Responding to the growing consensus among different medical bodies that (1) training in internal medicine has not kept pace with changes in the delivery of healthcare today, such as the tension between inpatient and outpatient medicine, (2) current training is leaving residents ill-equipped for the many functions they have to perform, and (3) the numbers of residents who are going into general internal medicine have diminished significantly, the Association of Program Directors in Internal Medicine (APDIM) and the American College of Physicians (ACP) released independent position papers outlining their proposals for redesigning the education of internal medicine in residency programs. The papers are published in the same issue of the Annals of Internal Medicine.^1,2

APDIM’s Proposal
Educational environment
The APDIM suggests that residents should be assigned to clinical rotations based on educational goals and objectives, rather than the exigencies of service needs and financial pressures of teaching hospitals. The APDIM stresses that high-quality patient care should be the sine qua non of residency education.

Residents must first understand the needs of individual patients before they move on to evidence-based diagnosis and treatment. The APDIM believes that quality of care can be improved if residents and teachers are allowed to analyze errors and “near-misses” in a blame-free environment.

Residents must learn how to function as both a member and a leader of a multidisciplinary team. In addition, continually evolving information technology demands that residents understand and be comfortable with procedures such as computer-based order entry, bar coding, and electronic medical records.

The focus of residents should be the care of patients, initially in close collaboration with faculty mentors, and gradually progressing to greater autonomy and independence in tandem with the increasing competency and confidence demonstrated by the resident. Finally, the APDIM proposes that inpatient and ambulatory care experiences provide residents with sufficient patients and patient diversity, as well as with enough time to provide care and to reflect on the care they have provided.

Curriculum
While continuing to endorse the 3-year curriculum as the only way to ensure broad competency, the APDIM proposes establishing specific goals for each year.

The first year would include closely supervised ambulatory and inpatient experiences and exposure to potential career pathways, including ambulatory and inpatient general medicine and subspecialties.

During the second year, supervision would be tempered with independent decision making.

The third year should be tailored to the resident’s chosen career plans, while also focusing on the acquisition of leadership skills and on learning how to provide safe, efficient, and cost-effective care in an increasingly complex healthcare environment.

Other critical issues
The APDIM acknowledges that many medical students accumulate large debts that they feel could best be handled by opting for a more lucrative career than primary care practice. To attract more students to general internal medicine, the organization recommends narrowing the reimbursement gap between cognitive and procedural specialties, improving loan repayment programs for primary care physicians, employing more generalist clinician-educators, and stressing flexible career options such as hospitalists.

ACP Redesign Priorities
The residency model
The ACP, too, believes that the current 3 years of residency training is the minimum amount of time needed to accommodate the broad, experience-based internal medicine curriculum. The ACP disagrees with those who believe that training should be shortened before residents enter fellowship training, instead proposing that the research component of fellowship training be eliminated to abbreviate the total training time for clinician subspecialists.

The ACP advocates 2 years of core training that focus on the knowledge and skills relevant to all internists, followed by 1 year of training customized to meet the resident’s chosen career goal. Thus, a future hospitalist would spend the bulk of the third year in hospital-based activities, and a would-be ambulatory care specialist in ambulatory practice. For trainees who wish to continue working in both fields, their third year would include experiences in both settings.

To overcome the imbalance between service needs and education, which often overburdens residents with excessive workloads, the ACP proposes bringing hospitalists, nonteaching services, and midlevel practitioners (ie, physician assistants) into the mix on teaching services.

Ambulatory training
The ACP sees a need to place more emphasis on ambulatory training, preferably in settings that employ advanced technology and innovative techniques (ie, web-based scheduling, monitoring the quality of patient care, electronic medical records), instead of the dysfunctional practice settings residents often find themselves in, which only breed discouragement and distaste for generalists careers.

Since residents are often strapped for time to meet the demands of both ambulatory and inpatient responsibilities, the ACP proposes redesigning the core training period to achieve the following goals:

• Providing longitudinal ambulatory experiences in well-functioning practices. To ensure that this does not compete with inpatient responsibilities, the ACP offers suggestions such as using frequent block rotations instead of the typical half-day clinics at the end of inpatient rotations.

• Shifting the training balance, so that the emphasis on ambulatory training time and responsibility is increased or equal to that placed on inpatient experiences.

• Incorporating team-based care into training, because it is becoming the paradigm in healthcare and also because it is more amenable to training redesigns. Team-based care can be as simple as pairing 2 residents, so that one is providing inpatient care, and the other is providing ambulatory patient care.

• Stressing professionalism, expressed as core values and ethical standards that all residents should strive for. These include patient-centered, culturally sensitive, evidence-based care; effective partnering with patients; lifelong learning; self-evaluation and self-reflection to improve the quality of care; and social activism on behalf of the patients.

The purpose of physician training is to meet the needs of patients and society, which, the ACP notes, can only be achieved in an atmosphere that encourages trainees to move on to long and satisfying professional careers. Medicine evolves. Physicians’ interests evolve. So should residency training programs.

References
1. Fitzgibbons JP, Bordley DR, Berkowitz LR, et al. Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine. Ann Intern Med. 2006; 144:920-926.

2. Weinberger SE, Smith LG, Collier VU, for the Education Committee of the American College of Physicians. Redesigning training for internal medicine. Ann Intern Med. 2006; 144:927-932.