To create circumstances under which first-year residents can thrive, commitment and collaboration among multiple stakeholders are essential. The information passed from medical schools to residency programs should provide an accurate assessment of student strengths and weaknesses through reliable, digestible metrics.
That much was agreed upon when faculty members from three schools in the AMA’s Accelerating Change in Medical Education Consortium presented on improving the continuum of learning between undergraduate and graduate medical education during the recent AMA ChangeMedEd® 2017 National Conference. The methods for creating the ideal educational handover, however, were the subject of much debate.
The dilemma: Every residency application is accompanied by the Medical Student Performance Evaluation (MSPE) letter, formerly known as the Dean’s Letter. That document, in theory, works as a summary of the student’s academic track record and assessment of their potential as a resident. There is, however, some concern about the inherent conflict of interest—medical schools want their students entering the best residency programs possible.
Solution 1: Offer a more honest, robust Dean’s Letter with objective data.
Kim Lomis, MD, associate dean for undergraduate medical education at Vanderbilt University School of Medicine, spoke in favor of this course of action. Dr. Lomis said medical students are shifting toward earlier clerkships, offering a window post-clerkship for in-depth assessment that includes the accumulation of data to measure student performance. That data will give residency program directors a better idea where applicants stand and how they will fit into the program. There is a down side, however. If other institutions are not providing the same comprehensive data, applicants from the schools that do offer that information could be adversely affected.
“We’re very invested in asking if we can generate meaningful information that is distinguishing and could help broaden how applicants are selected,” Dr. Lomis said. “We would love to advocate for greater transparency at the time of the Match process and provide greater information in advance of that process.”
Solution 2: Supplement the MSPE with a document assessing a student upon medical school graduation.
MSPEs are sent Oct. 1. This timing leaves a window in which students can grow their skill set, which is not reported. Helen Morgan, MD, associate professor of obstetrics and gynecology at the University of Michigan Medical School, believes the solution might be a second period of assessment and a document highlighting students’ strengths and weaknesses closer to the time when they join a residency. That second document is presented post-graduation, several months after the application and Match process has been completed.
“There’s such a different objective to the Dean’s Letter,” Dr. Morgan said. “The Dean’s Letter is to help the student get into a good residency. What we want to send at the end of medical school is more along the lines of helping the learner succeed once they start their residency.”
The dilemma: Medical students enter into residency as unfinished products, and the challenge for medical schools is to identify where or how the product is unfinished. Once that is identified, it is key for medical schools to indicate how a student measures up and transmit this information to residency institutions in a format that is easy to comprehend. That format needs to go further than measuring students against classmates. It should measure the skills that medical students need to be a physician and offer a pathway to mastery of those skills.
Solution 1: Follow the Core Entrustable Professional Activities for Entering Residency (EPAs).
Published by the Association of American Medical Colleges in 2014, the 13 Core EPAs provide a set of tasks that learners should be able to perform upon entering residency. Rather than focusing on facts and lessons, the EPAs focus on tasks—such as working in an interprofessional team or performing a history and examination—and how a student is progressing toward being able to perform them well without supervision from a faculty member.
George C. Mejicano, MD, is the senior associate dean for education at Oregon Health & Science University (OHSU) and proponent of EPAs as a good way to measure students going into residency. Starting with the class of 2018, after the Match, OHSU plans to send an additional document to residency programs that represents where medical students who are entering residency stand from an EPA perspective.
“Patients don’t care about what a doctor knows,” Dr. Mejicano said. “What they care about is feeling better. The EPA framework gets to that patient and clinical perspective. It gets to tasks that actually matter because they are related to tasks the clinicians actually do.”
Solution 2: Follow the core competencies and specialty-specific milestones set forth by the Accreditation Council for Graduate Medical Education (ACGME).
The six ACGME core competencies describe trainable attributes of an individual that apply to all physicians. The milestones are specialty-specific achievements. In both instances, they are designed to evaluate and track residents. In essence, they are mile markers indicating how much further a trainee has to go. They are also part of an evaluation framework commonly used by residency programs. So if they are applied at the undergraduate medical education level, residency programs are more likely to understand what they mean in relation to a medical student’s progress.
Sally Santen, MD, PhD, is a professor of emergency medicine and assistant dean for educational research and quality improvement at the University of Michigan Medical School. Michigan informs medical schools where students stand on specialty-specific ACGME milestones in a letter sent after the Match.
“Many of the medical schools had been using the competencies to begin with, so it was easy just to continue with that,” Dr. Santen said. “Program directors understood the language. So they understood what they were getting [with the supplemental letter].”
The session on the transition to residency was among dozens that took place during the ChangeMedEd conference. The event showcased how the AMA, through its Accelerating Change in Medical Education initiative, is working to reimagine and shape the future of medical education.