Residents who are beginning their training this month are in for a rigorous few years, and that’s nothing new. But the realities of graduate medical education have shifted significantly over the years.
John Andrews, MD, is the AMA’s vice president for GME innovations—and one of the leaders of the AMA Reimagining Residency initiative. He has worked with residents for several decades. Dr. Andrews offered his thoughts on four key ways training has shifted.
In 2003 the initial set of duty hour restrictions were implemented by the Accreditation Council for Graduate Medical Education (ACGME), instituting the 80-hour work week. Dr. Andrews believes these limited hours don’t necessarily make training easier.
“I get challenged in talks I’ve given when I say [residency is] actually harder now than when I went through it. I certainly worked more hours than residents work now,” he said. “There’s no question about that. I trained in an era before duty hours were regulated. But my work was less complex than what residents are currently called upon to do. There are more available approaches and treatments than when I was a resident. Lengths of stay are shorter and that means patient turnover is greater. It’s changing all the time.”
Physicians worked in electronic health record (EHR) platforms in the ’90s. Following a report published early in the millennium by The Institute of Medicine highlighting EHR contributions to patient safety, use became more widespread. Today, first-year residents are spending an average of more than 100 hours per month working on electronic patient records.
“The EHR has its merits,” Dr. Andrews said. “When I was training everything was on paper and if someone else had the chart, you didn’t have access to necessary information.
“But, it’s also the case that a lot of the work residents currently do is less in service to the patient than it is in service to the EHR. So, there’s been a shift in balance there.”
The amount of available medical information has changed the way trainees approach the profession, Dr. Andrews believes.
“When I was training, the adage was you better pay attention to the medical literature because everything you know is going to be obsolete in five years, which seemed very scary,” Dr. Andrews said. “Well, the doubling time for medical literature is now something like 45 days. So, you can’t keep up. There once was a belief that becoming a physician expert had to do with mastery of a body of knowledge. Now the process is about mastering the skills to learn. It’s not an exercise in knowing everything, it’s an exercise in being able to learn anything.”
The career paths available to graduating residents have multiplied over the years. Positions in health system leadership and public policy were less viable for young physicians a generation ago, Dr. Andrews said.
“There is an increased acknowledgement of the breadth of medicine and the breadth of the environment for practice,” Dr. Andrews said. “There are more clear career directions for people to pursue now. For someone who wants to practice independently in a rural community there are clear training paths to do that. A generation ago, you had to seek the training that you thought you needed to meet the needs of those communities and then go apply those skills in a different environment. The context for the practice of medicine is considered more now than it used to be and that creates more opportunities, which is more exciting.”
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