Medical residents should enter practice when their skills indicate they are ready, and that may not correspond with the training calendar. A pilot program taking shape within Mass General Brigham—formerly known as Partners HealthCare System—aims to de-emphasize the element of time-based advancement in residency training.
Debra M. Weinstein, MD, vice president of graduate medical education at the Massachusetts General Brigham health system, recently presented on the pilot program—"Promotion in Place: Enhancing Trainee Well Being and Patient Care Through Time Variable Graduate Medical Education”—at the AMA GME Innovations Summit.
Promotion in Place is a multispecialty pilot that will allow residents to graduate early or extend their training as needed based on competency development. Residents who achieve competency before the standard training duration will transition early to independent practice at their training institution until their originally targeted graduation date.
In instances in which residents advance early, they do so with what Dr. Weinstein referred to as “sheltered independence.” By that she means they will act as attending physicians with increased support from faculty members and traditional more senior attendings who were their mentors throughout their training.
“Residents gain different skills at different rates and achieve competency for independent practice at different times in their training,” Dr. Weinstein said “They come in with quite variable past experiences, different career goals and interests. And they spend their time and put their emphasis in different places. Some are heading toward a research career and some are going to be clinicians. So, many factors, not just ability, can influence when an individual is ready to graduate from residency.
On both a program and resident level, participation in the pilot will be optional. Dr. Weinstein said five residency programs within the health system have plans to participate. The pilot was scheduled to begin in the summer of 2020. Due to the pandemic, that start date has been delayed a year—though the pathology pilot could begin earlier, since the American Board of Pathology has approved the pilot.
One of the major challenges in implementing the Promotion in Place pilot will be making it flexible enough to be applied across different specialties. Programs may customize the pilot in several ways; for example, applying it just to new recruits versus offering the chance for residents near the end of their training to participate.
In some residency programs, in which the final year is largely elective, residents who advance early would be unlikely to miss any standard specialty-specific training. In other cases, planned parts of the curriculum might be omitted—as occurred during the COVID-19 pandemic, when routine patient care and planned educational experiences were disrupted. In instances in which residents lost training, governing bodies in medical education allowed programs discretion to advance residents to graduation—based on assessment of competency—without certain aspect of the curriculum under their belt.
“In the situation of the COVID-19 disruption, program directors are, in general, graduating those residents who didn’t have the full complement of training or their case logs completed,” Dr. Weinstein said. “However, in planning for competency-based advancement as the basis for graduation, a rigorous review of our assessment processes and efforts to optimize them is important.”
With more than 100 presentations over three days, the AMA GME Innovations Summit was an extension of the AMA’s ongoing work to reshape GME. The AMA Reimagining Residency initiative, of which the Promotion in Place pilot is a part, has awarded more than $15 million in grants to institutions that will transform residency training to meet the workforce needs of America’s current and future health care system.