Why graduate medical education is failing

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.

But that doesn’t typically happen anymore.  Training programs now are less harsh, less demanding, and for lots of reasons — work hour restrictions, work load restrictions, and just plain old lack of grit — the products of those programs are less prepared for the stress and strain of being an independent physician.  The difficulty in this process, in going from doctor to physician, is when you finally realize that there is no one else behind you, and you have to make the decision, and in your hands, and with that decision, rests a person’s health, well-being, and sometimes life.   Without that training that strives to ensure that whatever else happens, you are ready to act as a independent physician upon graduation, many newly minted post-GME doctors just aren’t ready to assume the mantel of being a physician.  They aren’t able – because they never have had to make any independent decisions before.

I think this thrust of training programs is a huge disservice.  As we have looked for additional partners for my practice over the years, a common theme has emerged.  The doctors coming out of current GME training programs do not know how to act as a independent physician.   They are unable to decide the right test to order, or the right medicine to prescribe, or what to do in the middle of the night when they are called to the bedside of a patient whose blood pressure is dangerously low, or who can’t breathe.

GME programs are ideally designed to take newly minted doctors and turn them into professional physicians, able to walk out of their training and start running a practice.  They currently are not succeeding.  One of he areas that this is manifest is the inability of new GME graduates to bear the responsibility of making a decision that may, in that moment, affect someone’s life.    The training required to attain that level of confidence and knowledge is tough.  Our relaxing of the standards we hold GME trainees to is starting to have the adverse consequences of producing less-than physicians.  And this is a big disservice to our patients, current and future.

J. Russell Strader is chief, cardiovascular services, the Medical Center of Plano.

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  • guest

    Our group has been hiring more and more physicians with several years of practice under their belt rather than anyone right out of training. The reasons are exactly what you describe in this article.

    However, I think even in the “old fashioned” system of GME physicians right out of residency still needed several years of practice to become confident, independent physicians. A new grad is a new grad. We all needed help right out of the gate.

    • neverdonelearning

      I agree that it takes time for anyone to get their sea legs, no matter how amazing your training. This article is another example of an older generation lamenting that the younger one just isn’t as good as they were when they were young.

      • PoliticallyIncorrectMD

        I am hardly an “older generation” physician, but I can second the author’s observations. The younger physicians are not criticized, the system is. It shelters future physicians form taking responsibility and making decisions. And, yes, interns and junior residents and fellows should be making decisions, while those with more experience should assure those decisions are the right ones. In addition, the system sets the wrong priorities. During my residency days our mantra was “patient, team, service, self”, with self being last on the list. Now ACGME is more concerned with whether residents are protected, while patient care suffers.

        • guest

          But were you ready as a new grad to operate confidently, independently and without second guessing yourself? I trained at arguably one of the top programs in the country (where Ted Kennedy had surgery) in the “old days,” and I can definitely admit that I made a lot of mistakes in my early days of practice. It took a few years before I was really independent and confident.

          It does seem that GME nowadays is lighter on actual education and emphasizes shorter workdays and workweeks. My argument though is we’ve never been ready to practice out of the gate. We weren’t then and we aren’t now. That’s not new or different.

  • David Gelber MD

    But what happens when there is no one to call?

    • Shirie Leng, MD

      Good point. There should ALWAYS be someone to call. And residents shouldn’t be shamed for calling. These are real patients. I think thats what neverdonelearning is saying.

    • neverdonelearning

      I sure hope that fellows aren’t left without an attending’s or another (more senior) fellow’s phone number during their first year…

      • PoliticallyIncorrectMD

        I think Dr. Gelber meant “What happens if [you are out of training and you are the Attending] and there is no one to call?

        • David Gelber MD

          That is exactly what I meant.

    • FEDUP MD

      The third year fellow should be able to run the unit on their own, yes. The first year fellow? No. Otherwise why do the other two years?

  • David Gelber MD

    I agree that GME is failing. General Surgeons I have met who are fresh out of residency admit they have been sheltered during their residency years. Their attending surgeons were always present and made many or all of the important decisions.
    I’ve always thought that the trade off a patient makes when cared for by residents is that they accept having a less experienced physician who is (or should be) more vigilant. This vigilance makes up for the lack of experience. I know that after I did my first appendectomy as an intern I saw that patient several times a day until sh went home, just to be sure she was OK.

  • Shirie Leng, MD

    Totally agree. When I was an intern in 2001 I had a friend 2 years ahead of me who was running the MICU overnight with no immediate oversight, and damn if that guy didn’t learn how to run a unit. My program pussy-footed around and in my third year I couldn’t make a move without the attending. I think a large part is litigation. The higher-ups get scared when something bad happens or potentially happens and yank away autonomy. A good training program knows each resident and how much rope to give each senior. Seniors who are hesitant should be identified and steps taken.

  • PoliticallyIncorrectMD

    So your impression of successful Internal Medicine residency graduate is of a person being able to summon appropriate number of consultants (preferably one per each body system)?

    • neverdonelearning

      If you feel the patient may suffer because of your knowledge gap, then yes you should get consultants on board. The author gave an example of himself as a new cardiology fellow in the CCU- the person overseeing the most complex cardiac patients in the hospital. 1) Patient care should come first before the worry about a bruised ego over calling a superior and 2) A learner (such as a fellow) should never feel ashamed for asking for help.

    • buzzkillerjsmith

      Ouch. If you think that of IM, I don’t want to know what you think of FM.

      • PoliticallyIncorrectMD

        It is NOT what I think of IM (or FM) and it is not how I practice it. It meant to be a sarcastic paraphrasing of what I thought neverdonelearning was suggesting … I guess it did not come across this way :(

    • Mengles

      What do you think Hospitalists do?

      • PoliticallyIncorrectMD

        Exactly! Sad!

  • John Hunt

    I have several chapters on this very issue in “Assume the Physician” in which our heroic mentor, Dr. Blow, stands up against ACGME and its insane love of rules, and it will make you laugh, which is always my hope. I am happy to send a particularly relevant chapter as an excerpt from the book. Just send me an email at jhunt@readjohnhunt.com.

    It is always the people who like to make and enforce rules that cause so much discontent.

  • guest

    Understood. Though I respectfully disagree. New grads appear to me as fearful yet decisive as I remember being.

  • Rudy

    Without actually mentioning it, Dr. Strader points out the unitended consequence of the increased supervision rules following in the wake of the Libby Zion case.
    Whether or not one does a fellowship, at some point all docs have to start making decisions without minute to minute, mandated, 24 hr a day direct supervisions by other docs.
    That process used to happen during residency and fellowship. At the end of the day, or the end of the night, or the beginning of the weekd, those decisons were reviewed by multiple people in an environment set up for education.
    But now, those independent decsions are first made when one is out in private practice….. without any supervision.
    If old school graduates (OK, I’m almost 60, I qualify as an old fart) made those idependent decsions as a routine part of their training, and new school graduates have never made a single one during their training, then by definition, newer graduates are far less well prepared. Period.

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