PM&R
Volume 2, Issue 2 , Pages 87-90, February 2010

From Novice to Expert: Obstacles and Opportunities for Residency Programs

Departments of Rehabilitation Medicine & Pediatrics, University of Washington, 1900 NE Pacific St, Box 356490, Seattle, WA 98195†

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Introduction 

Physical medicine and rehabilitation (PM&R) residency programs have a duty to the public to educate physicians who will practice competently and independently and to their residents to help them become lifelong learners who will maintain their expertise. In pursuit of these goals, residency programs and their directors are enabled, and at times impeded by, local resources and national regulatory requirements. Some of the challenges and changes facing residency programs and the field include the demographics of the trainees, the environment of teaching, the evolution toward fellowship training, and preparation for engaging in maintenance of certification (MOC). Although my experiences have been informed by my work as residency program director (PD) at the University of Washington, as a director of the American Board of PM&R, and as a member of the Accreditation Council of Graduate Medical Education (ACGME) PM&R Review Committee, the opinions expressed herein are my own.

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Demographics 

The number of residency positions in PM&R has remained relatively stable at approximately 1200 positions during the last decade. In 2008, 56.2% of positions were filled by students from United States (US) allopathic medical schools, up from a low of 45.3% in 2000. The number of positions filled by students from osteopathic schools has steadily increased from 12.1% in 2000 to 25% in 2008. PM&R has the greatest proportion of osteopathic resident physicians on duty in ACGME-accredited residency programs. International medical graduates, the bulk of whom are US citizens, now comprise only 18.6% of trainees, down from 38.6% in 2000 [1, 2].

The Association of American Medical Colleges supports a 30% increase in US medical school enrollment by 2015 [3] and is currently advocating to Congress that the final health-care reform agreement have a 15% increase in the number of Medicare supported graduate medical education (GME) slots. In the 2009 match, PM&R had the second lowest ratio of US (allopathic) senior students to available positions, meaning that we have enough positions to accommodate all US seniors who want to go into PM&R [4]. Even with the increasing number of osteopathic students entering PM&R, the increase in positions would not result in a larger US-trained PM&R cohort. We must continue our efforts to compete for and recruit allopathic and osteopathic students to our field. We also have to continue to gain the interest of women, future physician scientists, and the brightest medical students. PM&R does not appear to be as attractive to women as other specialties. In 2008, women comprised 40% of trainees, compared with an average of 45% in all specialties [1].

Further, although the primary duty of residency programs is to train competent clinicians, we must also tend the future physician scientists. The Rehabilitation Medicine Scientist Training Program is a great avenue for physiatry residents who are interested in academic careers. We would likely also increase the numbers of academic physicians if we attracted more students from Medical Scientist Training Programs. Between 2004 and 2008, less than 1% of graduates from Medical Scientist Training Programs entered PM&R [5].

Finally, PM&R residency programs do not currently attract students who achieve high Unites States Medical Licensing Exam (USMLE) scores or who are elected to Alpha Omega Alpha. In the 2009 National Resident Matching Program (NRMP) match, the USMLE scores of those entering PM&R were 11 points lower than the average scores of matched US seniors and 5 to 9 points lower than the average matched independent applicant (all others). The USMLE scores of US seniors and independent applicants entering PM&R are among the lowest of any specialty. Only 4% of US seniors who matched into PM&R were elected to Alpha Omega Alpha, compared with 15.3% of all applicants who matched to their preferred specialty [4]. These characteristics are by no means the only measures of quality in students, but they should not be ignored. We do not want our field to be viewed as a safe second choice by subpar medical students.

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Environment of Teaching 

In concert with the American Board of Medical Specialties, the ACGME began the “Outcomes Project” in 1999 to shift residency training away from processes to a learner-centered, competency-based system of education, driven by outcomes [6]. Unfortunately, meaningful outcomes were difficult for PDs to define; therefore, in 2008, the ACGME began the sequential launch of a new project, known as the Milestones. Each specialty will be required to detail the expectations and time frame to attain specific competencies and the tools that will be used to evaluate residents. Recently, the field of internal medicine published its attempt to identify milestones for internal medicine residents. There are more than 140 per resident in a 3-year residency [7]! Once more of the larger specialties have accomplished this, ACGME will convene PM&R PDs to do the same for our specialty. The resulting requirements could improve education, but risk creating a tremendous burden of assessment and record keeping.

It is important to remember that the “E” in GME is education. There are tensions between education and service, education and clinical productivity of faculty, and education and regulations/training requirements. Our residents' time to learn PM&R can be compromised by rotations that do not have strong educational value, by managing ACGME-specified minimum numbers of inpatients who may have extremely high medical acuity, by working with cumbersome electronic medical records, or by hospital and institutional requirements to complete increasing amounts of generic training modules. PM&R PDs need to actively engage and advise the ACGME about outdated training requirements that are no longer appropriate for high-acuity patients with short lengths of hospital stays.

PDs should seek opportunities to participate in their institution's GME committee, to help stem the tide of ever growing training regulations. PM&R departments should consider implementing an educational impact statement for each new proposed clinical activity, addressing the question, “Is the activity of educational value?” If not, departments may need to find other personnel, including midlevel providers, to manage the patients. If the activity is of educational value, the chair needs to set productivity expectations that are not so high as to preclude the desire or ability of faculty to teach. Education requires more than an apprenticeship model of working side by side with the expert. To acquire clinical expertise, residents need time to study domain-specific content, they need experts to assess their analytical skills and metacognitive skills, and they need repeated clinical exposure to begin to develop pattern recognition [8].

There are 3 to 4 generations of faculty, residents, and students in medical schools in the United States. Nicknames include the silent generation (1922-1943), baby boomers (1943-1960), Gen X (1960-1980), and the iGeneration (1980-2000). Each has been raised among different defining events and trends. They have distinct loyalties, different expectations of work and life outside work, and differing technological literacy. Department heads and senior faculty are likely to be baby boomers, whereas junior faculty and residents are Gen X or early iGeneration [9]. Along with this generation gap is there also a learning gap? I concur with the concerns raised by Wear [10], who proposed that the convergence of bullet point teaching, the anatomization of competencies, and the shift to reading on a screen have created a perfect storm of dysfunctional learning that is counter to the cognitive and affective habits of self-reflection, deliberation, an eye for nuance and ambiguity, and the recognition that becoming a doctor requires more than memorizing and performing skills. The development of an expert will require more than a Twitter exposure to a clinical question. The widespread use of PowerPoint may encourage fragmented thinking, and oversimplification and screen reading invites scanning. Compartmentalizing competence into discrete elements for residents to pass does not necessarily imply that they can respond to “whole-patient” problems under evolving conditions. As PDs, we don't want to train residents for bite-sized competence at the bedside—we want to train a “whole physician.” Becoming an expert physician requires in depth content-specific mastery as well as multiple clinical exposures. Perhaps we need to bring what is known as the “Slow Movement” to medical education (the Slow Movement is a cultural shift toward slowing down the pace of life).

We demand use of evidence-based medicine skills for patient care, yet much of the way we educate residents is without any scientific foundation. Given the aforementioned concerns noted, it is possible that much of what we currently rely on for teaching methods, presentations, and assessment are completely inappropriate. Faculty development is an important mission for our academic departments. We need leaders in education who have the opportunity to study educational interventions and who can train faculty in effective teaching and assessment methods.

One of the key players in the environment of teaching is the residency PD. Unfortunately, PM&R has among the lowest length of service of PDs among all specialties, 5.7 years (versus 7.04) averaged since 2001. Between 2004 and 2009, we have had 49 new PDs in our 78 programs [11]. This turnover and low longevity are direct obstacles to creating a cadre of leaders in education. In my own 18 years of experience, being a PD has led to training in a Teaching Scholars curriculum, educational research and publications, opportunities to serve national organizations, and to faculty promotion. These “rewards” can only occur if the chair and the department also value them and provide adequate financial support, protected time and resources. At a regulatory level, ACGME must follow through on its strategic priority to enhance efficiency and reduce burden in accreditation [12].

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Evolution Toward Fellowship Training 

The American Medical Association annual survey of 1999 to 2000 included 357 graduating PM&R residents. A total of 298 of these had known plans and, of these, 46 (15%) were pursuing further training [13]. Although similar data are no longer collected by the American Medical Association, Smith [14] estimated that as many as 50% of graduating PM&R residents are now pursuing fellowship training. Such opportunities include accredited fellowships such as sports, spinal cord injury, pediatrics, neuromuscular and pain, as well as other opportunities such as research and unaccredited musculoskeletal fellowships. During the last decade, students applying to PM&R residencies have shown a steady increase in interest in musculoskeletal medicine. Now many are more specifically interested in sports medicine, and I wonder if this is because of their ability to pursue subspecialty certification in sports medicine versus a desire to avoid caring for “old” people. Perhaps as Barry Smith suggested in this column in October 2009 [14], it is time for us to develop a subspecialty certification that encompasses what musculoskeletal physiatrists do, instead of parceling it out to pain and sports medicine. And why stop there? Why not subspecialty certification in stroke, brain injury, cancer, amputation, or geriatric rehabilitation? The field will need to decide what the benefits and risks of subspecialty certification are.

Risks/burdens include the increasing requirements for maintaining specialty and subspecialty certifications. For residency programs, it means deciding what comprises core versus subspecialty training. If subspecialty certification becomes available in all of the aforementioned areas, what part of our practice is a graduating resident competent to practice independently? The specific topic most discussed by PDs at our annual council meeting is how many and what type of procedures should a resident perform? Programs have to report resident experience in spasticity and pain (joint, soft tissue, and axial injections) management to ACGME, yet they vary widely in the experiences offered to residents. ACGME has just instituted a requirement for residents to log their procedures in an ACGME database. PDs anticipate that minimum numbers for procedures will eventually be defined, much like we have minimum expectations for numbers of electrodiagnostic studies. Can a number guarantee minimum competence? How will such a decision be made, given the absence of scientific/education literature on this? It could be made by the ACGME; a minimum could be chosen, proposed in new residency requirements, and “debated” during a 45-day comment period during which interested parties could write to the ACGME. This strategy does not seem like a well-informed way to solve this issue. Clearly this is a fruitful area for educational research. Musculoskeletal and procedural physiatrists should research more than outcomes of injections, but how competence in performing them is achieved.

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Preparation for Engaging in MOC 

At the end of residency, PDs certify that residents are competent to enter independent practice. With ensuing clinical experience, physicians should ideally progress to expert and continue their learning to maintain this expertise. The MOC process is a work in progress. Maintaining PM&R and subspecialty certifications became more demanding with the move to closed book computer-based testing. To the frustration of many, MOC is continuing to evolve with requirements for periodic self-assessment examinations, practice improvement projects, and improved patient safety. No doubt physicians for whom these have recently become requirements wish they had had some training in residency on quality improvement and systems/error management. Other residencies, such as surgery and internal medicine, have long had morbidity and mortality conferences, but PM&R residency programs have been slower to adopt these. To really influence quality improvement and systems, residents need to be included in the system (ie, hospital) programs.

However, it is cumbersome for hospitals to include hundreds of residents in their quality improvement activities. Meeting times may not be convenient for residents and quality improvement cycles may take longer than a resident's tenure at a particular hospital. Yet the inducement for a hospital to include residents is that they are on the front lines of care and can first hand identify many systems issues that would be hidden from faculty or staff. If there are several faculty who have MOC requirements to do a practice improvement project, it may help to have the department or clinical service orchestrate a group activity that includes residents. Resident physicians would then have some comprehension of how to do performance improvement activities once they enter practice.

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Conclusion 

There are many challenges and changes we face in PM&R resident education, and I have addressed just a few here. We must continue our efforts to attract capable medical students. Resident education needs to be an important mission of our academic departments. We need to research educational methods and teach using evidence based techniques in order to develop residents from novices to competent physiatrists. Residents must be prepared for effective and continuous lifelong learning. Finally, we need to influence regulatory agencies to enhance efficiency and reduce burdens on residents and residency programs. We need to be nimble in order to modify and adapt resident education to meet the challenges and changes ahead.

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References 

  1. Brotherton SE, Etzel SI. Graduate Medical Education, 2008-2009. JAMA. 2009;302(12):1357–1372
  2. Appendix II: Graduate Medical Education. JAMA. 2001;286(9):1095–1107
  3. AAMC Statement on the Physician Workforce. http://www.aamc.org/workforce/workforceposition.pdf2006;Accessed January 4, 2010
  4. National Resident Matching Program and Association of American Medical Colleges. Charting outcomes in the match: Characteristics of applicants who matched to their preferred specialty in the 2009 main residency match. 3rd Edition, August 2009. http://www.nrmp.org/data/resultsanddata2009.pdfAccessed January 13, 2010
  5. Paik JC, Howard G, Lorenz RG. Postgraduate choices of graduates from medical scientist training programs, 2004-2008. JAMA. 2009;302(12):1271–1273
  6. The ACGME Outcome Project: an introduction. http://www.acgme.org/Outcome/Accessed January 4, 2010
  7. Green ML, Aagard EM, Caverzagie KJ, et al. Charting the road to competence: Developmental milestones for internal medicine residency training. J Graduate Med Ed. 2009;1(1):5–20
  8. Bordage G. Elaborated knowledge: A key to successful diagnostic thinking. Acad Med. 1994;69(11):883–885
  9. Howell LP, Servis G, Bonham A. Multigenerational challenges in academic medicine: UC Davis' responses. Acad Med. 2005;80:527–532
  10. Wear D. A perfect storm: The convergence of bullet points, competencies and screen reading in medical education. Acad Med. 2009;84:1500–1504
  11. ACGME Accredited Program and Institutional Listing—Public Access. http://www.acgme.org/adspublic/Accessed January 4, 2010
  12. Philibert I. Resources to clarify the accreditation process (ACGME-Bulletin). http://www.acgme.org/acWebsite/bulletin-e/ebu_index.aspSeptember 2007;Accessed January 4, 2010
  13. Brotherton SE, Simon FA, Tomany SC. US Graduate Medical Education, 1999-2000. JAMA. 2000;284(9):1121–1126
  14. Smith BS. Subspecialization training in PM&R. PM&R. 2009;1:905–907
  • † Disclosure: nothing to disclose

 Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org

PII: S1934-1482(10)00008-0

doi:10.1016/j.pmrj.2010.01.006

PM&R
Volume 2, Issue 2 , Pages 87-90, February 2010

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