Redesigning Training for Internal Medicine

As the single largest group of physicians, internists represent the backbone of the health care system. They not only diagnose and treat diseases of adults but also coordinate health care and play a critical role in preventing disease and promoting health and well-being. Internists practice in a variety of settings, ranging from outpatient offices and clinics to inpatient acute care hospitals to long-term care facilities. Their expertise and scopes of practice extend from a broad base of internal medicine (encompassing all organ systems) to highly specialized clinical areas. In addition to direct patient care, internists are also involved in many other types and combinations of activities, including teaching, research, administration, and health care policy. Over several years, educational leaders in internal medicine have become increasingly concerned about whether current residency training is appropriately designed to train internists for these varied roles and for practice in the 21st century (1-5). Optimizing training in the context of the current health care system is important for trainees, for patients, and for the well-being and attractiveness of internal medicine. Reform of residency training must ensure the following: 1) the quality and relevance of the educational experience and the associated satisfaction of trainees with that experience, 2) the effectiveness of the educational process in facilitating residents' acquisition of competencies needed to provide the best possible patient care, and 3) the ability of internists to understand and adapt to changes in the rapidly evolving system of health care delivery and to remain current with the expanding body of medical knowledge. This paper synthesizes 2 American College of Physician (ACP) position papers on redesign of training, each of which was based on a combination of literature review and expert opinion. Both position papers were written by staff and members of the ACP's Education Committee, with input from the ACP Council of Associates and the Council of Student Members, and were approved by ACP's Education Committee and Board of Regents. Recommendations were made by consensus, with agreement to concentrate on the high-priority issues related to training. Several factors support the need to redesign training in internal medicine. Tables 1 and 2 summarize these concerns, together with related goals and proposals for training redesign. In addition, concern exists about the declining numbers of residents entering general internal medicine careers. Analysis of data from residents completing the Resident Survey during the Internal Medicine In-Training Examination showed that the proportion of third-year residents (PGY3) intending to pursue generalist careers decreased from 54% to 27% over the 5-year period from 1998 to 2003 (6). Although this decline undoubtedly can be attributed to many reasons unrelated to training, it is likely that stress during residency training, inadequate ambulatory medicine experiences, and the exposure of medical students and junior residents to unhappy supervising residents and discouraged faculty are turning some students away from general internal medicine (7-10). Table 1. Redesign of Undergraduate Medical Education Table 2. Redesign of Graduate Training in Internal Medicine Specific Recommendations for Redesign of Training Undergraduate Medical Education Although a detailed discussion of the overall structure and curriculum of medical school is beyond the scope of this paper, we believe that a critical examination of the medical school experience is warranted, including consideration of potential modifications throughout the 4 years that might simultaneously increase the appeal of internal medicine to undecided students and improve the preparatory training for students already planning careers in internal medicine. Because initial decisions about specialty choice are made during medical school, it is critical that the educational program in internal medicine for medical students be as robust as possible. Starting even during the first year of medical school, students need to be exposed to the many career possibilities and types of activities encompassed by the discipline of internal medicine. To relieve the curriculum gridlock in undergraduate medical education and allow time for such exposure, premedical requirements should be reevaluated with an eye toward decompressing the first year of medical school. Flexible time should be available in the third year for students who are uncertain about future plans to explore specialty choices and further experience the intellectual challenges and personal satisfactions that come from a career in internal medicine. Training, particularly in the ambulatory setting, should occur in well-functioning practice environments that demonstrate patient-centered, service-oriented approaches and have organizational structures to deliver and document the highest quality of patient care and safety. Students must be exposed to enthusiastic role modelsboth faculty (academic and volunteer) and residents from both inpatient and outpatient settingswho are positive about their own careers in internal medicine. Although students are largely taught by internal medicine faculty during the preclinical years, these faculty often do not transmit enthusiasm and zeal for the field of internal medicine or professional satisfaction with their own careers. It is particularly critical that faculty and residents who teach students during the third-year clerkship in internal medicine be enthusiastic role models. Students must see not only residents and junior faculty just out of residency, but also senior faculty and master clinicians who practice internal medicine with confidence, competence, and professional pride. Other faculty-related issues are discussed in more detail in the section on graduate medical education, but the recommendations mentioned there apply equally to faculty involvement in medical student education. Students who have decided to pursue residency training in internal medicine should have additional well-designed curricular experiences that complement the required clinical clerkships and address ultimate career needs. We propose that high-quality experiences late in the third year or in the fourth year in each of the following areas would be particularly valuable both to students entering internal medicine residencies and to uncommitted medical students: 1. Revisiting pathophysiology and mechanisms of disease. After completing their internal medicine clerkship or clerkships, students should revisit the scientific (molecular and pathophysiologic) underpinnings of clinical medicine through a block or longitudinal learning experience that links current science and pathophysiology with clinical medicine. Bridging science with clinical medicine after students have had clinical experiences serves to reinforce both areasthe science makes more sense in the appropriate clinical context, and it greatly amplifies the student's understanding of disease processes. 2. Translating knowledge into best practice. Given the current concern about the quality of health care, students should receive translational education, defined as education that helps a student or resident translate medical knowledge into high-quality patient care. This includes an understanding of effective and efficient systems of delivery of care, the value of a team-based approach, measuring and improving quality of care, and patient safety. Students should actively apply this knowledge through participation in efforts to measure and improve the quality of care. 3. Developing analytic and interpretive skills. Students should develop the critical analytic, interpretive, and clinical decision-making skills that are important for understanding the medical literature and applying the new information with which they will be presented throughout their careers. Again, an ideal time to learn (or reinforce) these skills is after students have been introduced to clinical medicine in their clerkships. Developing confidence in these analytic and interpretive skills fosters a commitment to, and prepares a student for, lifelong learning and self-improvement. 4. Preparing for residency training. Although many medical schools currently require subinternships, we believe that every student should have at least one high-intensity, preresidency clinical experience that will develop the skill set necessary for a successful residency. This will allow the student after graduation to concentrate quickly on learning internal medicine rather than the logistic skills of internship. Graduate Medical Education Underlying these proposals for training redesign is the recognition that being a good internist requires much more than just a satisfactory knowledge base in internal medicine. The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties have adopted a broader set of 6 general competencies that extend well beyond medical knowledge. We fully support the need for residency programs to train physicians and for boards to evaluate candidates for certification on the basis of all 6 competencies (11). We further recognize that actual physician practice performance and the quality of delivered care provide the substrates for evaluating the competencies of patient care, communication, professionalism, systems-based practice, and practice-based learning and improvement. 1. Defining the design model for residency training. Because of the broad, experience-based curriculum necessary for all internists, no matter what their eventual scopes of practice, the duration of the internal medicine training period should not be less than the current 3 years. Conversely, lengthening the period of training might have a negative impact on recruitment of medical students into internal medicine and should be avoided. We recognize that