Residency education: Where we’ve come from and where we need to go

A new calendar year always prompts both looking back and looking forward.  This mindset has led me to reflect about graduate medical education (GME), which had been my principal focus for many years and is one of Michigan Medicine’s outstanding gems. Our GME residency and fellowship programs retain many of our outstanding students, lure other top medical school grads to U-M, and provide a pipeline of talented and dedicated physicians to the faculty.

It’s interesting how quickly health care delivery is being transformed. Physician training is also undergoing fundamental change, albeit more slowly. Some aspects of GME have been significantly strengthened, while others remain ripe for innovation. 

GME has always relied on experiential training (“learn by doing”). When I trained, the underlying assumption was that each resident would see and learn everything we needed through immersion in patient care, so a curriculum seemed unnecessary.  Our assignments to various inpatient services reflected patient care needs, rather than an education plan. Supervision and assessment were informal: “see one, do one, teach one.” Residency graduation was largely based on completing the required number of years for each specialty without raising serious concerns. 

Today’s residency programs are strengthened by curricula focused on achieving defined core competencies.  Work hours are regulated, which is even more essential amid today’s higher patient acuity and focus on efficiency. Supervision and assessment are more explicit and deliberate, though both represent works-in-progress. In addition, residency programs are moving toward holistic selection processes — along with a focus on diversity, equity and inclusion — to improve education and health care.   

Yet, nationally, the overall approach to GME remains time-based, inpatient-focused, limited in opportunities to individualize according to a resident’s learning needs or career goals. Several factors have constrained innovation: inadequate funding for medical education research; historic de-valuing of education scholarship in promotions processes; a web of regulations and requirements perpetuating current processes; ongoing reliance on trainees to provide care; lack of a mechanism to coordinate GME research across institutions; and no standard or shared data infrastructure.

But a window of opportunity is opening …