COMMENTARY

What Would You Change About Residency?

Alexa M. Mieses, MD, MPH

Disclosures

June 20, 2019

As a medical trainee, it often feels like we live at the hospital; however, if you were a resident around 100 years ago, that is exactly what you would have done. In fact, that's how residency training was named. Although we no longer literally live where we work, what else is truly all that different about graduate medical education?

Technology has obviously revolutionized medicine and thus medical training. Trainees in the past had some responsibilities that would seem foreign to us today. For example, residents often performed their own manual blood tests. Today we just sign an order, and within hours a result appears in the patient's electronic medical record. Many of us do not even obtain the patient's blood.

Although technology has freed us from some burdens, new ones have emerged. We now have more buttons to click, billing codes to learn, and compliance standards to follow, even if, at times, they seem arbitrary. Technology has improved life expectancy and quality of life for patients while redefining the roles of all members of the healthcare team. It has also been a catalyst for burnout.

Has Medical Education Really Changed That Much?

Maybe medical education hasn't changed as much as we would like to believe. In a piece for JAMA that examined training practices of the past, Eric J. Cassell, MD, reflected on his time as a medical resident in the 1950s. He noted three assumptions from his era that, unfortunately, still have not been completely abolished. These assumptions are (1) that pathophysiologic findings adequately explains a person's illness; (2) that the same disease in different people is still the same disease; and (3) that knowing the science and pathophysiology of a disease means knowing its diagnosis and management. The echoes of these antiquated assumptions still reverberate throughout modern graduate and undergraduate medical education.

So, if you could redesign residency training, what would it look like? The American Medical Association recently awarded $14.4 million to eight projects designed to do exactly this. The grant recipients will attempt to tackle burnout, improve the transition from medical school to residency, and address workforce shortages, among other intended improvements. I am excited to see the impact these ambitious projects may have. As the grant recipients and others work to reimagine a better residency experience, here are the three changes in philosophic approach that I believe would make residency training more worthwhile.

Change 1: Emphasize Population and Public Health

When I first applied to medical school, I intended to become a psychiatrist or pediatrician. I was always interested in considering the entire patient, not just diseases. I was also passionate about advocacy. When I reached medical school, however, I discovered family medicine.

The specialty of family medicine grew out of the social justice movement of the 1960s. Training emphasizes caring for the whole person from "cradle to grave," with special attention to the patient within the context of his or her family and community. Principles of both public and population health are integral to what family medicine physicians do, in addition to clinical medicine. Therefore, the decision to become a family physician was a no-brainer for me. Once I discovered the field, I felt I had found my place.

Even if you are in a field that only studies one age group, sex, or part of the body, a big-picture emphasis on the person as a whole and on the environment is crucial. As Cassell noted, assuming a disease can be treated the same and will behave the same way in all people is flat-out false.

To combat these flawed assumptions, public and population health principles need to be integrated into all medical training, starting in medical school. They should continue to be integrated throughout residency training, no matter the specialty.

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