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Rapid Responses to:
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Electronic letters published:
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif){kind=icon}
Redesigning Internal Medicine Training
Steps Underway to Strengthen GME in Internal Medicine
Internal medicine: What needs to be done?
Redesigning training of internal medicine
Decline of General Internists
Redesigning Training with the Adult Learner in Mind
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Steven E. Weinberger, MD American College of Physicians, Lawrence G. Smith, and Virginia U. Collier
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sweinberger{at}acponline.org Steven E. Weinberger, et al.
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To the Editor: We agree with Dr. Mansi that the model of internists serving as “traffic directors” is not only unattractive to physicians but also delivers suboptimal care to patients. Appropriate procedural training is an important component of residency, though difficulty in assuring that each resident receives sufficient experience to achieve competency and the widely differing eventual needs of residents have contributed to an absence of agreement about what procedures should be required (1,2). We favor a model in which procedures fall into 3 categories: procedures required of all residents; procedures which should be available and are encouraged but not required during training; and specialized procedures which require additional training and experience that can be obtained during the customized component of residency training by residents who wish to gain competence in performing these procedures. Such a model for procedural training is currently being developed by the Alliance for Academic Internal Medicine (AAIM) Redesign Task Force. Drs. Horning and Dalekos both point out correctly that redesigning training is only one component of the changes that need to be made in the best interests of internists and their patients. Such additional objectives as redesigning the dysfunctional payment system and improving physician satisfaction (through decreasing physician “hassles” and implementing better practice models) are high priorities of the American College of Physicians (ACP), which is working actively to address these issues. It is also critical for society to recognize that broadly trained specialists in internal medicine represent the cornerstone of the American health care system – through their application of scientific and pathophysiologic knowledge to diagnosis and treatment, and through their longitudinal care of patients with complex and chronic illness. Drs. Fitzgibbons and Meyers have outlined the activities of the AAIM Redesign Task Force in contributing to redesign of residency training. The Task Force has been extremely valuable in convening a variety of stakeholders in internal medicine training for the purpose of implementing many of the changes proposed in our paper (3) as well as the position paper of the Association of Program Directors in Internal Medicine (4). In response to the challenge posed by Drs. Schroeder and Sox (5) to “putt or get off the green,” the Task Force will be an important vehicle for effecting changes in training. The ACP is pleased to be one of the organizations participating in the Task Force, and we look forward to substantial progress in achieving the goals of redesign. Steven E. Weinberger, MD, Lawrence G. Smith, MD, Virginia U. Collier, MD, American College of Physicians, Philadelphia, PA 19106 References 1. Wigton RS, Blank LL, Nicolas JA, Tape TG. Procedural skills training in internal medicine residencies. A survey of program directors. Ann Intern Med. 1989;111:932-8. 2. Fincher RM. Procedural competence of internal medicine residents: time to address the gap. J Gen Intern Med. 2000;15:432-3. 3. Weinberger SE, Smith LG, Collier VU. Redesigning training for internal medicine. Ann Intern Med. 2006;144:927-32. 4. Fitzgibbons JP, Bordley DR, Berkowitz LR, Miller BW, Henderson MC. Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine. Ann Intern Med. 2006;144:920-6. 5. Schroeder SA, Sox HC. Internal medicine training: putt or get off the green. Ann Intern Med. 2006;144:938-9. Conflict of Interest:None declared |
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John P. Fitzgibbons, MD Lehigh Valley Hospital, Frederick J. Meyers, MD
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john.fitzgibbons{at}lvh.com John P. Fitzgibbons, et al.
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To the Editor: The internal medicine community is beginning to reach consensus on how to strengthen graduate medical education. In “Position Paper: Redesigning Training for Internal Medicine” and “Redesigning Residency Education in Internal Medicine,” the American College of Physicians (ACP) and the Association of Program Directors in Internal Medicine (APDIM), respectively, continue this discussion (1, 2). For two years, the Alliance for Academic Internal Medicine (AAIM) Education Redesign Task Force—which includes representatives from the five associations in the alliance as well as ACP and the American Board of Internal Medicine (ABIM)—has been working to: 1. Define core competency in internal medicine. This “core” is common to all of internal medicine, which means internists should maintain these competencies irrespective of their careers as generalists or hospitalists, as cognitive or procedural specialists, as physician- scientists or clinician-educators, as clinicians in rural or urban communities. 2. Explain how all internal medicine residents can pursue “individualized career pathways” in internal medicine. Unfortunately, some observers have misunderstood individualized career pathways (3, 4). During a three-year internal medicine residency, residents would demonstrate competence in the core and have opportunities to pursue training that relates to their ultimate career goals, such as ambulatory, hospital, research, or specialty emphasis or a traditional pathway similar to the current mix of experience in ambulatory and hospital settings. In addition to defining the core and encouraging individualized career pathways, the recommendations from the AAIM Education Redesign Task Force will cover a number of important topics. These topics include the timing of career selection, the need for fully embracing competency-based education and evaluation, and faculty development. AAIM consists of the Association of Professors of Medicine, APDIM, the Association of Specialty Professors, the Clerkship Directors in Internal Medicine, and the Administrators of Internal Medicine. The five associations in AAIM represent faculty and staff in departments of internal medicine at medical schools and teaching hospitals in the Untied States and Canada. AAIM and the associations include department chairs, division chiefs, fellowship program directors, residency program directors, clerkship directors, and other departmental faculty as well as executive and administrative staff. As a result, the alliance is well positioned to turn the recommendations of the AAIM Education Redesign Task Force into lasting change. Currently, the AAIM Education Redesign Task Force is distributing a set of preliminary recommendations throughout the internal medicine community. AAIM looks forward to working with the rest of the community—particularly ACP, ABIM, the Residency Review Committee for Internal Medicine, and the specialty societies—to implement the changes necessary for strengthening training in internal medicine. Sincerely, John P. Fitzgibbons, MD Frederick J. Meyers, MD Co-Chairs AAIM Education Redesign Task Force References 1. Weinberger SE, Smith LG, Collier VU. ACP position paper: redesigning training for internal medicine. Ann Internal Med. 2006;114: 927-932. 2. Fitzgibbons JP, Bordley DR, Berkowitz LR, Miller BW, Henderson MC. Redesigning residency education in internal medicine: A Position Paper from the Association of Program Directors in Internal Medicine. Ann Internal Med. 2006;114: 920-926. 3. Whitcomb ME. The future of academic health centers. Acad Med. 2006;81:299-300. 4. Rockey PH. American Medical Association GME E-Letter, May 2006. Available at http://www.ama-assn.org/ama/pub/category/16225.html. Referenced May 16, 2006. Conflict of Interest:None declared |
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George N. Dalekos, Associate Professor of Medicine Larissa Medical School, University of Thessaly, Greece, Konstantinos Makaritsis, Eirini I. Rigopoulou
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dalekos{at}med.uth.gr George N. Dalekos, et al.
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In the recent paper by Weinberger et al1 a comprehensive approach to factors that support the need for redesigning training in internal medicine is given. However, we think that some issues could be addressed in a more straightforward manner in order to strengthen the urgent need for revisiting internal medicine training2. ·What are the problems for internal medicine? Internal medicine has been asleep for too long. Some of the dynamic and technology-supported subspecialties consider that if a patient’s condition leads him first to an internist, it acts simply as a detour. Thus, internal medicine should be able to show its competencies convincingly to the public or to the decision-makers in health care. ·Do the health care system need internal medicine? It is known that there is a steadily increasing number of old and polymorbid patients with complex and chronic diseases. Their management is a core competency of internal medicine as it is patient-centered and committed to ethical, scientific and holistic principles of patients’ care. Additionally, a well-trained internist is competent to use appropriate diagnostic-therapeutic procedures taking always into account the avoidance of costly over-diagnostics and double-diagnostics schedules. ·Do the patients need internal medicine? A patient with acute renal failure may go directly to the nephrologist, but if the patient is sick due to an undetermined disease or there are several diagnostic-therapeutic options (e.g. multiple myeloma or leptospirosis leading to acute renal failure), the best physician for him is the internist and the best place to go is the department of internal medicine. Thus, for all cases involving several specialties, internal medicine is the discipline that oversees, links and coordinates them all not by considering itself better or as the “mother” but simply as the integrating service that is so urgently needed in today practice. ·What actions should be done? To our opinion, the most important issues that need consideration in training programs of internal medicine is the pathophysiology and disease mechanisms during the under graduate education and the conflict between service and education during the graduate education. Decision-makers in politics and institutions, insurers, journalists, and the general public need a better understanding of what internal medicine can offer to the health care system and to the individual patient. An established permanent contact with politicians and other decision-makers in health care could be helpful in an attempt to achieve the best combination between responsible patient care, quality of training and the satisfaction of the trainee. References 1.Weinberger SE, Smith LG, Collier VU, for the Education Committee of the American College of Physicians*. Position paper: Redesigning training for internal medicine. Ann Intern Med 2006:0000605-200606200-00124. 2.Jotkowitz AB, Porath A. Internal medicine in Europe. Eur J Intern Med 2005; 16:543-44. Conflict of Interest:None declared |
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Ishak A Mansi, MD, FACP Louisiana State University Health Science Center,
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imansi{at}lsuhsc.edu Ishak A Mansi
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In the recent position paper of the American College of Physicians: “Redesigning training for internal medicine”, initiatives to redesign training were recommended including emphasis on ambulatory care experience. (1) Another important facet in redesigning internal medicine training is to train them to “DO”, not only to know “what to do”, the most commonly needed procedures for both inpatients and outpatients care. Our current training seems to prepare residents to treat more complicated medical problems but not simpler ones.(2-4) Yet, in handling these complicated diagnoses they call on subspecialists to do what they know should be done, and do not know how to do it. For example, they know that stress test might be done in the context of management of chest pain but do not know how to perform it, or that joint tapping is necessary for the diagnosis of inflamed joint, but they are not very skilled in performing the procedure. On the other hand, they do not feel comfortable in dealing with simple problems such as headache or vaginitis, and the associated procedures such as PAP smear. This results in internists acting as traffic directors, who are independently incapable of handling minor or major problems, with minimal job satisfaction.(5) A major need in redesigning internal medicine for satisfaction of both patients and doctors is to adequately train them, beyond the current requirements of few procedures, for the most commonly performed procedures in clinical life such as stress tests, sigmoidoscopy, PAP smears, joint aspiration and injections, skin lesion removal, etc… Such a change might restore job satisfaction and improve financial compensation that rewards procedural medicine more than cognitive one. References: 1. Weinberger SE, Smith LG, Collier VU, for the Education Committee of the American College of Physicians*. Position Paper: Redesigning Training for Internal Medicine. Ann Intern Med. 2006:0000605-200606200- 00124. 2. Wiest FC, Ferris TG, Gokhale M, Campbell EG, Weissman JS, Blumenthal D. Preparedness of internal medicine and family practice residents for treating common conditions. Jama. 2002;288(20):2609-14. 3. Mandel JH, Rich EC, Luxenberg MG, Spilane MT, Kern DC, Parrino TA. Preparation for practice in internal medicine. A study of ten years of residency graduates. Arch Intern Med. 1988;148(4):853-6. 4. Biro FM, Siegel DM, Parker RM, Gillman MW. A comparison of self- perceived clinical competencies in primary care residency graduates. Pediatr Res. 1993;34(5):555-9. 5. Horning J. Decline of general internists. Rapid response. Available at: http://www.annals.org/cgi/eletters/0000605-200606200- 00124v1. Accessed 4/17/2006. Conflict of Interest:None declared |
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James R Horning, MD, FACP U of S Dakota, VA
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drjrh1{at}sio.midco.net James R Horning
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Redesigning the training of Internal Medicine Residents may prepare some for their future positions but I do not think it will do anything to increase the number of general internists. Having been in private practice on and off for 16 years, and having been with a University sponsored Internal Medicine Residency program and the VA on and off for 10 years, I think you have to change the end point, not the training. General Internists need to be able to work less hard and be compensated more for what they do. In a small town setting, they will have to provide both inpatient and outpatient services. In a larger city, one is often a traffic director merely sending patients to various subspecialists. An often occurrence is for a post-op cardiac patient to develop dyspepsia, an acute gout attack, and stress elevation of glucose. Instead of having a general internist handle all 3 of these entities, 3 consultations are effected, all of whom are remibursed much more than if the general internist cared for the patient. The general internist has to be very adept at running patients through, coping with the coding maze, and handling the insurance company and medicare harrassment. Our residents are poorly trained for these non- medical entities. Residents are NOT stupid. They see the dissatisfaction in the general internist's life and seek out fellowships - any fellowship to get out of the thought of having to do general internal medicine. The powers to be have been very ineffective in obtaining reasonable remuneration for generalists. The subspecialites have been much more effective in this area. The ACP-ASIM, ACGME, ABIM, RRC, (AMA) etc. will have to work through Congress to improve the general internist's situation (insurance companies usually follow) before any major change in the declining numbers of general internists will take place. This goal in the face of the fact that the NIH budget has been cut for the first time in 36 years and with the cost of the war, etc. this is not a good time to expect any success. Conflict of Interest:None declared |
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Lori W. Wagner, MD, FACP Assistant Professor, University of Louisville
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lwwagn01{at}louisville.edu Lori W. Wagner
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Some of the proposed changes in your early release position paper, “Redesigning Training for Internal Medicine” by Weinberger and colleagues, can find additional basis for support in the literature of adult education. Malcolm Knowles brought the term andragogy into focus as a conceptual framework for adult education in the late 1960’s. His description of the adult learner includes a need to direct their own educational experience and a desire for practical and immediate utilization of their newly acquired knowledge (1-2). The suggested customization of training during the third year of residency allows the learner more opportunity to employ their own personal educational and career goals and increases the proximity of their training to their professional path choice; thus the more individualized approach to learning suggested can better match the needs and attributes of the adult learner. References 1.Smith MK. Malcolm Knowles, informal adult education, self- direction and andragogy. The Encyclopedia of Adult Education. 2002. Last Updated 20 October 2005. Accessed at www.infed.org/thinkers/et-knowl.htm on 11 April 2006. 2.Merriam SB. The new update on adult learning theory. 2001: 1-13 Conflict of Interest:None declared |
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