The future of graduate medical education
As my family medicine residency nears completion, I am reflecting on what I did well, what I could have improved and what, if anything, I can influence to change for those who come after. Of these things, I wish to offer a suggestion for the future of graduate medical education, particularly for the family medicine specialty.
Medical clinical competency is measured in multiple ways. The more familiar of which are:
- Completion of core rotations such as emergency medicine, pediatrics and neurology
- Procedural requirements such as vaginal deliveries, knee injections and pap smears
- A minimum quantity of ambulatory continuity patient encounters over the three years of residency, which is important for our specialty
Another essential aspect of medical training is the business of medicine. Though not a core educational requirement for graduation, I believe it is important in understanding billing and productivity as it relates to medical practice post-graduation. A component to billing and productivity includes qualifying the degree of complexity of the provider medical decision making process. Fortunately, Duke Community and Family Medicine not only touches on these components of medicine, but provides introduction to payment models, review of patient access to care and relevant policy decisions affecting health care. So how does this relate to the evaluation of a resident’s clinical knowledge?
Assessing clinical competency is indeed tricky, and as mentioned previously, there are many tools to measure as such. However I propose instead of solely assessing the quantity of patients seen, the complexity of each encounter should also be taken into consideration.
For instance, this spring I have seen an increase in clinic visits for complaints of cough. Of these patients, some have no other medical conditions, whilst more often a single patient can have four to six uncontrolled chronic medical conditions which influence my medical decision making.
The management and treatment of a patient with chronic obstructive pulmonary disease (COPD), uncontrolled high blood pressure, poorly controlled diabetes, limited mobility, congestive heart failure and medication-induced electrolyte imbalances differs from another with the same complaint who is otherwise healthy. Moreover, the educational potential for each case is exponentially disparate, and as I have recently learned, so too is the difference in billing.
Moving forward, I hope we as a specialty rethink how we assess clinical encounters as part of residency training; particularly given considerations to increase the quantity of required clinical encounters in an already challenging learning environment of a busy academic practice.
Not only do I think focusing on the complexity over the quantity of clinical encounters may improve patient care, but it may perhaps also address a core issue faced across graduate medical education – improving clinical knowledge and the learning experience of both residents and faculty.
Nikki Henry is a third-year resident with the Duke Family Medicine Residency Program. Email nikki.henry@duke.edu with questions.
Editor’s note: Duke Family Medicine residents guest blog once a month.