Confronting the damaging hierarchy in graduate medical education

Although I have a deep respect for everyone who contributes to the education of our next generation of physicians, I also feel that the current hierarchy in graduate medical education is damaging U.S. health care. That is, the best students go to the best residency programs and get the best jobs and subsequently teach the best students, and so on, creating highly respected centers of excellence. That’s wonderful, but how often do we consider the opposite end of the spectrum: the least competitive students take the least competitive spots in lesser training programs, receive weaker training, and also end up teaching the next generation of their peers in the same settings, and so on, creating troubling centers of mediocrity. Should the ACGME accept this as just a manifestation of the “American way,” or should they intervene?

As a hospitalist who has worked in 8 states in a variety of academic and community settings, from centers of excellence to rural training programs, I can only speak for a tiny slice of graduate medical education, but from what I’ve seen, I feel obligated to raise a red flag.

To be more specific, a rural internal medicine program with which I worked relied almost entirely on the post-match “scramble” to fill their spots every year. As an educator, I felt responsible for the proper education of each of these residents, and I cringed at seeing scores on the in-training exams as low as the zeroth percentile and only one exemplary score above the 30th percentile. The first-time pass rate for the ABIM board exam was 33 percent when I arrived. There were no morning reports, no bedside rounds, the residents gave most of the noon lectures to themselves (mostly unattended by faculty), and only a few specialty services were represented in the hospital (and no dialysis, MRI, or cath lab). Complex cases were all transferred out. Predictably, the majority of the teaching faculty had trained at this program, who else would come there? It was a continual struggle just to find warm bodies to “staff” the residents, let alone individuals dedicated to providing a quality education. Sadly, the foundation of our residents’ board exam preparation consisted of repeatedly running through thousands of sample board review questions. Unfortunately, like learning a foreign language without ever visiting the country, it’s just not the same. The clinical subtleties of history, exam, diagnostic reasoning, and prudent clinical decision-making are not learned from mastering exam questions. I believe that all of the above resulted in numerous cases of substandard and sometimes dangerous medical care, of which I kept a record. (Some internal medicine graduates also went on to staff local emergency rooms, amplifying the problem.)

The fact that the CFO of this small hospital seemed to have more control over the structure of the residents’ schedule than the program director supported the concern that the residents were primarily being used as cheap labor. For example, my attempt to institute interactive, daily morning report teaching was fairly quickly quashed by the CFO due to discharge times being affected.

I am not critical of the residents and educators themselves in this situation. They were doing the best they could, based on their experience, training, and resources; but most of them had never witnessed “excellence,” and this is where, I believe, an opportunity exists.

As an educator, I think that, in any profession, it is extremely valuable for trainees to witness excellence firsthand. The experience can be transformative, like a young athlete attending a professional sports camp and seeing the pros in action. The reality is that, in rural programs, trainees never have the opportunity to witness excellence.

So what’s the solution?

Honestly, I think the best thing to do would be to expand training programs at centers of excellence to allow the majority of physicians the opportunity to train in such settings so that they could ultimately bring a standard platform of excellence to small communities and to simultaneously eliminate accreditation of programs that are based in hospitals without a complete platform of services and specialties. Those hospitals could and should certainly be satellites to larger programs, but they shouldn’t ever be their home.

Since such a disruption is unlikely to happen, I believe the alternative is that every medical trainee in the U.S. should have the opportunity and be required to experience a center of excellence during a significant portion of their training.

Consider the following:

  • Formally link every rural or small community program to at least one academic center of excellence as a sister organization.
  • Exchange both faculty and residents (including chief residents) throughout the year between the rural program and the academic program.
  • Link live-streamed, interactive conferences and grand rounds from academic centers to smaller programs.
  • Require residents to formally report on the management and outcomes of all patients transferred out to a referral hospital (ideally with resident-to-resident communication about the case between the two facilities).
  • Faculty and residents from both sides would benefit from this “prince and pauper” type exchange. Teaching methods, documentation quality, clinical decision-making, and guideline-based management would all be strongly impacted. (The exchange would also likely lead to fewer unnecessary patient transfers to academic centers due to the improved clinical knowledge, experience, and confidence of rural doctors).

Certainly, program directors reading this are cringing at the logistical nightmare and added costs this exchange would create. Perhaps the faculty and residents of top training programs have little desire to be “dragged down” and “encumbered” by working with rural programs (and may even be embarrassed or afraid to have weaker residents rounding on their patients), and rural programs may resent the “condescending” or “out of touch” judgments of doctors from academia, but I believe the ultimate benefit for the health care of the U.S. would more than offset the costs.

All health systems have a mission statement that claims a desire to provide the “best possible care” to all patients, but I do not believe that we can achieve this, especially in rural areas, with the current hierarchy in graduate medical education.

David M. Mitchell is a hospitalist.

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