Michael D. Stillman, MD
This article was published online first at www.annals.org on 8 April 2014.
Disclosures: None. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2358.
Requests for Single Reprints: Michael D. Stillman, MD, Ambulatory Care Building–Ambulatory Internal Medicine Clinic, 550 South Jackson Street, Louisville, KY 40202; e-mail, firstname.lastname@example.org.
Author Contributions: Conception and design: M.D. Stillman.
Drafting of the article: M.D. Stillman.
Critical revision of the article for important intellectual content: M.D. Stillman.
Final approval of the article: M.D. Stillman.
Stillman M.; Training for the 21st Century?. Ann Intern Med. 2014;160:800-801. doi: 10.7326/M13-2358
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Published: Ann Intern Med. 2014;160(11):800-801.
Proposed in 2009, the “milestones” are specialty-specific observable behaviors meant to clarify the Accreditation Council on Graduate Medical Education's (ACGME) 6 core competencies. These competencies—patient care, medical knowledge, professionalism, systems-based practice, practice-based learning, and interpersonal and communication skills—have been deemed essential to medical training and practice yet are difficult to evaluate objectively. Adoption of the more concrete milestones is intended to anchor curricular development, ease trainee remediation, and transform resident assessment from a “process” to a “competency-based” endeavor (1).
The Next Accreditation System (NAS), an ACGME-mandated venture, was introduced in 2012 to move residency program accreditation from episodic evaluation toward continuous self-assessment and improvement (2). Under NAS, programs must submit biannual data confirming that each of their residents is progressing through the milestones and yearly reviews of “key performance measurements.” Well-performing programs will be subject to fewer site visits and program requirements, although it remains unclear which regulations will be loosened.
Thomas Jefferson University
April 8, 2014
I find it supremely ironic that from an organization that espouses the need for a firm evidence base in clinical decision making, we have embarked on radical changes in the education of an entire generation of healthcare providers without a scintilla of evidence that it will improve clinical care or training. In fact my anecdotal impression is that the changes we have already instituted in terms of work- rules for medical trainees has both compromised patient care and the education of our trainees.
James Scheuer MD
Albert Einstein College of Medicine/Montefiore Medical Center
June 11, 2014
Evidence Based Evaluations
To the Editor:The thoughtful comments by Dr. Michael D. Stillman (1) with regard to changes that have been instituted by the ACGME deserve serious consideration.As a former chief of cardiology and chair of medicine, and past leader of several approved training programs, I have been puzzled by some of changes introduced by the ACGME over the last decade or so.Over the time of my career our practice has increasingly become guided by well designed prospective, randomized studies which helped us practice Evidence Based Medicine. Cardiology and Internal Medicine have led the way in developing these tools.My perception is that at the same time the ACGME has imposed their new requirements, virtually bypassing any system to objectively evaluate the changes they promulgated.Leaders of Internal Medicine programs would not accept that kind of process for changing patient care, and should not do so for changing how their trainees and their training programs are evaluated.Obviously, as the structure of medical care evolves alterations in training programs are required. However, these changes should be evaluated with objective tools.Reference:Stillman, M.D., Training for the 21st Century?, Ann Intern Med. 2014; 160(11):800-801James Scheuer, M.D. University Chairman of Medicine Emeritus Distinguished Professor Emeritus, The Albert Einstein College of Medicine/Montefiore Medical Center 111 East 210th Street New York, NY 10467Email: email@example.com
Nayan K. Kothari MD; MACP
Saint Peter's University Hospital
June 27, 2014
To the editor
To the Editor
In the June 3 issue of the Annals, Dr. Stillman raises an important issue about medical training for the 21st century 1. For the past several decades, the internal medicine community has come up with novel ideas which continue to diminish and devalue the core science of internal medicine. It began with the abolition of the clinical examination by the American Board of Internal Medicine. No certifying examination solely can assess the clinical skills of a physician. This important task of assessing clinical skills was delegated to the program directors. Program directors cannot and do not assume this responsibility objectively. Nationwide nearly every candidate is rated clinically competent. In addition, the certifying examination does not challenge the examinees in the basic sciences – a core to the clinical sciences. It is believed by many that a good apprentice can pass this examination with a current pass rate of 85%.
Then came the Competencies. Although they make sense and seem to be noble ideas, they fall short. Four of the six competencies have nothing to do with the science of medicine. In spite of the hyper-emphasis on professionalism and communication skills, there is no evidence that we are producing better communicative professionals.
Then came the Milestones. It is a simplistic notion that residents will behave like babies who develop a predictable, clearly defined, observable, and measurable milestones. The milestones do not stress or highlight the central and essential tenet of clinical medicine – namely clinical reasoning. The excessive emphasis on non-clinical issues devalues the clinical side of medicine. With the milestones driven training, we will produce physicians who understand less about the value of history taking than its price, less about the Starling’s law than about socioeconomics of heart failure, less about performance than about performance measurement. When diabetes, obesity, and metabolic syndrome devastate our population, why is there not a milestone to understand, identify, prevent, and treat these conditions? We need to remind ourselves that a highly professional physician with aspirational qualities in System Based Practice, but lacking medical knowledge and its application (patient care) is a menace to the society, and will be more fit to become an administrator than a compassionate, caring, knowledgeable physician.
The NAS has noble goals and most of the ideas are sound. However, the asymmetric emphasis on non-clinical areas is likely to further downgrade the cerebral nature of our discipline.
1. Stillman MD
Training for the 21st Century
Ann, Intern. Med. 2014: 160; 800-801
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