Having had the privilege of directing two university hospital-based psychiatry residency programs over a 24-year period (1987–2011), first at Boston's Beth Israel Hospital and then the Harvard Longwood Psychiatry Residency, I have witnessed many changes in residency education. Most of these have reflected the evolution of residency from a “clinical apprenticeship” model to a highly-regulated “professional education” model of clinical and non-clinical learning experiences in response to the changing accreditation requirements of the Accreditation Council for Graduate Medical Education (ACGME) and its Residency Review Committees (RRCs). I will describe some of these changes, their impact on residents, faculty, and residency program directors, and their implications for the future. These descriptions are based upon my reading of the literature, observation of the faculty and residents in the program I directed, as well as what I have learned from countless conversations and meetings with fellow training directors over the years.
During the 1980s, in his annual welcoming letter to incoming and newly-promoted house officers, the then-President and CEO of Beth Israel Hospital would typically tell residents “…we use a simple guide for these times — two questions only need to be asked, in the following order: How can we help the patient? In doing so, what can we learn?” This statement evokes a simpler time when residents and faculty alike had the relatively straightforward notion that a resident’s primary role was to take care of patients within an apprenticeship model. Residents worked long hours, evaluated and treated many patients, and at times also performed some non-professional tasks (such as blood-drawing, performing simple laboratory tests, and transporting patients) when others were unavailable. In return for their considerable efforts, residents were provided the opportunity to observe, work closely with and be taught by more-senior residents, attending physicians, and non-physician colleagues, and thereby learn how to be competent clinicians.
Today, the ACGME describes residency as “an essential dimension of the transformation of the medical student to the independent practitioner along the continuum of medical education” (1). Residents are now learners engaged in this process and are no longer principally defined as physicians or clinicians, with the previous “deal” of hard clinical work in exchange for education no longer in place. The details of the current model are then prescribed by the ACGME’s RRCs in their specialty-specific “Program Requirements,” as are the roles of the program director, teaching faculty, and residents. Thomas J. Nasca, M.D., CEO of the ACGME, recently summarized the work of that organization over the past 30 years as follows:
When the ACGME was established, in 1981, the GME environment was facing two major stresses: variability in the quality of resident education and the emerging formalization of subspecialty education. In response, the ACGME's approach emphasized program structure, increased the amount and quality of formal teaching, fostered a balance between service and education, promoted resident evaluation and feedback, and required financial and benefit support for trainees. These dimensions were incorporated into program requirements that became increasingly more specific during the next 30 years (2).
Although this statement reflects the important work of the ACGME in trying to ensure greater uniformity in the structure and quality of resident education, it only hints at the detailed specificity of these requirements. Table 1 is a partial list of the current program requirement domains for psychiatry residency, which fill 35 printed pages (3). These requirements have had enormous impact on most aspects of residency training today.
The multitude of ACGME requirements has greatly affected the role of the program director. The requirements state that the director's role is “to administer and maintain an educational environment conducive to educating the residents in each of the ACGME competency areas,” but, remarkably, among the approximately two dozen program director’s responsibilities delineated in the requirements, the words “teach,” “teacher,” “mentor,” or “mentorship” do not appear (3). The best directors still try to find time to teach, mentor, and innovate, but this is the “icing,” with “the cake” being program administration. Program directors have increasingly become administrative-compliance officers whose first duty is to see that their programs are in compliance with the ever-growing number of requirements.
Ensuring compliance with the specific requirements consumes considerable time, effort, and resources of both the program and program director. As delineated in Table 1, formal structures must be in place to recruit, appoint, and credential residents, evaluate their work on every clinical rotation, and have them regularly meet with the program director to review their progress. Faculty members must be evaluated by the residents they supervise and teach, and receive annual reviews. The program must evaluate itself based on formal resident and faculty input, including the results of the annual ACGME survey of residents, and then implement an action plan to address areas of concern. Required clinical rotations, research opportunities, and a schedule of didactic courses and conferences must be put in place, coordinated, and evaluated to help residents achieve competency in the ACGME’s six core areas. Several ongoing residency committees are required, including an education committee to oversee the entire program and other committees to monitor the progress and promotion of residents, the assignments and adequacy of teaching faculty, resident selection, and the residency curriculum. Residents participate in some of these committees, and the resident group also may have its own committees. Policies and procedures to govern all of the above must be in place and distributed to all residents and faculty routinely. Moreover, compliance with all of these requirements must be well documented.
Nasca et al. also acknowledge adverse consequences of the current accreditation requirements, as follows:
“… success has come at a cost. Program requirements have become prescriptive, and opportunities for innovation have progressively disappeared. As administrative burdens have grown, program directors have been forced to manage programs rather than mentor residents, with a recent study reporting administrative tasks related to compliance as a factor in burnout among directors of anesthesiology programs (2).”
As recent American Association of Directors of Psychiatric Residency Training list-serve discussions demonstrate, the compliance aspects of their role sit uneasily with many program directors, who chose that role because of their interest in teaching, mentorship, and educational innovation, but feel frustrated by the lack of time and resources to pursue these things. Program directors complain about the administrative burdens of their position, and some do not see the value of many ACGME requirements, regarding them as ”unfunded mandates” that lack good evidence of bringing about improved quality of training or better preparation of graduates for clinical practice. In recent correspondence in The New England Journal of Medicine, authors have questioned the evidence supporting ACGME’s claims that its standards have either led to outcomes that have improved the quality of residency graduates and the care they provide to the public or are worth the associated costs of their implementation (4, 5).
The increased requirements have also greatly affected the role of the resident, who is no longer in residency primarily to “help the patient… (and) in doing so…learn.” The clinical aspects of the resident’s role are in part limited by the requirement that “Faculty members functioning as supervising physicians should delegate portions of care to residents, based on the needs of the patient and the skills of the residents (3).” Today, the resident is rarely “the patient's doctor;” rather he or she is a junior member of a team of physicians caring for the patient, with the resident never fully “owning” the care of the patient.
The resident’s role is to participate in all aspects of the multifaceted training program, only one component of which is patient care. Residents are required to prepare for and attend classes, attend grand rounds and other conferences, become involved in psychiatric research, participate in both residency and hospital committees, comply with duty-hours, and take part in many other nonclinical activities—leaving them considerably less time to spend with patients. Under current ACGME rules, residents still work long hours, but are also required to be in classes and conferences (from several hours up to the equivalent of 1 day per week) and also to leave the hospital after taking call to comply with duty-hour requirements. These, and other requirements, result in residents’ being on their clinical services far less than full time and, in some cases, only half the week’s workdays. Because they are often unavailable for clinical care, they are sometimes (wrongly) viewed by others on the care team as less than fully committed and incapable of being central to the care of patients because of the discontinuous nature of their role. This tension leaves many residents feeling uneasy, devalued, and torn between conflicting activities, even if the requirements of the program are clearly defined. Hoop has noted that such “conflicting loyalties” during residency are “ethically thorny,” and add to the stress of residency (6).
Residents also are increasingly in the role of “consumers” of residency education. They complete an annual anonymous ACGME survey that covers a range of issues, including duty-hour compliance, supervision, evaluation, educational content of the program, the relative emphasis of service versus education, patient safety, teamwork, etc.
The tension between the resident’s roles as student and clinician is brought home powerfully in two 2011 survey questions, which ask “How often do your rotations and other major assignments provide an appropriate balance between your residency education and other clinical demands?” and “How often has your clinical education been compromised by excessive service obligations?” Although the survey may help to detect excessive use of residents to meet hospital clinical service demands, it also implies to residents that time spent caring for patients interferes with their education. This implication is confusing and distressing for many residents and faculty members alike. For this reason, among others, the survey has not been well received by training directors (7).
As residents have become less available clinically, many of their duties have fallen to faculty physicians, who, in some instances, complain, correctly or not, that they work longer hours than the residents and have no duty-hour regulations to protect them. On many inpatient services, residents are viewed as requiring more work and time than their efforts save the attending physicians, and the number of attending physicians on inpatient teaching units usually exceeds that on non-teaching units.
Considerable attention has been paid to the ACGME’s restrictions on duty-hours, initially imposed in 2003, and increased and further elaborated in 2011, which many view as a response to external pressure and fear of governmental takeover of the ACGME’s functions. The 2011 requirements have had enormous impact on what residents do when they are on call and when and how much time they spend in the hospital. These include a maximum 80-hour work week, no more than 16 consecutive hours of patient care for PGY−1 residents and 24 consecutive hours for PGY−2-and-above residents, and specific defined levels of faculty supervision for residents. Also, because of concern about residents’ sleep patterns, “strategic napping” during the clinical-care day is recommended (8); this has led to jokes about the infantalization of residents, who, like babies and young children, must take naps. These restrictions have also required major alterations in rotation schedules, with greater use of night floats, more frequent night call for senior residents, and a greater number of clinical care “handoffs,” which decrease continuity in the care received by individual patients and delivered by residents. These requirements place residents in more student-like roles, in which they are again unable to take ownership of the patient’s care. As a result, residents are less sure of their ability to practice independently upon graduation, which is likely an important contributor to the greatly increased frequency of graduates’ electing post-residency fellowship training. The 2011 requirements about resident hours and roles also have added to the work of the program director, who must find ways to implement an educationally-sound coverage and call system within the duty-hour requirements, determine which residents’ tasks require a given level of supervision, and arrange for different types of supervision to be in place for different-level residents. They must also ensure that residents document their duty-hours and that these hours do not exceed the established limitations.
The new duty-hours regulations have not been warmly received by either training directors or residents. A 2012 national study of over 6,000 residents at 123 institutions surveyed the respondents’ impressions of the new duty-hour regulations after they had been in place for 5–8 months: 27% of the respondents thought patient care was worse; 52.6% thought it unchanged; and only 29.4% thought it was better. Forty-one percent thought that the quality of resident education was worse; 42.8% thought it was unchanged; and only 16.3% thought it was better. Forty-eight percent reported that they disapproved of the regulations; 28.8% were neutral; and only 22.9% approved of these new regulations (9). Another 2012 study looked at the responses of 216 orthopedics residents to the 2003 duty-hour changes in annual surveys from 2003 through 2009. The surveys revealed that, although residents tended to feel less fatigued, they did not get more sleep. They reported perceived improvement in patient safety and quality of care, but also noted a drop in general clinical experience, procedural experience, and a diminished sense of “clinical preparedness” (10). One can hypothesize that faculty impressions of these new regulations would be at least as unenthusiastic as those of the residents, as the latter supposedly have the most to gain from duty-hour restrictions. Although there have yet to be studies of the impact upon and reception by psychiatry residents and faculty of these latest requirements, the response to the more modest 2003 requirements were mixed (11). It appears that the ACGME has not won the confidence of the medical community with these major changes.
In early 2012, the ACGME unveiled its Next Accreditation System (NAS), the aims of which are to “enhance the ability of the peer-review system to prepare physicians for practice in the 21st century, to accelerate the ACGME’s movement toward accreditation on the basis of educational outcomes, and to reduce the burden associated with the current structure- and process-based approach (2).” There will no longer be accreditation site visits every 3 to 5 years, but instead they will occur every 10 years, after an extensive self-study process. Each accredited residency specialty and fellowship subspecialty field is to develop a series of 30–36 educational developmental “milestones” based on the ACGME’s core competencies, upon which residents will be evaluated every 6 months, with the results of these evaluations sent to the ACGME and used as one measure of a program’s success in meeting its educational goals. Over time, those programs that are deemed particularly successful by this process will have other requirements relaxed and be permitted to be more innovative, with the hope that the NAS will require less administrative work for program directors and leave more room for creative educational programs.
It is unclear whether this approach will prove less burdensome to program directors, who will now be required to evaluate their residents’ achievements of milestones and submit reports to ACGME every 6 months. Given that many outcome measures to assess achievement of the required milestones have yet to be developed, it also is unclear how the latter can be used as measures of program quality for accreditation purposes. Also, with individual programs as the assessors of milestone achievement by their own residents, there is concern that programs of marginal quality wishing to continue their accreditation will have an incentive to “pass” their residents and report milestone achievement to the ACGME. Some cynically predict that the most successful program directors of the future may be those who are the best fiction writers, good at reporting milestone attainment, rather than educational leaders, teachers, and mentors, who, by example, model academic and clinical excellence.
Graduate medical education training programs have the societal responsibility to provide sufficient teaching, supervision, and real-life clinical experience to prepare residency graduates for the safe, competent, independent practice of medicine. Although the ACGME initially provided greater consistency in graduate medical education, over the past three decades, requirements and processes have become over-regulated and burdensome, stifling both residents’ patient-care experience and educational innovation. They have decreased the opportunity for residents to benefit from training directors and clinical faculty as teachers, mentors, and role models, while increasing unfunded mandates at a time when resources for GME are shrinking. The growing implied division between educational and clinical activity leaves residents feeling torn and clinical faculty feeling devalued, and the relationship between residents and faculty appears, if anything, less collaborative and convivial than in the recent past. Restrictions on duty-hours, with the resultant need for increased patient-care handoffs, have yet to be shown to improve patient safety, but do decrease the continuity of personal care by resident physicians for their patients and opportunities for residents to gain progressive responsibility and autonomy in patient care. Less time with patients and insufficient independent patient “ownership” experiences during their training lead residents to pursue subspecialty fellowships to solidify their clinical mastery when there is a national need for more generalists, rather than subspecialists. With funding for graduate medical education likely to decrease substantially in the coming years and the aging of the “baby boomers,” this approach to mastering clinical skills will become less sustainable.
The NAS holds out the promise that graduating residents will have met measurable developmental learning milestones, that achievement of the milestones will be one valid measure of program quality worthy of ACGME accreditation, and that, over time, there will be less need for detailed regulation and greater opportunity for innovation and flexibility in the design of residencies. However, directors are appropriately worried about the burden of repeated milestone-testing and the uncertainty that meaningful milestones will be achieved and assessed in a reliable and valid manner.
For now, program directors will need to understand current regulations and address locally the educational challenges they pose to maximize opportunities for their residents’ learning and clinical mastery, sharing best practices with the larger field. They will need to monitor and evaluate the educational costs and benefits of the evolving accreditation system and urge the ACGME to modify and streamline requirements to ensure the quality of resident clinical education. Program directors must also monitor the impact of ACGME requirements on their institutions and faculty to ensure that motivation and commitment to education remain at the highest levels. Together, residency program directors and the ACGME will need to find that regulatory “sweet spot” between the ideal and the “good-enough” necessary to produce competent physicians. We owe this to both our future residents and to the patients they will serve.
The author acknowledges the thoughtful contributions of Jonathan F. Borus, M.D., to this article.