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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