation was to emphasize the advantages of a significant expansion of ambulatory care training time, c o m p l e m e n t e d by increased exposures to behavioral medicine, decision analysis, c o s t - b e n e f i t issues, practice management, and related outpatient disciplines. This theme has been elaborated u p o n in a n u m b e r of excellent manuscripts, all of which have strongly supported this approach for residency education. Flahetty, 19 Goldfinger, t3 and Byyny,2° among others, have stressed the many advantages of outpatient and officebased education, including the opportunity to enhance residents' skills in history taking, physical diagnosis, patient education, disease prevention, and health promotion. Training in the judicious use of consultants as well as a continuing emphasis on cost-effective diagnostic and therapeutic strategies w o u l d be further positive outcomes that would be fostered by involvement in
the longitudinal care of patients. In parallel with this shift in education to ambulatory care, it w o u l d be most desirable to encourage the d e v e l o p m e n t of n e w research endeavors in this setting. 2° Opportunities and financial support for such studies are growing rapidly. However, critical commentators have pointed out significant impediments to the widespread implementation of ambulatory care training. These include issues o f financial support, which Bentley and his colleagues 2~ and others have analyzed in detail; coverage of inpatient services w h e n residents spend more time in ambulatory care; space constraints; patient acceptability; operational inefficiencies; and several others. Despite these problems, I believe there is a strong commitment by the internal medicine c o m m u n i t y to embrace this plan, as evidenced by the Report o f the ABIM Task Force on the Future Internist,22 the n e w Resid e n c y Review Committee (RRC) Special Requirements for Residency Training in Internal Medicine, the Association of Professors of Medicine (APM)/AAMC recent Retreat on the Curriculum, and the ABIM 1991 Summer Conference on the Internal Medicine Curriculum. To summarize: 1) Retrospective surveys of our graduates have pointed out p e r c e i v e d deficits in their training in ambulatory care medicine and related areas of practice. 2) Skills in the same areas are e x p e c t e d to be the desired physician attributes for meeting the future needs of patients and our society and for working within the structural organization of the health care system of the future. 3) After careful and critical analysis of the issues, there is widespread and enthusiastic support for these changes among leaders o f the internal medicine community. In this non-controversial climate, with remarkably widespread agreement by so many constituencies, one may justifiably ask, Are there any problems? What remains to be done? There are indeed significant problems and challenges that still require a great deal of attention. I will highlight three issues. The first is related to implementing ambulatory care rotations of sufficient duration and quality to both fulfill trainees' expectations and needs and diminish the reliance on the inpatient experience. Most training programs have not b e e n able to accomplish a major reduction in inpatient responsibilities because of issues related to service obligations and methods used for calculating reimbursement. I believe that it will be very difficult to focus attention on providing innovative and comprehensive training in the ambulatory care setting unless w e significantly reduce the n u m b e r of months that most programs require their trainees to spend on inpatient rotations and do not just attempt to add these n e w obligations to the existing ones. This issue is even more important in light of the need to provide more time in the curriculum for geriatrics, dermatology, gynecology, nutrition, medical orthopedics, drug and alcohol abuse, rehabilitative medicine, clinical decision mak-
JOURNALOFGENERALINTERNALMEDICINE,Volume 7 (March/April), 1992
ing, preventive medicine, e c o n o m i c assessment of medical care, and so on. My recommendation is that the RRC and the ABIM actually l i m i t the n u m b e r of months that can be spent on inpatient rotations, in addition to mandating a minimum n u m b e r of months that must be spent on meaningful patient care activities. In this regard, this latter category of activity may n e e d to be redefined and r e d u c e d as the format of a new curriculum is developed. An alternative strategy w o u l d be to prolong the training program for general internists to four years, as several commentators 23 have suggested, I do not think this is a tenable option at present due to the many financial implications of such a plan. In parallel with this shift of time to the ambulatory care setting is the need for detailed planning of an ambulatory care curriculum; careful organization of patient availability and faculty mentorship; balancing short-term with continuity-care responsibilities; and division of time between general medicine and subspecialty clinic rotations, as well as many other important challenges. Second, we need to change our value system so that faculty members whose primary responsibilities involve mainly clinical work and teaching are rewarded for excellence, as are their colleagues w h o spend most of their time in research endeavors. Furthermore, as Koshland has written in an editorial in S c i e n c e , 2~ " t h e title o f Professor should be reserved for those willing to be an earnest part of the c o m m u n i t y o f scholars. Professors reluctant to teach can be called 'distinguished research investigators,' or something else, but if they are not interested in teaching, it may be that we should recognize that they are not professors." A c o m m o n statement about teaching is that it is difficult to evaluate. While there is probably some truth in this belief, I was impressed by the argument of Timothy Johnston, Associate Dean of the College o f Arts and Sciences of the University of North Carolina, w h o wrote in response to Koshland's editorial: " T h e 'quantitative measures' of research ability that [Koshland] cites (grant support, invitations to speak, prizes, and so forth) are, after all, only indices of the scientific community's evaluation of the quality of research. This evaluation is c o n d u c t e d through the time-consuming processes of p e e r review, citation analysis and all the other, less formal mechanisms by w h i c h a scientist's research comes to be assessed. If we were to accord teaching the same serious attention accorded to research, no doubt equivalent quantitative measures of teaching ability and productivity w o u l d be forthcoming."2s In this regard there are several encouraging developments, including the growth in size and importance of divisions of general medicine; 2° the recognition faculty members in these divisions have earned in the academic community, the extraordinary success of the Society of General Internal Medicine, which represents these faculties' interests, and the formation of a society of clerkship directors in internal medicine. There is
219
also an increasing n u m b e r of seminars directed towards teaching teachers h o w to teach. In addition, Janet Bickel, of the AAMC, has pointed out that over threefourths of U.S. medical schools have recently made or are in the process of completing changes in their faculty appointment and p r o m o t i o n practices. The most c o m m o n stimulus for this change has b e e n the need for increased flexibility in retaining and rewarding faculty necessary to meet institutional needs, including, of course, clinicians and teachers. 26 Senior members and leaders of academic departments must encourage these developments by agreeing to the use of departmental funds to support and reward these faculty members and teaching programs in general. My last point may represent the most difficult challenge facing internal medicine graduate and undergraduate education. I refer to the central importance of role models for attracting students into internal medicine, for setting the tone for the discipline, and for conveying the excitement and enthusiasm created by the challenges of internal medicine. Any doubts I ever had about this issue w e r e assuaged by the study of Claire Kohrman 27 of The University of Chicago's Center for Health Administration Studies, w h o wrote " W h y do I begin with mentors? Mentors m u s t be first because w h e n I say at the beginning of an interview, 'Please tell me about your training and w h y you chose internal medicine,' mentors are the most frequent and spontaneous explanation." In these interviews, Walter Palmer spoke about Dr. Sippy, Jack Myers told of his relationship with Dr. Arthur Bloomfield, and Eugene Stead spoke of Dr. Soma Weiss, w h o guided his early career. 27 Petersdorf has written movingly of the impacts of Drs. Blake, Peters, Beeson, Thorn, and Williams on his career. 2* Preston Reynolds, a resident at Johns Hopkins, w r o t e " A critical c o m p o n e n t o f the educational process should be mentoring, the c o m m i t m e n t of energy and time to the professional growth of junior colleagues b y the faculty. Mentoring is a one-on-one responsibility that provides greater support for and thus assists students and residents in reaching for higher levels of a c h i e v e m e n t . - - R o l e models also help residents develop professional values and demeanor. We most respect the physicians w h o combine the rigors of a scientific approach to patient care with a d e e p abiding respect for the patient as a person. In the normal rhythm and bustle of the day, it is those moments w h e n an attending physician takes the time to discuss a patient or review pertinent physical findings with a resident that enrich the learning experience. To safeguard the art of medicine and its passage to future physicians, program directors could identify master clinicianteachers and pay them to teach both on the wards and in the clinics. 29 I w o n d e r w h e t h e r some of our current problems in internal medicine stem mainly from our failure to develop an adequate n u m b e r of these master-clinician
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Rubenstein, RESIDENCYTRAINING
role models, w h o s e expertise is congruent with the n e w educational requirements o f residents and students. H o w many chairmen, division chiefs, or senior faculty are capable of playing this role in the ambulatory care setting? H o w many of us are involved w i t h training residents in diagnostic and therapeutic strategies, w h i l e managing our patients in the outpatient clinic? H o w many of us are comfortable demonstrating
history taking and physical diagnosis skills to residents during their continuity clinic time? Role models today, in my experience, tend to be senior residents, junior f a c u l t y , a n d p h y s i c i a n s in p r i v a t e p r a c t i c e . W h i l e t h e y have filled the void and perform admirably, their efforts may not be sufficient to make up for our deficiencies. A f t e r all, s u r g e o n s , a n e s t h e s i o l o g i s t s , o p h t h a l m o l o gists, a n d r a d i o l o g i s t s at all l e v e l s o f s e n i o r i t y c o n t i n u e to demonstrate their professional skills to students and r e s i d e n t s d i r e c t l y , as t h e y a l w a y s h a v e . I f w e c a n m e e t t h i s c h a l l e n g e b y r e c o g n i z i n g its i m p o r t a n c e a n d c o m m i t t i n g o u r s e l v e s t o d e v e l o p i n g t h e a p p r o p r i a t e skills, then I am optimistic that internal medicine will again thrive and attract the best and brightest to our discipline. C h a r l e s L e w i s has e x p r e s s e d p e s s i m i s m a b o u t t h e likelihood that changes in internal medicine training programs would occur through the process of rational debate and accumulated evidence, saying rather that changes will probably follow long periods of emotional discussions and stressful interactions, coupled with s o m e t y p e o f c a t a c l y s m i c o r w a t e r s h e d e v e n t . 3° F i v e y e a r s later, I c o n c e d e t h a t h e m a y b e c o r r e c t , b u t I a m encouraged by definite signs indicating that incremental c h a n g e s m a y b e o c c u r r i n g a n d t h a t o u r r e s i d e n c i e s may evolve through the continuous-improvement model into an attractive, relevant, and stimulating experience.
REFERENCES 1. Nelson RL, McCaffrey LA, Nobrega FT, et al. Altering residency curriculum in response to a changing practice environment: use of the Mayo Internal Medicine Residency Alumni Survey. Mayo Clin Proc. 1990;65:809-17. 2. Kern DC, Parrino TA, Korst DR. The lasting value of clinical skills. JAMA. 1985;254:70-6. 3. Kantor SM, Griner PF. Educational needs in general internal medicine as perceived by prior residents. J Med Educ. 1981; 56:748-56. 4. Linn LS, Brook RH, Clark VA, Fink A, Kosecoff J. Evaluation of ambulatory care training by graduates of internal medicine residencies. J Med Educ. 1986;61:293-302. 5. Mandel JH, Rich EC, Luxenberg MG, Spilane MT, Kern DC, Par-
6.
7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.
28. 29. 30.
rind TA. Preparation for practice in internal medicine: a study of ten years of residency graduates. Arch Intern Med. 1988; 148:853-6. Martin GJ, Curry RH, Yarnold PR. The content of internal medicine residency training and its relevance to the practice of medicine: implications for primary care curricula. J Gen Intern Med. 1989;4:304-8. McPhee SJ, Mitchell TF, Schroeder SA, Perez-Stable EJ, Bindman AB. Training in a primary care internal medicine residency program: the first ten years. JAMA. 1987;258:1491-5, Reuben DB, McCue JD, Gerbert B. The residency - practice training mismatch: a primary care education dilemma. Arch Intern Med. 1988;148:914-9. Tarlov AR. Changing health care delivery and the role of internist: internal medicine manpower needs. American Board of Internal Medicine Summer Conference Report. 1987; 1-12. The centennial of Johns Hopkins Medicine: Symposium, DoctoringAmerica: the last 1OOyears and the next 100 years, Baltimore, MD, Feb 23-24, 1990. White KL (ed). The task of medicine: dialogue at Wickenburg. Menlo Park, CA: The HenryJ. Kaiser Foundation, 1988. Proceedings of the Conference on Vertical Integration in Health Care: Implications for medical education and practice (February 1986). Chicago, IL: American Medical Association, 1987, Summer Conference Reports, 1985 and 1987. Philadelphia: American Board of Internal Medicine. The state of internal medicine--1991. Ann Intern Med. 1991;114:1-100. JAMA. 1991;265:2491-567. Thier SO. The future of internal medicine: framing the questions. Ann Intern Med. 1991;114:88-9. Schroeder SA, Showstack JA, Gerbert B. Residency training in internal medicine: time for a change? Ann Intern Med. 1986; 104:554-61. Perkoff GT. Teaching clinical medicine in the ambulatory setting: an idea whose time may have finally come. N Engl J Med. 1986;314:27-31. Flaherty JA. A new golden standard for residency training. Arch Intern Med. 1988;148:2341-3. Byyny RL. Challenges in the education of the general internist. Arch Intern Med. 1988;148:369-72. BentleyJD, Knapp RM, Petersdorf RG. Education in ambulatory care--financing is one piece of the puzzle. N Engl J Med. 1989;320:1531-4. The Task Force on the Future Internist, American Board of Internal Medicine. The future internist. Ann Intern Med. 1988; 108:139-41. SteinJH. Grand cru versus generic: different approaches toaltering the ratio of general internists to subspecialists. Ann Intern Med. 1991;114:79-82. Koshland DE. Teaching and research. Science. 1991;251:249. Johnston TD. Evaluating teaching. Science. 1991; 251:1547. Bickel J. The changing faces of promotion and tenure at U.S. medical schools. Acad Med. 1991;66:249-56. Kohrman CH, Andersen R, Clements MM, Lyttle C. Training in internal medicine: mystery, inquiry, and technology: reflections from interviews and surveys. The University of Chicago Center for Health Administration Studies: Spring Quarter Workshop Series. Chicago, IL, 1991 (May 9). Petersdorf RG. If I had to do it again: suggestions for today's department of medicine chairman. Pharos 1991 ;54:12-6. Reynolds PP. Professionalism in residency. Ann Intern Med. 1991;114:91-2. Lewis CE. Training in internal medicine: time to retool the factory? Ann Intern Med. 1986;104:570-2.
"LowellT. Coggeshall Distinguished ServiceProfessorof Medical Sciencesand Chairman, Department of Medicine, The University of Chicago, Chicago, Illinois. Presented at the Symposiumto Honor John Benson, Philadelphia, Pennsylvania,June 12, 1991. Address correspondence and reprint requests to Dr. Rubenstein, Department of Medicine, University of Chicago, 5841 South MarylandAvenue, Chicago, IL 60637.
skills, and the need for additional ambulatory care rotations. Although there are legitimate, acknowledged criticisms of these studies, 6 including the rates of the responses, which were sometimes quite low, the fact that they were based on subjective, self-reported perceptions and might have b e e n influenced by other experiences in the years since residency, and the heterogenous composition of the respondents, I believe that the consistency of the findings merits careful consideration. Of course, retrospective surveys can indicate only deficiencies or successes in the preparation of graduates for practicing in the past or the present health care system. What about training physicians for the future? Our challenge is thus to predict th e structure and organization of medicine in the years ahead and to anticipate the role that internists will and should play. Tarlov, my mentor during his chairmanship of the Department of Medicine at The University of Chicago, has summarized his views o f the important determinants of health and the potential points of productive interventions in a n u m b e r of outstanding papers dealing with this topic. 9 Numerous books, scholarly manuscripts, journals, conference proceedings, symposia, newspaper and magazine articles, and so on also bear on it. Some that I have found particularly informative include: Doctoring America: The Last 100 Years a n d the Next 100 Years, 1opublished under the aegis of The Johns Hopkins University Society of Scholars; The Task o f M e d i c i n e - - D i a l o g u e at Wickenburg, edited by Kerr White 11 and published u n d e r the auspices of The Henry J. Kaiser Family Foundation; Vertical Integration in Health Care: Implications f o r Medical Education a n d Practice, a symposium sponsored by the American Hospital Association, the American Medical Association, and the Association o f American Medical Collegest2; the 1985 and 1987 Summer Conference Reports published by the ABIM13; the January 1, 1991, Annals o f Internal Medicinel~; and the May 15, 1991, JAMA. 15 Despite this tremendous diversity of sources, there are certain central themes and critical issues that are repeatedly emphasized and agreed u p o n by almost every commentator. These include the needs for cost containment, access to care (without increased cost), and maintaining or enhancing quality of care (at the same or r e d u c e d cost). Other important and often interrelated issues that are stressed include the aging of the population, oversupply of physicians and their maldistribution, increasing numbers of specialists with too few generalists, costly malpractice litigation, excess use of expensive t e c h n o l o g y and laboratory test-
217
218
Rubenstein, RESIDENCYTRAINING
ing, inadequate attention to behavioral modification and prevention, and a reimbursement system that favors technical dexterity rather than cognitive skills. With specific regard to my topic, the adequacy of internal medicine residency training programs to meet the challenges that medicine faces, I agree with Dr. Thier's 16 conclusion that an analysis of this future supports the results of surveys of recently graduated general internists, namely, that w e need more preventive services delivered in " m o r e ambulatory, communitybased settings . . . . [That] The medical sciences [should] be defined more broadly to include skills in behavioral science and thinking about probabilities, populations, and prevention [that] Reimbursement [should] pay for those services that most effectively improve the health o f the public as opposed to those that have less or little utility but can more easily be d o c u m e n t e d . " ~6 Based on these past surveys and predictions regarding the organization of medical care in the future, remarkable unanimity has emerged among various experts as to the changes in internal medicine graduate training programs that w o u l d be desirable. These have b e e n detailed in a n u m b e r of excellent articles published during the past five years. Schroeder and colleagues tr and Perkoff, Is in their seminal papers published in 1986, pointed out that internal medicine residencies had undergone only modest changes in their organization despite dramatic changes in their major teaching site, the inpatient setting. They stressed the decline in length of stay of inpatients, the increasing acuity of their illnesses leading to the more frequent use o f intensive care units and coronary care units, the shift of diagnostic decision making to ambulatory care settings, the emphasis on admissions for invasive and surgical procedures, and the corresponding underrepresentation within the hospital of patients with certain illnesses, w h o c o m m o n l y present to general internists for their care in ambulatory settings. Their logical response to this situation was to emphasize the advantages of a significant expansion of ambulatory care training time, c o m p l e m e n t e d by increased exposures to behavioral medicine, decision analysis, c o s t - b e n e f i t issues, practice management, and related outpatient disciplines. This theme has been elaborated u p o n in a n u m b e r of excellent manuscripts, all of which have strongly supported this approach for residency education. Flahetty, 19 Goldfinger, t3 and Byyny,2° among others, have stressed the many advantages of outpatient and officebased education, including the opportunity to enhance residents' skills in history taking, physical diagnosis, patient education, disease prevention, and health promotion. Training in the judicious use of consultants as well as a continuing emphasis on cost-effective diagnostic and therapeutic strategies w o u l d be further positive outcomes that would be fostered by involvement in
the longitudinal care of patients. In parallel with this shift in education to ambulatory care, it w o u l d be most desirable to encourage the d e v e l o p m e n t of n e w research endeavors in this setting. 2° Opportunities and financial support for such studies are growing rapidly. However, critical commentators have pointed out significant impediments to the widespread implementation of ambulatory care training. These include issues o f financial support, which Bentley and his colleagues 2~ and others have analyzed in detail; coverage of inpatient services w h e n residents spend more time in ambulatory care; space constraints; patient acceptability; operational inefficiencies; and several others. Despite these problems, I believe there is a strong commitment by the internal medicine c o m m u n i t y to embrace this plan, as evidenced by the Report o f the ABIM Task Force on the Future Internist,22 the n e w Resid e n c y Review Committee (RRC) Special Requirements for Residency Training in Internal Medicine, the Association of Professors of Medicine (APM)/AAMC recent Retreat on the Curriculum, and the ABIM 1991 Summer Conference on the Internal Medicine Curriculum. To summarize: 1) Retrospective surveys of our graduates have pointed out p e r c e i v e d deficits in their training in ambulatory care medicine and related areas of practice. 2) Skills in the same areas are e x p e c t e d to be the desired physician attributes for meeting the future needs of patients and our society and for working within the structural organization of the health care system of the future. 3) After careful and critical analysis of the issues, there is widespread and enthusiastic support for these changes among leaders o f the internal medicine community. In this non-controversial climate, with remarkably widespread agreement by so many constituencies, one may justifiably ask, Are there any problems? What remains to be done? There are indeed significant problems and challenges that still require a great deal of attention. I will highlight three issues. The first is related to implementing ambulatory care rotations of sufficient duration and quality to both fulfill trainees' expectations and needs and diminish the reliance on the inpatient experience. Most training programs have not b e e n able to accomplish a major reduction in inpatient responsibilities because of issues related to service obligations and methods used for calculating reimbursement. I believe that it will be very difficult to focus attention on providing innovative and comprehensive training in the ambulatory care setting unless w e significantly reduce the n u m b e r of months that most programs require their trainees to spend on inpatient rotations and do not just attempt to add these n e w obligations to the existing ones. This issue is even more important in light of the need to provide more time in the curriculum for geriatrics, dermatology, gynecology, nutrition, medical orthopedics, drug and alcohol abuse, rehabilitative medicine, clinical decision mak-
JOURNALOFGENERALINTERNALMEDICINE,Volume 7 (March/April), 1992
ing, preventive medicine, e c o n o m i c assessment of medical care, and so on. My recommendation is that the RRC and the ABIM actually l i m i t the n u m b e r of months that can be spent on inpatient rotations, in addition to mandating a minimum n u m b e r of months that must be spent on meaningful patient care activities. In this regard, this latter category of activity may n e e d to be redefined and r e d u c e d as the format of a new curriculum is developed. An alternative strategy w o u l d be to prolong the training program for general internists to four years, as several commentators 23 have suggested, I do not think this is a tenable option at present due to the many financial implications of such a plan. In parallel with this shift of time to the ambulatory care setting is the need for detailed planning of an ambulatory care curriculum; careful organization of patient availability and faculty mentorship; balancing short-term with continuity-care responsibilities; and division of time between general medicine and subspecialty clinic rotations, as well as many other important challenges. Second, we need to change our value system so that faculty members whose primary responsibilities involve mainly clinical work and teaching are rewarded for excellence, as are their colleagues w h o spend most of their time in research endeavors. Furthermore, as Koshland has written in an editorial in S c i e n c e , 2~ " t h e title o f Professor should be reserved for those willing to be an earnest part of the c o m m u n i t y o f scholars. Professors reluctant to teach can be called 'distinguished research investigators,' or something else, but if they are not interested in teaching, it may be that we should recognize that they are not professors." A c o m m o n statement about teaching is that it is difficult to evaluate. While there is probably some truth in this belief, I was impressed by the argument of Timothy Johnston, Associate Dean of the College o f Arts and Sciences of the University of North Carolina, w h o wrote in response to Koshland's editorial: " T h e 'quantitative measures' of research ability that [Koshland] cites (grant support, invitations to speak, prizes, and so forth) are, after all, only indices of the scientific community's evaluation of the quality of research. This evaluation is c o n d u c t e d through the time-consuming processes of p e e r review, citation analysis and all the other, less formal mechanisms by w h i c h a scientist's research comes to be assessed. If we were to accord teaching the same serious attention accorded to research, no doubt equivalent quantitative measures of teaching ability and productivity w o u l d be forthcoming."2s In this regard there are several encouraging developments, including the growth in size and importance of divisions of general medicine; 2° the recognition faculty members in these divisions have earned in the academic community, the extraordinary success of the Society of General Internal Medicine, which represents these faculties' interests, and the formation of a society of clerkship directors in internal medicine. There is
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also an increasing n u m b e r of seminars directed towards teaching teachers h o w to teach. In addition, Janet Bickel, of the AAMC, has pointed out that over threefourths of U.S. medical schools have recently made or are in the process of completing changes in their faculty appointment and p r o m o t i o n practices. The most c o m m o n stimulus for this change has b e e n the need for increased flexibility in retaining and rewarding faculty necessary to meet institutional needs, including, of course, clinicians and teachers. 26 Senior members and leaders of academic departments must encourage these developments by agreeing to the use of departmental funds to support and reward these faculty members and teaching programs in general. My last point may represent the most difficult challenge facing internal medicine graduate and undergraduate education. I refer to the central importance of role models for attracting students into internal medicine, for setting the tone for the discipline, and for conveying the excitement and enthusiasm created by the challenges of internal medicine. Any doubts I ever had about this issue w e r e assuaged by the study of Claire Kohrman 27 of The University of Chicago's Center for Health Administration Studies, w h o wrote " W h y do I begin with mentors? Mentors m u s t be first because w h e n I say at the beginning of an interview, 'Please tell me about your training and w h y you chose internal medicine,' mentors are the most frequent and spontaneous explanation." In these interviews, Walter Palmer spoke about Dr. Sippy, Jack Myers told of his relationship with Dr. Arthur Bloomfield, and Eugene Stead spoke of Dr. Soma Weiss, w h o guided his early career. 27 Petersdorf has written movingly of the impacts of Drs. Blake, Peters, Beeson, Thorn, and Williams on his career. 2* Preston Reynolds, a resident at Johns Hopkins, w r o t e " A critical c o m p o n e n t o f the educational process should be mentoring, the c o m m i t m e n t of energy and time to the professional growth of junior colleagues b y the faculty. Mentoring is a one-on-one responsibility that provides greater support for and thus assists students and residents in reaching for higher levels of a c h i e v e m e n t . - - R o l e models also help residents develop professional values and demeanor. We most respect the physicians w h o combine the rigors of a scientific approach to patient care with a d e e p abiding respect for the patient as a person. In the normal rhythm and bustle of the day, it is those moments w h e n an attending physician takes the time to discuss a patient or review pertinent physical findings with a resident that enrich the learning experience. To safeguard the art of medicine and its passage to future physicians, program directors could identify master clinicianteachers and pay them to teach both on the wards and in the clinics. 29 I w o n d e r w h e t h e r some of our current problems in internal medicine stem mainly from our failure to develop an adequate n u m b e r of these master-clinician
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role models, w h o s e expertise is congruent with the n e w educational requirements o f residents and students. H o w many chairmen, division chiefs, or senior faculty are capable of playing this role in the ambulatory care setting? H o w many of us are involved w i t h training residents in diagnostic and therapeutic strategies, w h i l e managing our patients in the outpatient clinic? H o w many of us are comfortable demonstrating
history taking and physical diagnosis skills to residents during their continuity clinic time? Role models today, in my experience, tend to be senior residents, junior f a c u l t y , a n d p h y s i c i a n s in p r i v a t e p r a c t i c e . W h i l e t h e y have filled the void and perform admirably, their efforts may not be sufficient to make up for our deficiencies. A f t e r all, s u r g e o n s , a n e s t h e s i o l o g i s t s , o p h t h a l m o l o gists, a n d r a d i o l o g i s t s at all l e v e l s o f s e n i o r i t y c o n t i n u e to demonstrate their professional skills to students and r e s i d e n t s d i r e c t l y , as t h e y a l w a y s h a v e . I f w e c a n m e e t t h i s c h a l l e n g e b y r e c o g n i z i n g its i m p o r t a n c e a n d c o m m i t t i n g o u r s e l v e s t o d e v e l o p i n g t h e a p p r o p r i a t e skills, then I am optimistic that internal medicine will again thrive and attract the best and brightest to our discipline. C h a r l e s L e w i s has e x p r e s s e d p e s s i m i s m a b o u t t h e likelihood that changes in internal medicine training programs would occur through the process of rational debate and accumulated evidence, saying rather that changes will probably follow long periods of emotional discussions and stressful interactions, coupled with s o m e t y p e o f c a t a c l y s m i c o r w a t e r s h e d e v e n t . 3° F i v e y e a r s later, I c o n c e d e t h a t h e m a y b e c o r r e c t , b u t I a m encouraged by definite signs indicating that incremental c h a n g e s m a y b e o c c u r r i n g a n d t h a t o u r r e s i d e n c i e s may evolve through the continuous-improvement model into an attractive, relevant, and stimulating experience.
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