Making Better Doctors
Today’s model for residency training incorporates hi-tech advances while emphasizing the breadth of settings in which physicians and patients interact.
BY DAN GORDON
Hospital stays were measured in weeks. Medical records were paper based. To search the literature for information about a patient’s condition required thumbing through aging textbooks or perusing journals retrieved from the stacks at the biomedical library. Doctors did their own blood counts and gram stains. MRI, CT and PET were just random letters of the alphabet. There were barely more than a handful of antibiotics.
“You spent a lot more time just talking to patients and their families because there wasn’t as much to do for them, and you knew that when they were hospitalized, they were going to be there for awhile,” Dr. Neil Parker, senior associate dean for students and graduate medical education, recalls of his residency at UCLA in the mid-1970s. No one needs to tell Dr. Parker how different today’s mission of training physicians is from when he was a member of the UCLA house staff: He is among the leaders in ushering in a new model of residency training—one that incorporates computer and other technological advances while emphasizing the breadth of settings in which physicians now see patients, including ambulatory care, as well as other changes in the medical-practice environment.
Even with all those advances, however, the challenges are great. “We’re able to do so much more for patients but we also have to know much more,” says Dr. Jan Tillisch, executive vice chair of the Department of Medicine, who for three decades has played an active role in the education of UCLA physicians.When Dr. Tillisch was starting his career, in the late 1960s, he would learn a few fundamentally new concepts each year. “Today, if I stay vigilant I’ll learn something every day that changes the way I think about medicine,” he says. “That makes it incredibly exciting and enables one to be very optimistic about the future, but it also becomes a big challenge to train new doctors.”
In the traditional hospital training environment, keeping up with the rapidly accelerating pace of medical progress is only one part of the challenge. In addition to the significantly shorter hospital stays, inpatients have far greater acuity than in the past. Insurance and regulatory requirements have increased, eating into time that has become more scarce since the 80-hour workweek for trainees was implemented in 2003. The limits set on working hours for trainees, imposed nationally in response to concerns about fatigue and its effect on patient care, represented a seismic change in graduate medical education.
Fewer hours has meant a contracted workforce, and many institutions have struggled to avoid fostering a “shift mentality,” to ensure continuity of care, and to maintain an appropriate balance between patient care and education.
“Clearly, the 80-hour workweek changes the experience,” says Dr. Carl Bertelsen, a general surgeon in San Jose, Calif., who trained at UCLA from 1979 to 1986. “Now, when your 80 hours are up, you have to leave. That sort of thing was unheard of when I trained. You did what you had to do regardless of how little sleep you had.” Dr. Bertelsen recalls his years of training as a “phenomenal time” that he looks back upon with great fondness, despite the fact that it was “physically, mentally and emotionally trying.”
In their reassessments of how residents are taught, UCLA training programs have concluded that the competencies needed by today’s house staff can no longer be obtained in a single setting. As medicine has become more complex, Dr. Parker notes, individual facilities have become less likely to see the same wide spectrum of cases, both in terms of the diagnostic categories and severity.
Managed care perpetuated the trend. “Now you can’t just assume that because you have an outstanding hospital such as UCLA Medical Center, a trainee can get everything he or she needs,” Dr. Parker says. Indeed, as a tertiary/quaternary facility, UCLA Medical Center sees fewer primary-care and new diagnostic patients than in the past.
Thus, UCLA residents now work at multiple sites. Dr. Harish Lavu, a chief resident in general surgery, believes the breadth of clinical experience is among the program’s strengths. “We get to work not only at UCLAMedical Center, where we see the complex tertiary cases, but also at the VA Medical Center in West Los Angeles; a county hospital, Olive-View Medical Center; and a community hospital, Santa Monica-UCLA Medical Center,” he says. “By the time we’re finished, we are prepared in all of the surgical environments one might find after residency.”
With diagnosis and treatment so widely disbursed across settings and specialties, it’smore important than ever for trainees in the primary-care specialties to learn how to coordinate the vast array of services and tomake sense out of the information that comes from many different sources, Dr. Parker notes.
The dramatic reduction in length of hospital stays over the last generation, and the emphasis on outpatient management of diseases, has resulted in significantly different exposures for trainees. “When I was a house officer, we would see patients only at the end stage of a chronic disease, when they finally arrived in the hospital and were getting heroic treatment,” says
Dr. Joshua Goldhaber, professor in the Division of Cardiology, who trained at UCLA from 1984 to 1990. “Now, because we have more outpatient exposure to these diseases, we realize that we
were seeing only the worst cases—that in fact there is a spectrum, and patients withmilder forms can be treated very effectively and managed outside of the hospital.
As a result, prevention and early treatment get a lot more consideration than they used to, and the house officer gets into the mindset that chronic diseases are manageable. It’s a much more positive and hopeful experience.”
Dr. Tillisch, who was among those who spearheaded the greater outpatient emphasis, points out that although the experience is important and necessary given the direction medicine has taken, it raises new challenges. “The advantage of the inpatient setting has always been that it is an efficient training environment—the trainee can go back and visit the patient repetitively in a given day, and, particularly with longer hospital stays, could see some resolution of the problem over time,” he says. “Now, with shorter hospital stays, the resolution takes place on an outpatient basis over a longer period of time, and the trainee often isn’t able to see it. This challenges us to come up with new teaching paradigms and new ways of exposing trainees to diseases and their manifestations.”
The shifts toward training physicians more in ambulatory settings and in a variety of hospitals are two of the major changes resulting from a reassessment in which the leaders of UCLA programs have begun to identify more explicitly the specific skills trainees should acquire and then chart a course for getting there. Rather than simply treating residency as an apprenticeship, the tenets of undergraduate medical education—with a more explicit teaching and testing agenda—are being applied, stressing six core competencies spelled out by the Accreditation Council for Graduate Medical Education. In addition to medical knowledge and patient care, for example, greater emphasis is now placed on teaching professionalism. “We’ve always expected our doctors to be ethical and professional but now we’re looking at ways to actuallymeasure that and stress itmore than we did in the past,” says Dr. Parker.
Similarly, closer attention is being paid to teaching continuous quality improvement, systems of care and teamwork. As medicine and how it is delivered have become more complex, house staff and attendings are required to spend more time on documentation and other administrative work.
That, along with the 80-hour workweek, led to concerns that the amount of education and hands-on patient care for trainees was receiving short shrift. “There was a sense that many programs were starting to be weighted too far in the direction of service vs. educational activities,” says Dr. Jonathan Hiatt, chief of general surgery and director of surgical education. “Wheeling a patient down to X-ray and starting an IV may build character, but it doesn’t teach much about the management of the patient, and doing it 10 times a day is certainly not educational. So the challenge for training programs, particularly at a time when resources are tight, is to recalibrate the balance between education and service.”
To meet that challenge in surgery, Dr.Hiatt and colleagues have sought to employ an alternative workforce—using nurse practitioners and physician assistants where feasible—to pick up some of the patient-care duties that had been taking residents’ time. Beyond that, they have sought to make existing educational approaches more efficient and have looked to new educational paradigms. “I think the 80-hour workweek pushed us to be more concise and organized about our educational program and has made the didactic part of our training better,” says Dr. Jessica O’Connell, a chief resident in general surgery.
Wednesday morning conferences are now considered “protected time” during which house staff cannot be interrupted to attend to patient-care matters. The finite number of training hours has increased the emphasis on making the conferences of the highest quality.
In their search for new educational paradigms, the leaders of the programs have turned to resources that were unavailable when most of them trained.Many specialties have begun to incorporate simulator technology, following the model of the airline industry. In surgery, for example, residents use simulators to learn laparoscopic and endoscopic techniques outside the operating room.
In the future, Dr. Hiatt suggests, just as airlines require pilots to prove their mettle in the simulator before being allowed to fly a plane, surgical trainees will be required to demonstrate a certain level of proficiency with simulation technology before being able to operate on patients, or even animal models. Amore dramatic change has come with the incorporation of electronic resources into medical practice. “When I was an intern 22 years ago, if we wanted to know the results of a laboratory test on a patient, it involved a long walk down to the lab where we would wait to receive a slip of paper from an overworked clerk or technician,” says Dr. Goldhaber. “Now, we simply log on to one of the many computers at our disposal all over the hospital and punch in the patient’s ID number.”
Information technology also means that today’s trainees can have the world’s medical literature at their fingertips—literally. When they needed to learn more about a rare disease and its treatment, residents who trained with Dr. Goldhaber often had to go to the library in search of texts; today’s house staff can typically find all they need to know within five minutes of electronic searching at the point of care. It’s a good thing, because the explosion of medical knowledge has made it next to impossible for physicians to carry with them all of the most up-to-date information on even the conditions they commonly treat. “It used to be that you expected residents to know everything off the top of their heads,” says Dr. Parker. “Now, we have them carry PDAs and we teach them how to access and understand the literature so that they can practice evidence-based medicine.”
Technology can’t do everything, of course; much of the teaching process will always depend on the abilities of the teachers themselves. “You can learn technical aspects of medical diagnostics or therapy from simulators, but they’re not terribly useful in showing people how to think through a process,” says Dr. Tillisch.
Good teaching is based on both depth of experience and communication—including the ability to tailor material to the learners’ needs. But even more important, asserts Dr. Tillisch, are the same qualities that have always made for the best physicians. “When young physicians ask me what it takes to be a good doctor, I always say you have to care a great deal—so much that you’re ashamed to make a mistake, and so that your sense of self is secondary to the patient’s importance,” he says. “If you look around at the best teachers, they are simply the ones who are the most committed.”
In going through the interview process after medical school, Dr. Lavu was struck by the sense that at UCLA, far more than at other institutions he visited, trainees were treated with great respect. “Other institutions can be cutthroat and not very pleasant environments to work in,” he says. “At UCLA, I felt it was much more professional, and that the focus was really on education.” And he is as impressed with the quality of his fellow residents as with the faculty. “When you go to the graduation banquet every year and they talk about the achievements of the residents prior to coming to UCLA, as well as while they were here, it just blows you away,” he says. “A lot of the teaching occurs between the senior residents and the junior residents, and it’s not just how to care for patients but also how to carry yourself as a physician.”
“At a place like UCLA, you’re constantly exposed to the greatest minds, both in research and patient care, and to people who are enthusiastic about what they’re doing,” adds Dr. Stephanie Smooke, a chief resident in the Department of Medicine who is starting a fellowship in endocrinology. “That enthusiasm is contagious.” It’s also a characteristic that has remained constant through the significant changes in how UCLA residents are taught. “We’ve made a lot of adjustments,” says Dr. Hiatt, “but the spirit—that of a great institution with a busy and diverse clinical program, along with superb faculty and residents— is one that would be recognized by anyone who ever trained at UCLA.”