For res­i­dents, the doc­tor will see you now

The Globe and Mail Metro (Ontario Edition) - - NEWS - BLAIR BIGHAM

Ex­pe­ri­enced physi­cians are tak­ing on a more ac­tive coach­ing role at teach­ing hospi­tals

At work in the emer­gency depart­ment of St. Michael’s hos­pi­tal in Toronto, firstyear med­i­cal res­i­dent Winny Li in­ter­views a pa­tient with chest pain while her su­per­vi­sor hides be­hind a cur­tain, within earshot, but out of view. The over­sight – and the feed­back she will re­ceive later in the shift – is a hall­mark of Canada’s new sys­tem for teach­ing and eval­u­at­ing junior doc­tors.

The pro­gram, which launched at teach­ing hospi­tals across the coun­try on July 1, re­quires se­nior doc­tors to ob­serve res­i­dent doc­tors – those who have fin­ished med­i­cal school and are do­ing on­the-job train­ing in one of more than 30 spe­cial­ties – and pro­vide con­stant coach­ing, un­like the hands-off ap­proach in the past.

“It’s the big­gest change in med­i­cal ed­u­ca­tion in over a cen­tury,” says Ja­son Frank, an emer­gency physi­cian in Ot­tawa and the di­rec­tor of spe­cialty ed­u­ca­tion at the Royal Col­lege of Physi­cians and Sur­geons of Canada, who is lead­ing the over­haul, which started with this year’s crop of 3,000 res­i­dents. While univer­si­ties con­duct the train­ing, the col­lege sets out the pro­gram they will fol­low.

The new sys­tem is meant to iden­tify strug­gling res­i­dents early, so ed­u­ca­tors can in­ter­vene and make sure they have the skills they need when they move on to their own prac­tices.

Un­der the old way, which had been in place since 1910, doc­tors train­ing to be spe­cial­ists en­tered a res­i­dency pro­gram for a pre­de­ter­mined length of time – three years for pe­di­atrics, five for emer­gency medicine, seven for neu­ro­surgery, for ex­am­ple – and wrote a qual­i­fy­ing exam at the end, but were not eval­u­ated on skills such as com­mu­ni­cat­ing with pa­tients. Res­i­dents of­ten worked un­ob­served by se­nior doc­tors and re­ceived lit­tle feed­back to help them cor­rect bad habits or mis­con­cep­tions. Some may have missed out on de­vel­op­ing par­tic­u­lar skills be­cause sit­u­a­tions they needed to ex­pe­ri­ence did not oc­cur in the time al­lowed.

The problems have been ac­knowl­edged for decades. The World Health Or­ga­ni­za­tion said in a 1978 re­port that some doc­tors were learn­ing crit­i­cal skills on the job long af­ter be­ing li­censed. And as medicine be­comes in­creas­ingly com­plex, with pa­tients liv­ing longer, re­quir­ing more spe­cial­ized care, and new health problems emerg­ing, med­i­cal ed­u­ca­tors wanted to es­tab­lish a list of tasks on which res­i­dents must be as­sessed be­fore they can be li­censed.

“We are train­ing ex­cel­lent physi­cians, most of the time,” says Linda Snell, the col­lege’s se­nior clin­i­cian ed­u­ca­tor. But she adds that the exit-exam sys­tem does not test for ev­ery­thing a doc­tor needs to treat pa­tients well.

Work on a new model be­gan about 20 years ago, but un­til re­cently, there was not enough ev­i­dence to sup­port switch­ing the mam­moth med­i­cal ed­u­ca­tion sys­tem away from the old ap­proach, in which res­i­dents learned on the job and helped teach med­i­cal stu­dents at the same time. Un­der the new sys- tem, if a res­i­dent has not yet ex­pe­ri­enced a sit­u­a­tion or pro­ce­dure in­te­gral to their spe­cialty, a su­per­vis­ing doc­tor would note the fact and univer­si­ties would try to make it hap­pen, some­times us­ing sim­u­la­tion when real sit­u­a­tions are too rare.

The new model, called com­pe­tency-based med­i­cal ed­u­ca­tion (CBME), re­quires se­nior doc­tors to di­rectly ob­serve res­i­dents. When they have been seen to per­form well at a func­tion deemed es­sen­tial to their train­ing, they can be de­clared “en­trustable” in that area, mean­ing they may no longer re­quire su­per­vi­sion to do it. Once they have reached those mile­stones – such as be­ing able to man­age a pa­tient in need of re­sus­ci­ta­tion or de­liver a baby - they progress to more in­de­pen­dence and re­spon­si­bil­ity. Like res­i­dents in the old sys­tem, they will also take a fi­nal exam.

DAILY RE­SULTS

The new sys­tem may do more than catch doc­tors who might be not fully pre­pared. An idea that re­mains con­tro­ver­sial among ed­u­ca­tion sci­en­tists and front­line physi­cians is that it might also ac­cel­er­ate learn­ing for some, and shave an en­tire year off res­i­dency for those who are eval­u­ated as hav­ing done all the tasks and are ready to prac­tice. That could pump fully qual­i­fied doc­tors into the sys­tem sooner.

The Univer­sity of Saskatchewan has al­ready ad­vanced one res­i­dent to the next stage early be­cause of pos­i­tive feed­back, but Rob Woods, di­rec­tor of the emer­gency-medicine res­i­dency pro­gram, says this does not nec­es­sar­ily mean they will fin­ish early. “Some res­i­dents will progress fast through some stages, and more slowly through oth­ers.”

Dr. Woods, who as­sesses the progress of emer­gency medicine res­i­dents, re­ceives daily writ­ten re­ports from su­per­vis­ing physi­cians that eval­u­ate res­i­dents’ per­for­mance, as­sign it a nu­mer­i­cal rat­ing, and of­fer di­rec­tion on how they can im­prove.

“CBME is go­ing to make my job a lot eas­ier,” Dr. Woods says. In the time-based sys­tem, re­ports were less de­tailed, and problems were of­ten not brought to the di­rec­tor’s at­ten­tion even if hos­pi­tal staff had no­ticed them. He says in­for­ma­tion in mul­ti­ple com­ments from su­per­vi­sors this sum­mer al­lowed him to coach a res­i­dent whose com­mu­ni­ca­tion style was a bit too ca­sual. If it were not for CBME “it would have been whis­pers in the shad­ows,” he says. “The old way, we only had enough data to make sure peo­ple were just meet­ing the bar. Now we have a de­vel­op­ment mind­set.”

The Col­lege of Fam­ily Physi­cians of Canada, which is re­spon­si­ble for the res­i­dency train­ing pro­grams of doc­tors who will be­come gen­eral prac­ti­tion­ers, be­gan us­ing a form of CBME in 2011. It had no­ticed that fam­ily doc­tors were aban­don­ing their tra­di­tional role of car­ing for ev­ery­one from ba­bies to the el­derly, lim­it­ing hos­pi­tal vis­its and re­fer­ring com­plex pa­tients to spe­cial­ists more of­ten. More than 7,000 fam­ily doc­tors have now been trained un­der the sys­tem, a few of whom needed more than the tra­di­tional two years, says the col­lege’s di­rec­tor of ed­u­ca­tion, Ivy Oan­dasan. Grad­u­ates of the CBME pro­gram are now more likely to prac­tice the full spec­trum of fam­ily medicine, she says, a role viewed as vi­tal out­side ur­ban ar­eas.

The Dutch med­i­cal train­ing sys­tem has used a form of CBME for 15 years, and in Cincin­nati the tech­nique has been found to iden­tify strug­gling res­i­dents sooner. Canada’s changes are broader than those pro­grams – in­clud­ing the data col­lec­tion and the list of re­quired com­pe­ten­cies – and are seen as cut­ting edge.

“Many coun­tries are watch­ing us,” Dr. Frank says.

A QUES­TION OF TIME AND RE­SOURCES

Over the past few years, pilot projects for CBME at McMaster Univer­sity, Queens Univer­sity and the Univer­sity of Ot­tawa have found that strug­gling res­i­dents are iden­ti­fied ear­lier and some are ad­vanced sooner.

But a 2009 study with 14 ortho-

It’s the big­gest change in med­i­cal ed­u­ca­tion in over a cen­tury.

JA­SON FRANK

DI­REC­TOR OF SPE­CIALTY ED­U­CA­TION AT THE ROYAL COL­LEGE OF PHYSI­CIANS AND SUR­GEONS OF CANADA

pedic surgery res­i­dents at the Univer­sity of Toronto and pro­vided lit­tle proof that CBME is bet­ter than the time-based model. Two fin­ished early, two later, and the rest the same, and no dis­cern­able dif­fer­ences in com­pe­tence were found com­pared to those trained in a time-based model.

That does not sur­prise Ge­off Nor­man, pro­fes­sor emer­i­tus in ed­u­ca­tion and clin­i­cal epi­demi­ol­ogy at McMaster Univer­sity. He says the the­ory be­hind com­pe­tency-based ed­u­ca­tion is flawed.

“This has been tried [in other ar­eas of study] be­fore, back in the 1970s,” he says, when be­hav­ior the­ory was dom­i­nant in ed­u­ca­tion. A res­i­dent who has man­aged a sit­u­a­tion well in the past is not guar­an­teed to do so each time in the fu­ture, Dr. Nor­man says. Sim­i­lar cases might present them­selves in thou­sands of ways, so the idea that a res­i­dent can be de­clared com­pe­tent based on a few ob­ser­va­tions does not add up, he says.

The big­gest flaw, he says, is that CBME as­sumes an up­ward tra­jec­tory of gain­ing com­pe­tence. “It sug­gests a smooth curve, but what ac­tu­ally hap­pens is a saw­tooth up-and-down,” he says of how res­i­dents learn and per­form. In other words, a res­i­dent could per­form very well in a sit­u­a­tion a few times, and move to the next level of re­spon­si­bil­ity, then per­form very poorly in a sim­i­lar sit­u­a­tion a few weeks later. While some tasks, like gall blad­der surgery, may seem rou­tine, com­pli­ca­tions such as bleed­ing or ac­ci­den­tally cut­ting the bile duct can hap­pen long af­ter a res­i­dent per­forms their first case by them­selves. It gets even trick­ier for cog­ni­tive tasks like di­ag­nos­ing rare dis­eases, be­cause lab tests, pa­tient his­to­ries and phys­i­cal ex­ams re­quire in­ter­pre­ta­tion and “a good amount of gut feel­ing,” says Dr. Nor­man, who be­lieves there is no sub­sti­tute for the ex­pe­ri­ence gained in a time-based sys­tem.

The pro­gram also puts too much of a bur­den on su­per­vis­ing doc­tors, who have their own work, he says. “Staff doc­tors are spend­ing all their time watch­ing res­i­dents in­stead of see­ing pa­tients.” If ex­cep­tional res­i­dents grad­u­ate early, he adds, hospi­tals could end up short staffed.

Pro­vin­cial min­istries of health say they are mon­i­tor­ing the im­pact CBME could have on bud­gets and hos­pi­tal staffing, but the Royal Col­lege’s Dr. Frank says the im­pact will be mar­ginal, and that univer­si­ties funded the start-up costs. If an out­stand­ing res­i­dent grad­u­ates a year early, Dr. Frank says, one of about 100 med­i­cal school grad­u­ates who did not get a res­i­dency spot this year can take their place.

While ed­u­ca­tors and aca­demics ar­gue over how best to mea­sure suc­cess­ful train­ing, the Royal Col­lege is press­ing on, says Dr. Snell, who is also a pro­fes­sor of medicine at McGill Univer­sity’s Cen­tre for Med­i­cal Ed­u­ca­tion. “We have to dive in and do it.” Back at St. Michael’s, Dr. Li says she ap­pre­ci­ates the feed­back and ex­tra su­per­vi­sion the new sys­tem pro­vides.

“We need this type of dis­rup­tion in med­i­cal ed­u­ca­tion,” she says. “It’s so ben­e­fi­cial to get spe­cific ad­vice you can act on. You want to hear more than ‘good job,’ be­cause at the end of res­i­dency, you’re the at­tend­ing [physi­cian].”

Af­ter she in­ter­viewed the pa­tient with chest pain, her su­per­vi­sor said her as­sess­ment re­lied too much on test re­sults and not enough on the pa­tient’s per­sonal his­tory, and this led her to un­der­es­ti­mate the risk for heart problems and rec­om­mend that he be dis­charged. “Just be­cause your elec­tro­car­dio­gram and en­zymes are nor­mal, doesn’t al­ways mean you can go home,” she says later. “That just changed the way I think about ev­ery­one with chest pain.”

Blair Bigham is an emer­gency-room physi­cian and a free­lance health and sci­ence writer.

JEN­NIFER ROBERTS/THE GLOBE AND MAIL

Winny Li, a res­i­dent at St. Michael’s Hos­pi­tal in Toronto, likes the new sys­tem of feed­back and su­per­vi­sion.

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