Considerable variation in quality exists among residency programs in the United States, even among those in the same specialty, such as surgery, pediatrics, or internal medicine. Some are nationally and internationally renowned, others are known regionally, and still others are known only locally. The strongest programs, invariably at major teaching hospitals, attract far more applicants than they possibly can accommodate. The weakest programs, most commonly located at smaller community hospitals, encounter difficulty filling their residency positions. These programs, if they are to have a house staff, often have to fill their positions with graduates of foreign rather than US medical schools, and even then many of their positions frequently go unfilled. At the best programs, virtually all graduating residents pass their board examination on the first try; at the weaker programs, only one-third.
What accounts for the differences in educational quality among residency programs? Certainly, it is not anything that can be readily measured. All programs have adequate physical facilities, enough beds and teachers, good laboratories and libraries, and sufficient formal lectures and teaching conferences. Had they not, they would not have been accredited by the relevant Residency Review Committee. The structural characteristics of residency programs do not provide the answer.
Rather, the differences in quality among residency programs results from differences in their learning environment. Facts and procedures can be taught in school-child fashion from lectures and demonstrations. This is not the case, however, for higher intellectual abilities such as analytical rigor, problem-solving skill, creative capacity, or the ability to manage uncertainty. Clinical judgment simply cannot be learned from books. Rather, it involves informal learning from conversations, discussions, reflection, role modeling, and absorption of the values and attitudes of the faculty. The better these elements, the stronger the residency program.
The most important informal learning is that acquired from discussions about specific cases. Examples of such exchanges include conversations with attending physicians or consultants about complex patients in whom the treatment of one problem might exacerbate another, discussions with fellow house officers (and sometimes faculty members) at lunch or dinner, conversations with the attending surgeon while scrubbing or during the course of an operation, informal discussions with a faculty member about the flaws in a recent paper or about his current research, or discussions at morning report about not just how to make the diagnosis of systemic lupus erythematosus but also about whether there is enough evidence to make the diagnosis and begin treatment in the patient admitted last night (and if not, what needs to be done do make the diagnosis or establish the presence of a lookalike condition). Studies have shown that discussions at teaching hospitals regularly explore the underlying science, examine the rationale for current practices, foster critical thinking, and encourage exploration of the unknown. In contrast, teaching at community hospitals engage much less commonly in those activities, focusing instead on practical topics, particularly management of the more common problems.
In short, educational excellence in residency training is not a matter of formal curricula, lectures, or books, as valuable as these devices might be as educational supplements. Rather, excellence depends on the intangibles of the learning environment: the skill and dedication of the faculty, the ability and aspirations of the house officers, the opportunity to assume responsibility in care with a manageable number of patients, the freedom to pursue intellectual interests, and the presence of high standards and high expectations of the house staff. With these elements properly in place, excellence is assured, and residency training can continue to occupy a legitimate place in the university.
Next month I shall discuss why educational excellence in residency training matters to patients.
Heading image: New York Presbyterian-Cornell by Julia Sorenson. CC BY-SA 3.0 via Wikimedia Commons.
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