Ensuring Competent Physicians- Three Critical Questions in the Medical Education Process

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I was talking with a colleague of mine who is studying diligently for her Family Practice Recertification Boards. She has always passed them with flying colors every seven years, and was showing me some of the practice questions she now had to answer for this exam. One in particular was a very esoteric question about the management of an ICU patient. She has an ambulatory practice, and even if she did hospital medicine, it is quite doubtful that as a family physician she would be managing a complicated ICU patient. Even for me as an internist who could be managing this patient in the ICU, this was a real zebra question. It is even more irrelevant when applied to an ambulatory care physician who will never manage this patient in real practice.

This begs the first of three questions in critically evaluating the entire medical education process:

Question 1: How do we define the competent physician, and then how do we appropriately test for it in a recertification exam?

Are our recertification Boards are truly testing us for our competency in the fields in which we practice. Do they even have relevancy to our actual practice? Why should ambulatory family physicians waste valuable time memorizing esoteric minutia in an area they will never see in their practice.

Already busy and overworked physicians spend dozens of hours and several thousand dollars for each recertification cycle. For many physicians, recertification is necessary for their employment. Recertification is no small deal. And for many specialists, they have multiple boards to contend with. Recertification is almost a business in itself.

How relevant are the questions that are asked in these exams to the actual medical practice? The whole intent of recertification should be relevant to the scope of practice of that physician, especially when this exam will determine the certification, and even future employment, of this physician.

But let’s now look at the entirety of the medical education process and address two other questions:

Question 2: Does the application process for medical school, and ultimately who becomes a physician, appropriately selecting the best potential physicians?

When I look back on the whole process of getting into medical school I remember….

I had to get close to a 4.0 grade point average. I had to get an A in calculus. (OK docs, when was the last time you had to integrate an equation in practice?). When I think back amongst many of my college friends, many could never get the grade point in the first place. Has anyone done a study looking at college grade point average and ultimate performance as a physician?

Where is the emphasis on communication skills, patient empathy, teamwork and so many other critical aspects of being a good physician?

One could argue some of the best potential physicians were never even able to make it through a somewhat artificial barrier of entry into medical school.   Does the current process truly screen for the best potential physicians in the first place?

And then finally:

Question 3: Does medical school and residency truly prepare us for the realities of medical practice?

Looking back on medical school, I sometimes wonder what would have happened if we spent the corresponding percentage of time in school studying the things that actually took up the percentage of time in our time in practice. Could you imagine a full year medical school course in “Non-Compliance”? How about a six month course in “Irritable Bowel”…. or even “Overactive Bladder”? Or better yet, a two year course in “Insurance Forms”. Medical school and residency are done in an academic environment. For most in practice the environment is vastly different. As we move ahead, we need to truly examine the course and content of both medical schools and post graduate training in terms of are we actually teaching the material that is relative to the practice.

We will see enormous pressure put on physicians in the next generation of practice. As we critically and honestly evaluate what we have done well, and what we need to improve, we need to apply these three questions. Bottom line, are we selecting, training and monitoring in a way that optimizes the practice of medicine, and ultimately optimizes the delivery of Value to our patients: outstanding quality, patient experience, and cost-effectiveness.

3 responses to “Ensuring Competent Physicians- Three Critical Questions in the Medical Education Process”

  1. Steve. Great questions. The effectiveness of medical training is arguably one of the least studied essential aspects of medicine. In fact the best thoughts on this hold that it should be conceived of more broadly as Health Care WORKFORCE Training ( see Health Affairs from about a year ago). Without great evidence, we should not feel compelled to hold onto the status quo ( which by the way , now includes the unsubstantiated belief that it is a good option for primary care physicians to just do ambulatory work – a topic for another time). Your larger theme, the questioning of the status quo in medical education is critically important. There are enough compelling reasons ( if not yet grade A evidence) to move toward team based training.

    However the well entrenched structures of health care training in all professions are THE most formidable obstacles. If some higher body required Team based knowledge and experience for certification and recertification, perhaps there would be some movement ( in fact team based recertification/test taking would mitigate your concern about esoteric questions in that some member of a team caring for a select population of patients should know the answer to the ICU question- certainly is the case for the population of patients in our FQHC practice) . But the “powers that be” are not going to go away ( or even budge) without a fight.

    • You are spot on in your remarks. There is a huge existing infrastructure in the medical education world, and like any hierarchy, the first priority of the hierarchy is to preserve that hierarchy.

      I believe we really need to revisit the entire spectrum of medical education with the outcomes in mind, not the processes. Bottom line- our most important outcome is how do we train and maintain the most competent physicians that we can.

      David, thank you again for your comments and I am very interested in what others may have to say.

  2. I am one of the many who is going through the application process right now. I have taken the MCAT, and I’m getting ready to start filling out all of the paperwork. I have wondered about question 2 a lot of times through the process. It will be interesting to see how interviews go.

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