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Recommendations From the Coalition for Physician Accountability’s UME-to-GME Review Committee: Winners & Losers Edition

By BRYAN CARMODY

If you’re involved in medical education or residency selection, you know we’ve got problems.

And starting a couple of years ago, the corporations that govern much of those processes decided to start having meetings to consider solutions to those problems. One meeting begat another, bigger meeting, until last year, in the wake of the decision to report USMLE Step 1 scores as pass/fail, the Coalition for Physician Accountability convened a special committee to take on the undergraduate-to-graduate medical education transition. That committee – called the UME-to-GME Review Committee or UGRC – completed their work and released their final recommendations yesterday.

This isn’t the first time I’ve covered the UGRC’s work: back in April, I tallied up the winners and losers from their preliminary recommendations.

And if you haven’t read that post, you should. Many of my original criticisms still stand (e.g, on the lack of medical student representation, or the structural configuration that effectively gave corporate members veto power), but here I’m gonna try to turn over new ground as we break down the final recommendations, Winners & Losers style.

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The Step 1 Score Reporting Change – A Step in the Right Direction for IMGs?

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By TALAL HILAL, MD

The United States Medical Licensing Examination (USMLE) Step 1, a test co-sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), has been the exam that people love to hate. For many years, blogs, Twitter feeds, and opinion pieces have been accumulating urging the presidents of the FSMB/NBME to stop reporting a 3-digit score and instead report a pass/fail score. This animosity towards the Step 1 exam originates from the reality that medical schools have increasingly focused their curriculum on teaching what the Step 1 wants you to learn – medical trivia that almost always has no bearing on how to approach a clinical problem.

This “Step 1 Madness” is unhealthy. The reasons for its existence are many: residency and fellowship programs allow it to exist by idolizing higher scores, some believe it is a metric that can predict future quality of care, board pass rates, etc. And some are naïve enough to think that what is tested on the Step 1 is actually useful medical knowledge! It may be due to a combination of the above that the Step 1 has found itself in such a peculiar spot. However, the emphasis on the Step 1 score means that medical students’ fate is being determined by a single test. Nobody wants their fate to be so unmalleable.

Those who were writing vehemently against a 3-digit score rejoiced when the FSMB/NBME announced on February 12 that the Step 1 will finally become a pass/fail test as early as January 2022!

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#USMLEPassFail: A Brave New Day

By BRYAN CARMODY, MD

Well, it happened.

Beginning as soon as 2022, USMLE Step 1 scores will be reported pass/fail.

I’m shocked. Starting around two weeks ago, I began hearing rumors from some well-connected people that this might happen… but I still didn’t believe it.

I was wrong.

The response thus far has been enormous – I haven’t been able to clear my Twitter mentions since the news broke. And unsurprisingly, the reaction has been mixed.

In the future, I’ll post more detailed responses on where we go from here – but for now, I’d like to emphasize these five things.

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Why Do We Have Residency Training?

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By BRYAN CARMODY, MD

Surely every resident has had the experience of trying to explain to a patient or family what, exactly, a resident is. “Yes, I’m a real doctor… I just can’t do real doctor things by myself.”

In many ways, it’s a strange system we have. How come you can call yourself a doctor after medical school, but you can’t actually work as a physician until after residency? How – and why – did this system get started?

These are fundamental questions – and as we answer them, it will become apparent why some problems in the medical school-to-residency transition have been so difficult to fix.

In the beginning…

Go back to the 18th or 19th century, and medical training in the United States looked very different. Medical school graduates were not required to complete a residency – and in fact, most didn’t. The average doctor just picked up his diploma one day, and started his practice the next.

But that’s because the average doctor was a generalist. He made house calls and took care of patients in the community. In the parlance of the day, the average doctor was undistinguished. A physician who wanted to distinguish himself as being elite typically obtained some postdoctoral education abroad in Paris, Edinburgh, Vienna, or Germany.

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Applying Smarter, Part 1: Breaking Down the AAMC’s Apply Smart Campaign

By BRYAN CARMODY, MD

“YOUR LIKELIHOOD OF SECURING RESIDENCY TRAINING DEPENDS ON MANY FACTORS – INCLUDING THE NUMBER OF RESIDENCY PROGRAMS YOU APPLY TO.”

So begins the introduction to Apply Smart: Data to Consider When Applying to Residency – a informational campaign from the Association of American Medical Colleges (AAMC) designed to help medical students “anchor [their] initial thinking about the optimal number of applications.”

In the era of Application Fever – where the mean number of applications submitted by graduating U.S. medical students is now up to 60 – some data-driven guidance on how many applications to submit would be welcome, right?

Right?

And yet, the more I review the AAMC’s Apply Smart campaign, the more I think that it provides little useful data – and the information it does provide is likely to encourage students to submit even more applications.

This topic will be covered in two parts. In the first, I’ll explore the Apply Smart analyses and air my grievances against their logic and data presentation. In the second, I’ll suggest what the AAMC should do to provide more useful information to students.

Introduction to Apply Smart

The AAMC unveiled Apply Smart for Residency several years ago. The website includes lots of information for students, but the piece de resistance are the analyses and graphics that relate the number of applications submitted to the likelihood of successfully entering a residency program.

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Stay Out of my Wellness

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By VA WEST HAVEN COE CLINIC

On a sunny New England morning at a secluded guest house with a perfectly manicured lawn, medical residents, each with their own brightly colored yoga mat, were getting ready to assume the downward dog position. They were on an annual retreat organized by their residency program to promote wellness. One embraced the opportunity with delight, smiling through every pose.  Another grimaced  as his back spasmed. And yet another wandered off towards a lake to find his own kind of respite.

Physician wellness has become something of a buzzword in recent years, and rightfully so considering that the rates of burnout and suicide within medicine are rising. Individual residency programs have found burnout rates between 55% and 76%. Such burnout erodes well-being over time and may be contributing to suicide, which is now the second leading cause of death among residents nationwide. In 2014, the suicides of two medical interns in New York prompted the American College of Graduate Medical Education to take action. A series of initiatives to combat burnout were rolled out, including the consideration of wellness in its review of residency programs during site visits. In 2017, emergency medicine physicians convened the first Residency Wellness Consensus Summit to devise a module-based curriculum on wellness. Hospital systems have attempted to respond as well, through the hiring of chief wellness officers.

It is unsurprising that the medical community has taken such an analytical approach towards diagnosing burnout, much as we do with other diseases, in search for a cure. But perhaps such a prescriptive approach fails to capture the highly individualized and somewhat abstract concept of wellness. The reasons for resident burnout are personal and vast. Decreased wellness has been attributed to the lack of time for self-care, inadequate sleep, social isolation, negative work environments, excessive paperwork, long work hours, poor relationships with colleagues, and insufficient mentorship, among others in a lengthy list. Any attempt to standardize the definition of wellness should be met with caution.

So how do we as a society go forward in ensuring our resident physicians are well?Continue reading…

Has Med School Changed For the Better?

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By KARAN CHHABRA

karan chhabraEvery third-year has heard it.

“…When I was in your position, I was taking 24-hour calls every other night. If my resident was there, I was there….”

We’re regaled about the glory days, without shelf exams, without phlebotomists, and—by god—without those work-hour restrictions. The days when medical students wouldn’t dare ask their residents for help, or residents their chiefs, or chiefs their attendings, and so on. I hear a bit of romance: the heroism of providing total patient care, exactly when the patient needed it, unfettered by handoffs or outside interference. I envy the skill required to practice medicine almost-literally in one’s sleep.

As the veteran doc continues his (yes, usually his) soliloquy, he may admit that it wasn’t the safest model for patients, or the most humane for trainees. He may today be a better doctor for it, but he’s a bit ambivalent about whether it should remain exactly the same today. Presumably he wasn’t alone, because since the good ol’ days, the third year of medical school has morphed into something barely recognizable.

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Growing Up in the Era of Work-Hour Restrictions

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By Danielle Jones, MD

Danielle Jones

In 2008, the IOM study on resident work hours came out and in the years that followed the Accreditation Council for Graduate Medical Education (ACGME) subsequently implemented a gamut of “recommendations.”

As a medical student, I remember thinking it was a much needed change – why wouldn’t it be a good idea to improve patient safety and decrease resident fatigue?

Alas, as a newly minted intern growing up in the era of work-hour regulations, it’s become apparent that many of these changes may actually make life harder without achieving their main goal of improving patient care.

The 80-hour work week cap is fine; it’s been in effect on its own since 2003 and overall it seems to have made residency more humane. Most programs have found reasonable ways to limit work hours to this full-time-times-two amount, at least when hours are averaged over four-week periods.

However, the additional bullet point “recommendations” from 2010 seem to play out very differently in real life than they do on paper. Many of them seem to be arbitrary lines drawn in political sands hiding behind a facade of patient safety, but that’s another blog for another time.

So, what do the bullet point regulations look like in the hospital?

They look like: Interns can’t work 24-hour shifts. 

So, what used to be a two-and-a-half shift weekend turns into a four shift weekend. At a four intern/year program like mine, that means instead of two people splitting the weekends and having a post-call day after 24 hours on, one intern is committed to night-float six nights/week for a month while the remaining three interns take the three leftover weekend shifts.

The result: Fewer hours at a time in the hospital, but more working days in a row and more days/month away from your family.

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Why You Should Care about the New Accreditation Agreement for Osteopaths

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By John Schumann, MD

More than a century of American medical history was turned on its ear last week by the announcement that the groups that accredit medical residencies will unify their standards. Don’t be too hard on yourself if you failed to understand the significance (or notice at all).

But this should be viewed as good news across the land. As someone who trains doctors from both ‘traditions,’ I certainly welcome a more level playing field.

First, a little background:

Osteopathic physicians (those with a D.O., or Doctor of Osteopathy degree) have a history dating back to the 1800s. They comprise slightly more than 10% of practicing doctors in the United States. Currently, there are 35 osteopathic medical schools, compared with 135 ‘allopathic’ institutions, the kind that confer the M.D. (Doctor of Medicine) degree.

Though historically the two educational paths varied in principles and practice, there aren’t many remaining differences. Both disciplines now use biomedical science as their core.

Originally, osteopathy relied on manipulation of bones and joints to diagnose and treat illness.

This tradition, known as Osteopathic Manipulative Treatment (OMT), lives on in the osteopathic curriculum, though it’s now mostly used as an adjunct for treatment of chronic musculoskeletal conditions. Today, most D.O.s leave OMT behind after they finish their training.

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The Real Problem with Board Exams-and How to Solve It

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By Shiv Gaglani

This week there’s been a debate brewing about why so many young doctors are failing their board exams. On one side John Schumann writes that young clinicians may not have the time or study habits to engage in lifelong learning, so they default to “lifelong googling.” On the other, David Shaywitz blames the tests themselves as being outmoded rites of passage administered by guild-like medical societies. He poses the question: Are young doctors failing their boards, or are we failing them?

The answer is: (C) All of the above.

I can say this with high confidence because as a young doctor-in-training who just completed my second year of medical school, I’ve become pretty good at answering test questions. Well before our White Coat Ceremonies, medical students have been honed into lean, mean, test-taking machines by a series of now-distant acronyms: AP, SAT, ACT, MCAT. Looming ahead are even more acronyms, only these are slightly longer and significantly more expensive: NBME, COMLEX, USMLE, ABIM. Even though their letters and demographics differ, what each of these acronyms share is the ability to ideologically divide a room in less time than Limbaugh.

This controversy directly results from the clear dichotomy* between the theory behind the exams and their practical consequences. In theory these exams do serve necessary and even agreeable purposes, including:

1)     Ensuring a minimum body of knowledge or skill before advancing a student to the next level in her education,

2)     Providing an “objective” measure to compare applicants in situations where demand for positions exceeds supply.

So apart from the common, albeit inconvenient, side effects that students experience (fatigue, irritability, proctalgia), what are the problems with these tests in practice? These are five of the core issues that are cited as the basis for reformations to our current examination model:

1)     Lack of objectivity. Tests are created by humans and thus are inherently biased. While they aim to assess a broad base of knowledge or skills, performance can be underestimated not due to a lack of this base but due to issues with the testing format, such as duration, question types, and scoring procedure (e.g. the SAT penalizes guessers, whereas the ACT does not). Just as our current model of clinical trial testing is antithetical to personalized medicine (What is a standard dose? Or, more puzzlingly, a standard patient?), our current model of testing does not take into account these individual differences.

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