Why Graduate Medical Education Is Failing

Mon, 12/23/2013 - 9:04am
J. Russell Strader, M.D.

When a doctor finishes medical school, he or she then faces what is truly the most difficult part of their journey into becoming a physician: graduate medical education.  The goal of internship, residency, and fellowship training programs — what is collectively called graduate medical education, or GME — is to take newly minted doctors, just out of medical school, and turn them into competent physicians, able to practice in their specialty independently.   And if you’re asking, yes, there’s a difference.

When a doctor finishes medical school, he or she has been exposed to a lot of data, and has learned a few basic facts about how to be a physician.  But the haven’t learned really how to work independently in a field of medicine.  That takes the 3-10 extra years of training collectively known as GME to acquire that skill.  It is a skill that encompasses a lot of “non-data” abilities, one of the most critical of which is the ability to make a decision independently without having to ask someone if it’s the right decision.

GME is hard.  It is filled with long hours, late nights, and a whole lot of imposed stress.   The faculty in these teaching programs are charged with taking young doctors and teaching them the art and science of actually taking care of patients.  That occurs through years of supervised practice, with gradually increasing responsibility.  Ideally, the last year of one’s GME should be spent working as a de facto attending, being supervised only nominally.  In this way, the programs can assure that the graduates are able to hop from their training program into practice in a seamless transition.

It doesn’t happen that way so much anymore.  More and more the candidates we interview for our practice that are coming out of training are woefully unprepared.  While they may have passed lots of tests, and acquired lots of book knowledge, they lack these non-data skills to be a good physician.

The glaring omission in these new GME graduations is the lack of ability to work independently.  When I was a first-year cardiology fellow, it was my job to run the CCU at night.  If I had to call the attending for help, it was a failure.  And the attendings let me know it.  If I couldn’t make the right call — does the patient need urgent heart surgery or can it wait till morning?  Does the patient have septic or cardiogenic shock?  What test do you need now to stabilize the patient, and what can wait till morning?  That was a failure.  And for the next week that failure was hammered into you.  Papers were read, management techniques discussed, decisions picked apart, in a painful and sometimes embarrassing recounting of your failures.  During work rounds, during conferences, during lunch, it was dissected, pulled apart, analyzed, discussed, and corrected.

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