A middle-aged man was recently admitted to a Midwest hospital for “refractory congestive heart failure.” He had been followed in the hospital’s out-patient clinic for two years with that diagnosis. Yet, he continued to retain fluid and gain weight, despite optimal treatment for congestive heart failure. Finally, when his abdomen and scrotum had become so bloated that it was painful for him to put on his pajamas, he went to the emergency room at midnight, and from there he was admitted to the hospital. On the floor, his doctors made a startling discovery: he did not have heart disease, as presumed, but kidney disease. Clues to the kidney disease had in fact been present from the time the patient first started visiting the hospital’s clinic. With the correct diagnosis, the patient’s fluid retention was successfully addressed.
The above case illustrates a fundamental truth of medical practice: good doctors need to be able to think, not merely to follow protocols. Excellence in medical practice requires asking such questions as “what is the evidence to support a diagnosis or treatment plan?,” “what else could something be?,” and wondering “why?,” not just “what should we do?” Developing these skills is the purpose of residency education.
Although the public can be confident in the work of all accredited residency programs, it is also well known that some do a better job of producing skilled physicians than others. Success rates on the various specialty board examinations vary among programs, as does the frequency with which graduates of different programs subsequently achieve leadership positions in practice or in academic medicine.
What accounts for these differences among residency programs? Certainly, it is not with anything that can be readily measured. All programs have adequate physical facilities, enough beds and teachers, good clinical laboratories and libraries, and sufficient formal lectures and teaching conferences. Had they not, they would not have been accredited by the relevant Residency Review Committees. The structural characteristics of residency programs do not provide the answer.
Rather, the differences in educational quality among residency programs result 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 clinical judgment, analytical rigor, creative capacity, or the ability to manage uncertainty. Clinical judgment 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 faculty 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 residents’ report about not just how to make the diagnosis of systemic lupus erythematosus but also about whether there was sufficient evidence to make the diagnosis and begin treatment in the patient admitted last night (and if not, what needed to be done to make the diagnosis or establish the presence of a lookalike condition). Studies of residency programs have also observed that discussions at strong programs regularly explore the underlying science, examine the rationale for current practices, foster critical thinking, and encourage exploration of the unknown. In contrast, teaching at weaker programs rarely engages in those activities, focusing instead on practical topics, particularly patient management of the more common problems.
In short, excellence in residency education 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 education can continue to occupy a legitimate place in the university.
Heading image: RCSI Bahrain students taking a group photo following the 2013 White coat ceremony. By Mohamed CJ. CC BY-SA 3.0 via Wikimedia Commons.
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