inpatients and outpatients are discussed in de- tail. This program design ensures exposure to all the key elements of internal medicine in 3 years and should ...
Residency training in internal medicine: program design in an era of constraint Tim W. Meagher, MB, BCh, FRCPC
Directors of postgraduate internal medicine programs face many problems in program design, particularly when numbers of house staff continue to decrease. This paper examines the training requirements of a resident in internal medicine and proposes a curriculum based on set rotations in the three key areas of training subspecialty services, critical care and the clinical teaching unit. The distribution of time in these three areas and the balance of exposure to inpatients and outpatients are discussed in detail. This program design ensures exposure to all the key elements of internal medicine in 3 years and should prevent significant gaps in knowledge at the time of certification. The implications for "service" in major teaching hospitals is discussed. Hospital departments and administrators must confront the prospect of hospital units without house staff. Most important, program directors must resist sacrificing the pedagogic essentials of a training program for service requirements. Tout directeur de formation post-doctorale en medecine interne est confronte a de nombreuses difficultds dans l'etablissement de son programme, vu surtout la diminution du nombre d'internes et de residents. On cerne ici les besoins du rdsident en mddecine interne, et afin d'y subveDr. Meagher is assistant professor of medicine, McGill University, Montreal, and director of the residency training program, Department of Medicine, Montreal General Hospital.
Reprint requests to: Dr. Tim W. Meagher, Montreal General Hospital, Rm. 647, 1650 Cedar Ave., Montreal, PQ H3G 1A4
nir on propose des stages par roulement axes sur trois aspects fondamentaux: sous-spEcialites, soin des grands malades et le service d'enseignement clinique. On decrit en detail l'emploi du temps devolu a ces trois domaines et du temps consacre au contact avec des malades internes et externes. On s'assure de la sorte qu'en 3 ans le resident sera mis au courant de toutes les questions-clEs de la medecine interne et qu'au moment de passer l'examen du certificat il n'y aura pas de trous serieux dans ses connaissances. Quant aux exigences du soin des malades dans les hopitaux universitaires, il faut d'ores et dejk qu'administrateurs et chefs de departements envisagent l'dventualitE de services sans residents. C'est au directeur du programme d'empecher qu'on sacrifie les exigences de la formation k celles du soin des malades. anadian residency training programs in internal medicine are being constricted by the decreasing numbers of residents in specialty training. The dilemma for many institutions that' have traditionally relied on resident house staff for day-to-day patient care is the dramatic reorganization of the fashion in which this care is administered. It is important to resist the tendency to spread house staff ever more thinly in an effort to maintain "service" while sacrificing the pedagogic ideals of a training program. It is therefore appropriate to look at these ideals and attempt to design a residency program that is not susceptible to fluxes in numbers of house staff and that preserves pedagogic standards irrespective of the numbers. Although the ultimate goal of a residency training program is to produce a well-rounded, CMAJ, VOL. 138, APRIL 15, 1988
competent and empathetic internist, the ideal program with which to pursue such a goal has not been described in detail. The Royal College of Physicians and Surgeons of Canada' and the American College of Graduate Medical Education (ACGME)2 have provided broad guidelines, but how time should be spent from month to month during a 3-year program remains unclear. The ACGME,2 for example, has made the following observations. The ability to care for a wide range of clinical problems is one of the distinguishing characteristics of the internist; therefore ample opportunity for education in the broad field of internal medicine must be provided. The experience is fostered by rotations on several medical services, both inpatient and outpatient, with exposure to a wide spectrum of disease. Inpatient service assignments in which the resident has a meaningful responsibility must provide a substantial majority of a resident's clinical experience. . Education in the various subspecialty divisions of internal medicine is a vital part of the training program.- Most rotations on these subspecialties should be of at least 4 to 8 weeks' duration. Although it is not necessary that each resident rotate through formal subspecialty electives in all these areas, it is important that there be exposure to the specialized knowledge and methods of a sufficient number of the recognized medical subspecialties to gain experience with their contributions to the effective care of patients.... To achieve breadth of competence experience should be available in areas related to intemal medicine such as neurology, psychiatry and dermatology. Experience in medical ophthalmology, otolaryngology, non-operative orthopedics and office gynecology are also highly desirable.
Many training programs are "service driven" that is, allocation of house staff at the time of making schedules is governed by the "fill-in-allthe-holes" principle, which ensures that all patient care areas are fully staffed and that important subspecialties (usually those that shout loudest) receive a full complement of residents. This arrangement is often not in the best interest of a trainee and may result in uneven training, wherein some disciplines are overrepresented and others receive inadequate exposure. Recent reductions in the number of training posts for intemal medicine have led us to re-evaluate our postgraduate medical education program in light of fewer trainees, the pedagogic needs of the trainees and the service requirements of our hospital. To better understand our proposals I will briefly describe the main components of the residency training program at our hospital, which can be divided into three areas of rotation: subspecialty, critical care and dinical teaching. The first rotation includes time in subspecialty services, wherein the trainee usually has contact with both inpatients and outpatients. The critical care rotation includes time in intensive and coronary care units and the emergency department. The third rotation, in a clinical teaching unit, includes time on 35-bed general medical wards staffed by one or -
CMAJ, VOL. 138, APRIL 15, 1988
two attending staff, one third-year resident, one second-year resident, two intems and two medical students.
Subspecialty services Our first proposal for the redesigned program is that each trainee should receive exposure to all important subspecialty areas during the core 3-year program. These areas include cardiology, dermatology, endocrinology, gastroenterology, hematology, immunology and rheumatology, infectious diseases, internal medicine (i.e., general medical consultation on surgical services), nephrology, neurology, oncology and respirology. Gynecology, ophthalmology, orthopedics, radiology and tropical medicine are not considered essential in the rotations, but a trainee can rotate through three of these areas as well as one other area of choice during the 3 years. The members of our Residency Training Committee consider these subspecialties to represent the most important fields for a general internist. The choices, though arbitrary, are thought to be appropriate for an internal medicine practice in North America. The distribution of time for each subspecialty rotation is shown in Table I. Rotations are in blocks of 4 or occasionally 6 weeks, which allows 12 rotations per year plus a 4-week vacation, and are rounded off into 4-week intervals to interface with the undergraduate teaching program, attending staff schedules and subspecialty division schedules. Although our committee prefers rotations of more variable length the overall conTable - - Allocation of time to subspecialty rotatioc31m. including suggested percentage of tirne Si otUtpat'e.v.! clinics &~Tjp
Cardiologiy Dermatology Endocrinology
Gastroenterologqv Hematology immunology and rheumatology
Infectious diseases Internal medicine
Nephrology Neurology Oncology Respirology
4 4 L/
Gynecology ophthalmology orthopedics, radiology. tropical medicine Other Total
straints of time and program design do not, with some exceptions, allow variation from the single 4-week block. The amount of time in each subspecialty is decided by several variables: the prevalence of problems in that subspecialty in a general internal medicine practice in North America, the likelihood that knowledge in that area will not be gained from a rotation in general medicine, and the importance of close supervision by subspecialists for the acquisition of both knowledge and skill in a specific field. Some disciplines, such as dermatology, lend themselves almost entirely to outpatient experience, whereas others, such as infectious diseases, are more appropriately learned from dealing with inpatients (Table I). In determining the amount of time a trainee should spend in an outpatient clinic our committee attempted to answer the question Can a trainee become competent in a particular field by exposure to only an inpatient population or are some of the knowledge and skills of that subspecialty better acquired from dealing with outpatients? No time has been allocated for a research elective. We decided that any research should be carried out concurrently with other elements of the training program. At our hospital all house staff, with help from members of the Residency Research Committee, choose a research project during the second year of training; the project should be completed by the end of the third year, in time for presentation on Residents' Research Day. Throughout the 3-year program each trainee is committed to spending half a day a week in a general medicine ambulatory care clinic irrespective of the rotation he or she is in. This complies with the recommendations of the ACGME.
Critical care and the clinical teaching unit Our second proposal is that the balance of during the 3-year program be divided between the three critical care areas - the intensive care unit, the coronary care unit and the emergency department - and the general medicine clinical teaching units (Table II). The optimal time in the
Table II rotation
Breakdown of 3-year program by type of Time
Subspecialty As in Table Critical care Intensive care unit Coronary care unit
Emergency department Clinical teaching unit Total
64 8 4 16 52
critical care areas is deemed to be seven 4-week
periods - two in the intensive care unit, one in the
coronary care unit and four in the emergency
department. The time allocation for critical care training should reflect its value in clinical practice. The allocation of seven periods is, once again, arbitrary, but it reflects our bias regarding the time, required to develop an acceptable level of competence in handling critically ill patients. The balance of the 3-year program, 13 periods, is to be spent in general medicine clinical teaching units. The clinical teaching units in such a system should be general medicine units. Patients should come from many places, such as the emergency department, the intensive care unit, the coronary care unit, surgical services and secondary care institutions. Subspecialty services may be represented in different units, but an abundance of subspecialty beds in any one unit should be avoided. What balance should exist becomes arbi-
trary; indeed, the members of the committee were at times divided as to what was the appropriate
number of subspecialty beds per clinical teaching unit. The final compromise was that no more than one third of the beds in a clinical teaching unit would be reserved for subspecialties. It was also agreed that the specialty beds in each unit should be divided between one or more subspecialties, hence preserving the general spirit of the clinical teaching unit, preventing the unit from being known as a "GI ward" or an "oncology ward" and making power struggles between special interest groups less likely to occur. Clinical teaching units should be staffed by residents at three different levels of training. Interns and medical students are responsible for history-taking and physical examination at the time of admission and for the day-to-day care of all patients. Second-year residents supervise the work of the interns and medical students, review all new cases and are familiar with all decisions about patient care in the unit. Third-year residents have a more advisory function, becoming involved in more complex patient problems and having a specific role in the welfare of the medical students. They are also responsible for researching the challenging and contentious areas of patient management and for organizing teaching sessions for junior house staff. The deletion of any one level of training in such a structure alters significantly the educational value of the other levels of training. For these reasons we feel that such a hierarchy is essential. The appointment of unit directors to teach house staff and monitor the clinical teaching unit's activities is an advantage in units with an optimal patient mix.
Discussion The proposals I have outlined were approved by the department chairman, divisional directors CMAJ, VOL. 138, APRIL 15, 1988
and teaching faculty and were implemented as of July 1, 1987. Because of a sharp reduction in the number of house staff at our institution the immediate implication of this restructured training program was a 30% reduction in the number of clinical teaching units. Indeed, continuing decreases in house staff numbers will require us to re-evaluate annually the program and its impact on hospital services. The implications for the subspecialty services are generally positive, in that trainees will now be spending more elective periods in subspecialty areas. However, if the number of residents continues to decrease, even with the increased number of subspecialty rotations the subspecialty services will be adversely affected, and the burden of service will fall on attending staff. The clinical teaching units that no longer have house staff will now be operated primarily by attending physicians. Since attending staff in teaching institutions usually have many other responsibilities, such as teaching, research and administration, this additional load may significantly compromise the staff's function. Our interim solution is to admit to the units without house staff patients who require less physician involvement - for example, those undergoing cardiac catheterization or receiving chemotherapy. However, this is obviously not a definitive solution. To maintain quality of care, teaching hospitals have to seriously consider hiring new attending staff who are committed to patient care and have no other responsibilities. As the numbers of house staff continue to decrease more units will require new staff. To expect the present attending staff to fill the breach is unrealistic. To spread house staff more thinly, sacrificing pedagogic ideals, is equally unrealistic and should be resisted strongly by program directors. In summary, our new program design ensures that all trainees acquire similar training, prevents large gaps in knowledge and exposure, avoids situations in which programs must be compromised because of "service requirements" and should produce better trained internists. With fewer house staff serious problems in patient care are created that must be addressed by both attending staff and hospital administrators.
I thank Dr. Peter J. McLeod for his helpful criticism and the members of Montreal General Hospital's Residency Training Committee for their deliberations.
Oct. 2, 1988: 3rd Annual Conference on Physician Manpower H6tel Meridien, Montreal Abstract deadline is May 13, 1988. Eva Ryten, Association of Canadian Medical Colleges, 1006-151 Slater St., Ottawa, Ont. KlP 5N1; (613) 237-0070
References 1. Royal College of Physicians and Surgeons of Canada: Specialty Training Requirements in Internal Medicine, Ottawa, 1985: 1-2
2. Essentials of accredited residencies in graduate medical education (July 1, 1982). In The Directory of Residency Training Programs (1985-86), Am Med Assoc, Chicago, 1986: 35-36 708
CMAJ, VOL. 138, APRIL 15, 1988
continued from page 704 July 2-6, 1988: 65th Annual Meeting of the Canadian Paediatric Society Palliser Hotel, Calgary Dr. Victor Marchessault, executive vice-president, Canadian Paediatric Society, 401 Smyth Rd., Ottawa, Ont. K1H 8L1; (613) 737-2728 July 4-7, 1988: 79th Annual Conference of the Canadian Public Health Association Loews Le Concorde, Quebec Conference Division, Canadian Public Health Association, 210-1335 Carling Ave., Ottawa, Ont. K1Z 8N8; (613) 725-3769
July 6-9, 1988: Laser Surgery in Gynecology and Dermatology King Edward Hotel, Toronto Mary Ann Riopelle, Biomedical Communications, PO Box 224, Komoka, Ont. NOL 1RO; (519) 471-0300 July 30-Aug. 2, 1988: Health Effects of Fish and Fish Oils Hotel Newfoundland, St. John's Dr. R.K. Chandra, Janeway Child Health Centre, St. John's, Nfld. AlA 1R8; or Mrs. Enid O'Brien (709) 778-4519 Aug. 8-10, 1988: 14th Annual Health Administration Forum Royal Ottawa Hospital Jehaangir Bulsara, forum coordinator, Program in Health Administration, Rm. 255F, Vanier Hall, University of Ottawa, Ottawa, Ont. KlN 6N5; (613) 564-7017 or 837-7506
Aug. 25-26, 1988: The Power of Influence - Implementing Organizational Effectiveness in Health Care Royal York Hotel, Toronto Conference and Seminar Services, Humber College, 205 Humber College Blvd., Etobicoke, Ont. M9W 5L7; (416) 675-5077, FAX (416) 675-1483
Sept. 18-20, 1988: National Conference on Implications of AIDS for Health Institutions Holiday Inn Downtown, Toronto Canadian Hospital Association, Education Department, 100-17 York St., Ottawa, Ont. KlN 9J6; (613) 238-8005
Oct. 3-4, 1988: Annual Meeting of the Association of Canadian Medical Colleges and the Association of Canadian Teaching Hospitals Hotel Meridien, Montreal Janet Watt-Lafleur, executive secretary, Association of Canadian Medical Colleges, 1006-151 Slater St., Ottawa, Ont. K1P 5N1; (613) 237-0070