The Past Decade in Pediatric Education: Progress, Concerns, and Questions
The 1990s ended optimistically for the United States and for pediatric education: the country had accumulated a financial surplus, the pediatrics community had come together to deliberate the Future of Pediatric Education II, and medical education had a new paradigm (the Outcome Project). The past decade has been a tumultuous one, and optimism is now tempered by concerns and questions. Any attempt to discuss medical education needs to take into account the societal forces that affect health care, which is the context for medical education. Of the 10 issues addressed in this article, the first 5 are societal factors with implications for education; the last 5 are issues within medical education, with emphasis on pediatric education. The 10 are discussed individually but clearly interact and overlap. The order in which they are discussed is not intended to convey a rank of importance.
Societal factors with implications for medical education
1. Focus on patient safety
At the close of 1999, the Institute of Medicine (IOM) released its landmark report To Err is Human: Building a Safer Health System [1]. The report received widespread exposure and drew public attention to the need to reduce medical errors and increase patient safety, a need the IOM termed urgent. Public concern about the safety of care rendered by trainees has led to efforts to reduce the effect of fatigue on trainees by limiting the consecutive number of hours they are permitted to care for patients and to increase supervision by faculty.
Implications for education: graduate medical education work hour regulations
Consideration of the effect of resident fatigue on the care of patients largely stems from the death of 18-year-old Libby Zion in 1986. She was admitted to New York Hospital with fever, agitation, and abdominal pain. She did not reveal that she was taking a monoamine oxidase (MAO) inhibitor, phenelzine, prescribed by her psychiatrist. A resident on duty in the early hours of the morning prescribed meperidine to assuage her pain, and the combination of meperidine with the MAO inhibitor resulted in the young woman’s death. Sidney Zion, Libby’s father, a newspaper columnist and attorney, was convinced that the hospital was responsible for the death of his daughter. In the aftermath of Libby Zion’s death, a commission was formed, with Bertrand Bell as its leader. The Bell Commission identified both faculty supervision and resident fatigue from long work hours as issues that needed to be addressed. The resulting New York 405 Rules limited continuous work hours for residents to 24 with an additional 3 hours of nonpatient care activity permitted for education and to ensure adequate transfer of responsibility to another physician [2]. Hospitals that did not adhere to the Rules were subject to a fine, imposed daily until compliance was attained. In October, 2002, 13 years after the implementation of the 405 Rules, 75 of the 118 residency programs (64%) were found to be out of compliance [3], evidence of the inability of the profession to address what was publicly perceived to be a dangerous patient care situation.
In 2001, Representative Conyers proposed legislative action in the form of the Patient and Physician Safety Act, and Senator Corzine sponsored the act in the Senate in 2002. The Accreditation Council for Graduate Medical Education (ACGME) responded by developing work hour regulations that went into effect on July 1, 2003, forestalling federal legislation [4]. Continuous work hours were limited to 24 as in the 405 Rules, but an additional 6 hours were permitted for education and patient transfer, rather than 3. The total number of hours a resident could work per week was capped at 80, averaged over 4 weeks. A minimum of 10 hours was required between shifts (rather than 8 in the 405 Rules), and 1 day (24 continuous hours) free of clinical responsibility had to be provided per week, averaged over 4 weeks [2].
Although not a surprise to medical educators, a restriction in work hours did not result in a sharp decrease in mortality, and patient harm remained “common, with little evidence of widespread improvement” [5]. Some studies reported that residents were getting more sleep but felt no less stressed by the responsibilities of residency [6]; a study of residents in 3 large pediatric residency programs documented increased sleep and decreased rates of resident burnout but no change in medication errors, resident depression, or resident injuries [7]. Three potential reasons were proposed to explain the lack of consistent improvements: (1) work hours were still too long; (2) Compliance with the standard was lacking; (3) benefits from reduced fatigue might be offset by worsened continuity of care and inadequate handovers [8].
Evidence began to accumulate that a further reduction of work hours was associated with fewer medical errors and injuries [9,11]. Congress continued to apply pressure. The IOM responded by convening a panel and issuing Resident Duty Hours: Enhancing Sleep, Supervision, and Safety in December, 2008 [12]. Recommendations included keeping the 80 hours per week cap but without the flexibility to average over 4 weeks as in the 2003 ACGME regulations. The key changes were limiting shifts to no more than 16 hours unless 5 hours of protected sleep were provided and not permitting more than 4 night shifts in a row. Also included was the recommendation that interns be supervised by senior residents or faculty, not junior residents.
To assess public opinion regarding resident work hours, a national survey between November, 2009, and January, 2010, polled individuals from a sample designed to reflect the US Census estimates by region, gender, age, and race [13]. Of the 1200 respondents, only 1% approved of shifts lasting more than 24 hours. Respondents believed the maximum shift duration should be 10.9 hours and the maximum work week 50 hours; 81% believed that reducing resident work hours would be “very” or “somewhat” effective in reducing medical errors. A total of 81% believed patients should be informed if a treating resident had been working for more than 24 hours; 80% would then want a different doctor.
In response to the IOM report, the ACGME convened its own panel and issued regulations in 2010 [14]. The ACGME regulations were clearly influenced by the IOM recommendations but included some differences: flexibility to average the 80 hours per week cap over 4 weeks was maintained; the maximum number of night shifts in a row was set at 6, rather than 4. The most dramatic change recommended by the IOM (limiting shifts to a maximum of 16 hours) was adopted for interns, although residents beyond internship were still permitted 24-hour shifts, as in the 2003 regulations, but 4 hours for education and transfer of patient care rather than 6. The new ACGME regulations become effective on July 1, 2011. As of this writing, residency program directors are working to devise schedules that satisfy the new requirements [15].
Concerns and questions
Concern was raised in 2003 that an increased number of transitions of care (variably referred to as handovers, handoffs, signovers, or signouts) might offset any benefit to patients from being cared for by less fatigued residents. In the past 5 years, there has been more literature on the subject of handovers than in the previous 25 years, but the conclusion in 2010 is that “the ‘perfect’ handoff process does not yet exist” [16]. One proposed framework for handovers uses the mnemonic TEAM to identify 4 major domains: time, elements, anticipatory management, and mutual trust [16]. Several mnemonics have been developed to ensure that the necessary elements of handovers are addressed, but they can only ensure structure, not quality. As Philibert notes: “Much of the work to improve patient handoffs has focused on enhancing communication and access to data. Yet the handoff is first and foremost a clinical task that relies on participants’ ability to discern and interpret information about the patient’s condition, including the likelihood that it will worsen and the warning signs that this is occurring. Development of clinical acumen is critical to the emergence of this aspect of handoff skills that allows residents to convey this information when they are in the role as the outgoing physician and to understand it when they are the recipient” [17].
The ACGME Common Program Requirements for 2011 address the need to ensure effective transitions of care (“Sponsoring institutions and programs must ensure and monitor effective, structured handover processes to facilitate both continuity of care and patient safety”) but paradoxically state “Programs must design clinical assignments to minimize the number of transitions in patient care” and reduce work hours, inevitably creating more transitions [18].
It is not clear whether the reduced hours benefit patient care, as shown in studies and simulation [19], or whether more handovers increase errors. In addition, the effect on education is unknown. Will the reduced hours during internship make the transition from intern to supervising resident more difficult? Might a crisis of coverage prompt more than an exercise in rescheduling, resulting in a creative reengineering of how residents’ time is spent? Concerns about the effect on professionalism and the promotion of a shift mentality are being voiced again, as they were when the 2003 ACGME Requirements were instituted [4].
Implications for education: increased faculty supervision and direct involvement in patient care
Although increased supervision of residents was a major thrust of the Bell Commission and was reiterated by the IOM and the ACGME, the concern was largely lost in the tumult caused by the recommendations for reduced work hours. Direct involvement of teaching faculty in patient care has increased markedly in the past few decades (more because of reimbursement issues than because of concerns for patient safety or the quality improvement movement). In 1996, the Health Care Financing Administration (currently named the Centers for Medicare and Medicaid Services) issued Intermediary Letter 372 (IL-372), which prohibited teaching physicians from submitting bills to Medicare unless they personally provided services to the patient beyond supervising a resident and documented their services in the medical record [20]. Because academic departments have become increasingly dependent on clinical revenue (and test cases showed the resolve of the government to recover Medicare payments when documentation did not confirm the personal provision of services by faculty [21,22]), pressure was brought to bear on teaching physicians to be more directly involved in the care of patients. In recent years, additional factors may have resulted in increased direct care by teaching faculty: reduced resident presence (from restricted work hours and additional responsibilities such as continuity clinic); caps on the number of patients residents are permitted to admit; and the increasing number of hospitalists.
Concerns and questions
As trainee work hours are shortened and teaching physicians assume more direct responsibility for patient care, it becomes more challenging to ensure sufficient decision-making opportunities to prepare interns to become senior residents and to prepare senior residents for independent practice. Residents and faculty differ in their assessments of the degree of independence that should be permitted in various situations [23]. Trying to achieve and maintain a balance between supervision and autonomy “is among the greatest challenges in medical education. The ‘hidden curriculum’ that overvalues physician autonomy must be put aside for an explicit curriculum of safety, quality, and humility. Master clinician-educators at the bedside must provide ‘supervised autonomy’” [24]. Babbott refers to the process as “watching closely at a distance” [25].
A prospective study in 1 large residency program before the 2003 ACGME work hour restrictions showed that the introduction of a hospitalist program was associated with decreases in senior resident reports of their decision-making abilities and autonomy in the first few years of the program; the ratings then returned to the levels recorded before the hospitalist program [26]. The investigators speculate that the dip in ratings might have represented resident dissatisfaction with change, inexperienced hospitalists, or statistical fluctuation; they speculate further that the return to baseline levels may be because of the newer senior residents’ lack of awareness of the previous system or the learning curve of hospitalists. The data do not address the objective outcome of decision making when the senior residents graduated and were expected to function independently. Outcome data are the critical piece regarding preparation for practice, and are lacking.
2. The quality improvement movement
In 2001, 2 years after releasing To Err is Human: Building a Safer Health System [1], the IOM followed up with Crossing the Quality Chasm: A New Health System for the 21st Century [27]. Increasingly, the public, particularly payers, wanted to know what they were getting for their money, and report cards created awareness within health care systems of a higher level of accountability than previously.
Implications for education: ACGME Outcome Project identification of practice-based learning improvement and systems-based practice as core competencies
The education community was involved in quality improvement at the same time as the IOM reports. In 1999, the ACGME launched the Outcome Project (see number 6, later discussion) [28]. In conjunction with the American Board of Medical Specialties (ABMS) and its 24 Member Boards, the Project delineated 6 General Competencies, among which were 2 new ones: practice-based learning and improvement and systems-based practice. Both relate to quality improvement. The important distinction between the two is that practice-based learning applies to the improvements individuals can make in their own practice; systems-based practice involves making changes in a system of care. The requirement for practice-based learning and improvement was stated as follows: “Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to: analyze practice experience and perform practice-based improvement activities using a systematic methodology; locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems; obtain and use information about their own population of patients and the larger population from which their patients are drawn; apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness; use information technology to manage information, access online medical information, and support their own education; and facilitate the learning of students and other health care professionals.”
The ABMS and its 24 Member Boards embraced practice-based improvement as part of a transition from recertification to a more continuous maintenance of certification (MOC) process [29]. Part IV of MOC requires that physicians show that they can assess the quality of care they render and improve that care using follow-up measurements. During the past decade, the Accreditation Council for Continuing Medical Education (ACCME) has aligned its goals with those of the ACGME and ABMS MOC to require an assessment of the outcome of continuing medical education (CME) activities (ie, how they improve patient care) [30]. The move is away from random lectures and toward a process that begins with identifying gaps in care and what practitioners need to address such gaps. Evaluation of CME activities previously was generally limited to assessments of the speaker; now, the key question is whether clinical practice changes as a result of the activity.
Concerns and questions
The potential for the movement to improve quality has been shown in multiple individual projects, but it is not yet clear what the effect will be on the quality of care rendered by individual practitioners or the health of the public. Moreover, because report cards and related activities have increased the competitiveness of hospitals regarding quality outcomes, pressures on supervising physicians can affect education at all levels, not just the autonomy of senior residents discussed earlier. For example, formerly, the attending could teach, and the students and residents would do the charting: a trade-off in terms of time; now, the attending is required to document personally and extensively, resulting in less time available for teaching. As stated by Irby and Wilkerson, “Teaching—a time-intensive and largely unsponsored activity—has been slowly crowded out of the schedules of both full-time and voluntary medical school faculty members” [31]. Ludmerer suggests that we are returning to the pre-Flexner era, in which hospitals, rather than universities, directed medical education [32].
3. Advances in technology
Technology has advanced so rapidly that it is difficult to recall the era before the widespread access to the Internet, the ubiquitous use of cell phones, and affordable fast computer processors coupled with memory of sufficient capacity to enable complex activities such as simulation to be commonplace. It is difficult to overestimate the effect that advances in technology have had on daily life.
Implications for education
Electronic health records (EHRs) permit ready review of patient records for multiple purposes, including education and research. For example, practice-based learning is greatly facilitated by easily being able to identify patients with a particular condition and retrieve their records. Drug interactions can be identified as prescriptions are being written and as part of computerized physician order entry (CPOE) in hospitals. Programs that provide information when key words are clicked or that offer assistance with diagnoses can be incorporated in EHRs. This just-in-time education is valuable for patient care, patient safety, and education. Students and residents who receive training in an environment rich in technology resources and then move to institutions with less sophisticated technology perceive the latter as having lower “quality of care in many domains surveyed, including safety, efficiency, and system learning. Of considerable note, this group reported having less confidence in their knowledge about drug interactions and drug management than they did during their training, even months after changing institutions. Additionally, many respondents felt weakened in their ability to prescribe medications safely” [33].
The term e-learning comprises all forms of electronically supported learning and teaching, including distance learning and computer-assisted instruction [34]. Modules and entire courses can be accessed electronically. Relevant examples range from medical school courses that permit students to be widely dispersed, CME offerings in Web sites such as the American Academy of Pediatrics (AAP) PediaLink, and CME Master’s Programs in Medical Education [35]. The transition from books to electronic access has even permitted many medical libraries to go bookless, a cure for the increasing problem of finding space for the ever-increasing number of journals and books. Moreover, live webcasts can be interactive, and telemedicine instruction and consultation are becoming more widespread [36]. Software that can reduce or accelerate speech without altering pitch permits learners to process lectures at their own pace, improving both efficiency and effectiveness.
Simulation, of one sort or another, is currently used by all medical schools in the United States and Canada [37]. “The power of simulation,” as noted by Satava, “is that it gives ‘permission to fail’ in a safe environment (the laboratory setting), so students learn from their mistakes. Until now, whenever an error was committed, the patient suffered” [38]. The use of mannequins and software of ever-increasing sophistication permits the acquisition of competence under conditions that are controlled and can be altered to achieve specific learning objectives. The ability to simulate medical crises is particularly important for the training of pediatricians, because crises are rare events in children, making mastery of the skills and decision-making difficult to teach, to learn, and to assess. The difficulty is compounded by the unique features of neonates and children that limit the ability to transfer directly the skills acquired during the care of adults.
Computerized cases combine the benefits of simulation and e-learning. Educational objective 2 (ED-2) of the accrediting body for medical schools, the Liaison Committee for Medical Education (LCME), requires that faculty define “the types of patients and clinical conditions that students must encounter” and that “if a student does not encounter patients with a particular clinical condition (eg, because it is seasonal), the student should be able to remedy the gap by a simulated experience (such as standardized patient experiences, online or paper cases, etc.), or in another clerkship” [39]. Because many common conditions in pediatrics are seasonal (eg, respiratory syncytial virus infection) and others are important but not of such frequency as to ensure a clinical encounter during the brief period of a clerkship, computer-based cases have come into widespread use. In a 2005 survey, 83% of clerkships were using computer simulations, such as CLIPP (Computer-assisted Learning in Pediatrics Program), to meet ED-2 [40]. CLIPP consists of 32 cases designed to encompass the learning objectives of the Council on Medical Student Education in Pediatrics (COMSEP) curriculum [41]. Cases address child care at different ages and such situations as a newborn with respiratory distress, a 6-day-old with jaundice, a 2-week-old with lethargy, a 6-month-old with fever, a 10-month-old with a cough, an 18-month-old with congestion, a 16-month-old with a first seizure, and others. The cases include images, sound (eg, murmurs), and progressively revealed data, with frequent questions posed (and answered) along the way. In a study of CLIPP use and integration in pediatric clerkships, students spent an average of 17 hours using CLIPP and assessed it as being more valuable and effective than traditional learning methods; “reduction or elimination of redundant teaching activities such as required textbook reading or other unrelated assignments,” to make time for CLIPP, was associated with increased perception of integration, greater satisfaction, and increased perceived learning [42].
Searching the medical literature used to require visiting a medical library and flipping through countless pages of Index Medicus. Now, with programs such as PubMed, the medical literature can be searched anywhere a user has a computer (or handheld device) with Internet access.
Handheld devices with cameras and software enable physical findings to be captured and shared, references to be queried instantly, and communication to occur without having to return to an office. Trainees and practitioners stymied by a rash can capture its appearance digitally and solicit consultation without delay; they can become familiar with drugs their patients are taking, without having to leave the room and find a reference book; they can ensure that drug interactions do not occur before prescribing; and the list goes on. In 1 study, 70% of medical residents reported using a personal digital assistant (PDA) daily, most commonly for referencing medication-prescribing guides, medical textbooks, patient documentation programs, or medical calculators [43]. PDAs have also been shown to increase entries in patient logs by medical students when compared with paper logs, facilitating not only documentation but reflection and learning [44].
Concerns and questions
Implementing an EHR system is associated with decreased physician productivity because of the increased time required to record information. In 1 study spanning 2003 to 2006, the initial decrease in productivity was 25% to 33%, compared with data collected before the introduction of the EHR. In subsequent months, productivity by internists increased but neither pediatricians nor family physicians were able to return to their original productivity levels [45]. It is possible that more current EHR systems may be more user friendly and have less of a deleterious effect on productivity, but that remains to be shown. Many pediatricians are also concerned that attention to an inputting device draws attention away from the patient and family and may have a deleterious effect on rapport and the doctor-patient relationship. A creative solution for both productivity and rapport has been the use of scribes to enter information into the EHR [46]. There may be value not only for physicians but also for the scribes; undergraduates interested in medicine or preclinical medicine students can gain exposure to clinical encounters and become familiar with the questions used in the medical history and the findings elicited during physician examination.
The introduction of EHRs and CPOE in teaching hospitals has been accompanied by prohibition of students writing in the medical record in many hospitals [47,48]. The effect on learning and on developing a sense of responsibility for the patient (ownership) is concerning [47].
Although searching the medical literature has never been easier, it requires skill to avoid being overwhelmed by a long list of articles. The result may be reliance on the first page of references, which may not include the most useful article. If the journal article is not readily available on line, the abstract may be used as evidence, without recognition of the limitations of the study. Another alternative to a skillful search is to obtain a quick response from a generic search engine or online encyclopedia, the accuracy of which cannot always be verified.
Simulation is resource intensive, and the effect of medical school simulation training on later performance has not been well characterized. The Millennium Conference 2007 on Education Research identified studying the effect of simulation as the highest rated priority for education research [49]. Also, the role of computer-assisted instruction needs to be maintained as a complement to interaction with physician-instructors and real patient encounters, rather than as a replacement [42].
A growing concern relates to social networking and professional boundaries [50]. What may be considered humorous when whispered in the hospital may be considered offensive and unprofessional by the public. Students and physicians who use social networking sites may make a distinction between their personal life and their professional life, but such a distinction may not be made by the public, including their patients. The following is a case in point: “A patient’s family member requested a change in resident physician because of questionable behavior exhibited on a resident’s personal MySpace page. Such anecdotal reports continue to increase in frequency” [50].
4. Recognition of a need for more physicians
The public has been made aware that the aging of baby boomers will be associated with a shortage of physicians. By increasing the number of individuals who can access health care, health care reform legislation is expected to exacerbate the looming shortage. The Association of American Medical Colleges (AAMC) Center for Workforce Studies estimated in June, 2010, that the physician shortage in all specialties would reach 91,500 in 2020 and 130,600 in 2025 [51].
Implications for education: new medical schools, increased class sizes
In 2006, the AAMC recommended a 30% increase in US medical school enrollment by 2015 [52]. Compared with the first-year enrollment in 2002 (16,488), this recommendation would require an increase of 4946 students per year (to 21,434). One new medical school was authorized in 2000, after more than 2 decades in which no new allopathic medical schools were established [53]. Between 2006 and 2010, 15 institutions notified the LCME of their intent to start a new medical school; of these, 6 have received preliminary accreditation and 2 have suspended plans. New osteopathic schools have also been established or are in planning stages. In addition, 82% of the 125 medical schools accredited in 2002 have expanded their enrollment, and satellite training sites are now common. The most current projection is that first-year medical school enrollment in 2014 will be 20,281, a 23% increase over 2002. The 30% targeted increase is projected to be reached by 2018 [54].
Meeting the needs of a greatly increased number of medical students requires using facilities outside the medical school and its primary hospital, but there is also good reason to engage these sites. In 1999, the federal Council on Graduate Medical Education (COGME) recommended that “clinical education should occur in settings that are representative of the environment in which graduates will eventually practice. Medical schools and residency training programs should develop or acquire clinical teaching sites that offer the best learning opportunities and the highest standards of clinical practice” [55]. An additional hope of using community and rural sites is that familiarity and comfort in such settings might attract graduates and, thereby, help address the shortage of primary care physicians and the geographic maldistribution of primary care for children [56]. Previous attempts to attract physicians to primary care by simply providing more time in ambulatory settings have shown that dysfunction settings can discourage trainees from entering primary care [57]. Well-functioning community practices afford the opportunity to expose learners to optimal real-world primary care environments and achieve desired outcomes. Programs designed to increase the rural physician supply through a focused admissions process or extended rural clinical curriculum have been successful, with a rate of graduates practicing in rural areas of 53% to 64% [58]. Students in regional settings have scores on standardized tests at the end of clerkships comparable with students in tertiary settings but rate the experience more highly [59]. Pediatric residents whose continuity experience was in community practices have been shown to be particularly well prepared for primary care practice [60,61].
Concerns and questions
As noted earlier, the LCME requires that clerkship rotations at different sites be comparable and that experiences with types and numbers of patients be equivalent. Technology has been a valuable tool for meeting this requirement, but concerns about adequate space, faculty, community faculty development, staff, time, and finances remain. In the most recent AAMC survey, 73% of medical schools expressed concern with their supply of qualified preceptors, and 58% were concerned with the number of clinical training sites. Twelve schools indicated plans to reduce enrollment, mainly because of fiscal pressures [54]
