Residents prepare for switch to competency-based medical education

[bloh]

 

Does (doing a poor job at) 100 appy's mean you can do them on your own? What about the superstar who has the technique down after 12? You don't really need to see the next 88.

 

You typically try to get your numbers up to see what happens when **** hits the fan, which rarely happens in the first 12 procedures.

[BoyInTheBubble]

You typically try to get your numbers up to see what happens when **** hits the fan, which rarely happens in the first 12 procedures.

 

I made up those numbers to illustrate the point.

 

The idea is that you are competent to handle the case, whether it goes smooth or the poop hits the metaphorical fan. The number is irrelevant.

 

In the current system, if you hit the target number of cases, it assumed that you went through all varieties of cases and developed the skills along the way. So that after "100 appys" you will be good enough. (Again, made up number.)

 

Pick anything and apply it, eg how to manage CHF, hemicolectomy, LP, central line, or do a stroke protocol. The goal isn't "100 cases" because it's a high number, the numbers (whatever they are in each residency) are picked because it's assumed that's how many residents should do to become competent.

 

It's a fundamental shift in the educational model. It's clever, but how it will be implemented across the board is the unknown. During the transition years, I agree with the other posters' that residents will "compete for cases". However, they will be doing it under the assumption that doing more prepares them better, and thus applying the old model's strategy - get a specific volume - to the new model. This will create unnecessary havoc.

[BoyInTheBubble]

'More' does prepare you better.

 

But again, doing more for the sake of higher volume is not the goal. Use residency to learn skills for independent practice. Once you get the skills, you don't need to keep reinforcing your ego - you need to sit the exam and start your actual career.

[rmorelan]

I made up those numbers to illustrate the point.

 

The idea is that you are competent to handle the case, whether it goes smooth or the poop hits the metaphorical fan. The number is irrelevant.

 

In the current system, if you hit the target number of cases, it assumed that you went through all varieties of cases and developed the skills along the way. So that after "100 appys" you will be good enough. (Again, made up number.)

 

Pick anything and apply it, eg how to manage CHF, hemicolectomy, LP, central line, or do a stroke protocol. The goal isn't "100 cases" because it's a high number, the numbers (whatever they are in each residency) are picked because it's assumed that's how many residents should do to become competent.

 

It's a fundamental shift in the educational model. It's clever, but how it will be implemented across the board is the unknown. During the transition years, I agree with the other posters' that residents will "compete for cases". However, they will be doing it under the assumption that doing more prepares them better, and thus applying the old model's strategy - get a specific volume - to the new model. This will create unnecessary havoc.

 

Related tot this - I always though of it as it wasn't the number to be competent really but rather balancing the odds that you will have seen enough crap "hit the fan" by shear luck and repetition. It is how you handle things in those situations that matter - demonstrating a perfect operation under normal conditions doesn't impress me as true competence.

[BoyInTheBubble]

Related tot this - I always though of it as it wasn't the number to be competent really but rather balancing the odds that you will have seen enough crap "hit the fan" by shear luck and repetition. It is how you handle things in those situations that matter - demonstrating a perfect operation under normal conditions doesn't impress me as true competence.

 

 

"Come to Ottawa Radiology, you'll get lucky enough to see all the good scans!"

 

I'm going to assume that's not why you went there. You do not design a curriculum with "shear luck" being one of the assets all the learners depend on.

[rmorelan]

"Come to Ottawa Radiology, you'll get lucky enough to see all the good scans!"

 

I'm going to assume that's not why you went there. You do not design a curriculum with "shear luck" being one of the assets all the learners depend on.

 

well no of course not - but to a point "luck" plays a role. You have to work through complications, unusual anatomy, and combinations of co-morbidities etc. When those present are somewhat random and extremely difficult to simulate - will you know when you will have a call shift and that AAA repair needs to be done in an emergency situation? Will also residents have exact exposure to AAA repairs as a result. You cannot completely standardize any training program either as a result - I really think to a limited extent they make timelines as long as they do just to partially even out randomness.

 

You here residents all the time taking about "good case loads" "good exposure to interesting cases" "hands on opportunities" etc - basically to what degree you practise and gain experience - to be around long enough that number comes up and you do everything that you need to do.

[NLengr]

The other thing for surgery is when **** hits the fan, the staff are extremely quick to take full control and switch out of teaching mode. In a way, you never really learn how to deal with disaster by yourself until you are also staff.

[BoyInTheBubble]

well no of course not - but to a point "luck" plays a role. You have to work through complications, unusual anatomy, and combinations of co-morbidities etc. When those present are somewhat random and extremely difficult to simulate - will you know when you will have a call shift and that AAA repair needs to be done in an emergency situation? Will also residents have exact exposure to AAA repairs as a result. You cannot completely standardize any training program either as a result - I really think to a limited extent they make timelines as long as they do just to partially even out randomness.

 

You here residents all the time taking about "good case loads" "good exposure to interesting cases" "hands on opportunities" etc - basically to what degree you practise and gain experience - to be around long enough that number comes up and you do everything that you need to do.

 

I agree with your final paragraph and that's where competency based education comes in. You do the cases until you have done "everything you need to do", 5 years is irrelevant. If it takes you 7 years to achieve that case load, then you probably did something wrong, but residents should stay training until they have seen that many cases.

 

The 5 year program is likely more about maintaining traditional prestige than randomness.

[BoyInTheBubble]

The other thing for surgery is when **** hits the fan, the staff are extremely quick to take full control and switch out of teaching mode. In a way, you never really learn how to deal with disaster by yourself until you are also staff.

 

Agreed.

 

Regardless of how long you train, the first time things go poorly and you're the one responsible, it is going to be nerve racking. You'll likely wonder if you are doing the right thing, etc etc (you probably are because residency is rigorous, but it might not feel that way...)

[fugacity]

What I fear is that there will not be clearly set guidelines that list the "competencies" one needs to have. This opens doors for attending physicians to keep residents longer and pay them less while they are in fact fully qualified attending physicians themselves. For example, in the lab I worked at, many required 7-8 years before they obtained their Ph. D.s while having published numerous significant articles. This was allowed because the PI had the power to make them stay as long as he wished.

 

The money saved could be used to reduce the cost of health care in Canada, but more likely it will allow current attending physicians to be paid more to "make up" for time lost in longer residencies.

[lalab]

Will this policy affect mat leave more than the current system does?

 

Would a period of say 4 months missed due to mat leave qualify as having to make up with an extra year?

 

(I actually wasn't clear on the current policy's language how it works - I know the resident is expected to make up the time but does it mean still being able to graduate with their PGY peers or staying behind?)

[NLengr]

Will this policy affect mat leave more than the current system does?

 

Would a period of say 4 months missed due to mat leave qualify as having to make up with an extra year?

 

(I actually wasn't clear on the current policy's language how it works - I know the resident is expected to make up the time but does it mean still being able to graduate with their PGY peers or staying behind?)

 

It's actually university specific for having to make up time. Technically, the royal college says you can miss something like 3 months and as long as your program says you are competent you are allowed to write the exam.

 

Some universities, wanting to make sure they extract the full amount of slave labour from each person, have blanket policies that say you need to make up ALL time missed, even if you just took a week of leave, despite the fact you have passed your Royal College (and therefore are obviously fully trained). I'll bite my tongue as to what I think of those policies besides saying that I think it's extremely petty.

[lalab]

Some universities, wanting to make sure they extract the full amount of slave labour from each person, have blanket policies that say you need to make up ALL time missed, even if you just took a week of leave, despite the fact you have passed your Royal College (and therefore are obviously fully trained). I'll bite my tongue as to what I think of those policies besides saying that I think it's extremely petty.

 

Thanks for the info. Curious as to how (if) practice of this will change with the new residency evals.

 

Shouldn't change too much I think.

[NLengr]

I don't see why it would change.

[AtomSmasher19]

LOL!

 

I second Leon's interpretation. When is someone technically "done"? According to this model, that day may never come.

 

It's no coincidence that this comes after work-hour restriction controversies.

 

Residencies are going to be longer. Full stop.

 

I guess the term "permanent resident" may soon have another meaning. How will these guys fill out their tax returns now?

 

Sounds like a great opportunity for the CFPC to give themselves the 3rd year of FP residency they've been begging for. (I haven't been following them, but last I heard is that they want to bring back the general internship year.)

[rmorelan]

Sounds like a great opportunity for the CFPC to give themselves the 3rd year of FP residency they've been begging for. (I haven't been following them, but last I heard is that they want to bring back the general internship year.)

 

Really - they were the ones that killed that in the first place

[AtomSmasher19]

Really - they were the ones that killed that in the first place

 

A few months ago I heard some things about them wanting to bring it back again, making FM a 3 year residency.

[ChemPetE]

I heard that they wanted to make FM a three year residency program as well, however I was not sure if that was through an intern year or just extending it to a three year program (not that it's much different). Requiring an intern year and going through a second round of carms to match to a specialty would be an improvement on things, I think, although that would likely be a long shot.

[BoyInTheBubble]

A few months ago I heard some things about them wanting to bring it back again, making FM a 3 year residency.

 

How do you define an intern year?

 

An intern year in countries that have it, mostly UK style training, allows you to get a general medical license. Doesn't offer much besides the ability to continue working but says nothing about your training - eg surgical, IM, whatever.

 

If you just mean a year of rotating through various fields, well the majority of programs already do that.

 

The CFPC is considering making the residency three years but it has nothing to do with an internship. It has to do with the volume of knowledge and skills required to be a comprehensive family doctor. The PGY3 programs were designed to help residents (or family doctors in practice) develop a BROADER skillset. The PGY3 programs are used currently to develop skills in a specific area and decreased the amount of generalism, as they have a "special interest or focused practice", and they work in ER or sports med and ignore general family medicine.

 

The current training is the shortest in the world. Many (maybe most?) programs in the USA are transferring from 3 years to 4 years. UK and Aus/NZ takes 4 years plus however it takes you to join the program (after completing the internship).

 

So intern year? no. Three year program? Expect it to happen eventually.