Closing the gap between internal medicine training and practice: Recommendations from recent graduates

Abstract

The current training system for internal medicine has failed to evolve to reflect the changing practice of internal medicine. This has led to a "training-practice gap," a term that highlights the discrepancy between residency training and the practice of internal medicine in the 21st century. One reason for this gap is that current residency training protects the "Oslerian-generalist" model.1Huddle T.S. Centor R. Heudebert G.R. American internal medicine in the 21st century can an Oslerian generalism survive?.J Gen Intern Med. 2003; 18: 764-767Crossref PubMed Scopus (20) Google Scholar In honor of namesake Dr. William Osler, this model defines a breed of internist whose skills on hospital wards and in the office were enriched by experience in clinical and laboratory investigation. The "Oslerian-generalist," although philosophically appealing and unquestionably honorable, is not supported today in an environment of cost-containment, specialization, and increasing medical knowledge and technological advancement.2Young D.W. Saltman R.B. Medical practice, case mix, and cost containment a new role for the attending physician.JAMA. 1982; 247: 801-805Crossref PubMed Scopus (16) Google Scholar, 3Leitman R. Taylor H. Edwards J.N. Physicians' responses to their changing environment.J Am Health Policy. 1992; 2: 35-39PubMed Google Scholar, 4Ramsey Jr, C.N. Revolution in real time. Physician practice management in the 21st century.Arch Fam Med. 1992; 1: 139-148Crossref PubMed Scopus (8) Google Scholar, 5Schneider E.C. Eisenberg J.M. Strategies and methods for aligning current and best medical practices. The role of information technologies.West J Med. 1998; 168: 311-318PubMed Google Scholar As the practice of internal medicine has evolved to meet these demands of the US health care system, internal medicine training has been slow to evolve, resulting in this "training-practice gap." Another important cause of this gap is that internal medicine residency training programs continue to serve as the sole provider of care for diverse, underserved patients in academic teaching hospitals.6Reynolds P.P. Professionalism and residency reform.Acad Med. 1991; 67: 369-377Google Scholar This service obligation is often paired with another main core tenet for academic teaching hospitals, the teaching and training of residents. The familiar statement, "every patient is a great teaching case," justifies this uneasy marriage of service and graduate medical education. In fact, service and training are so intertwined that the major driving force for internal medicine residency proliferation was to meet the service needs of academic teaching hospitals in the late 1970s and early 1980s.7Butler P.W. Bentley J.D. Knapp R.M. Today's teaching hospitals old stereotypes and new realities.Ann Intern Med. 1980; 93: 614-618Crossref PubMed Scopus (10) Google Scholar This partnership was stressed with the Balanced Budget Act of 1997, which capped resident slots to a portion of the available beds per teaching hospital.8Council on Graduate Medical EducationThe Effects of the Balanced Budget Act of 1997 on Graduate Medical Education. 2004Google Scholar Due to this act, teaching hospitals were forced to rely on a fixed number of residents to provide care for an increasingly ill hospital population in an era that rewards short lengths of stay. As a result, workload per resident increased and the bulk of resident time was spent in inpatient service for academic teaching hospitals. This increased workload is a recognized factor in resident burnout, and consequently, the resulting erosion of professional behavior in the face of continued patient care.9Thomas N.K. Resident burnout.JAMA. 2004; 292: 2880-2889Crossref PubMed Scopus (679) Google Scholar, 10Mareiniss D.P. Decreasing GME training stress to foster residents' professionalism.Acad Med. 2004; 79: 825-831Crossref PubMed Scopus (45) Google Scholar More recently, the movement in health care quality and safety, borne out of a series of landmark studies and reports, is changing the practice of medicine.11Kohn L.T. Corrigan J.M. Donaldson M.S. To Err Is Human Building a Safer Health System. National Academy Press, Washington, DC2000Google Scholar, 12Committee on the Quality of Healthcare in AmericaCrossing the Quality Chasm. National Academy Press, Washington, DC2001Google Scholar Pay-for-performance and other incentive-based improvement programs at both individual and institutional levels are being utilized and sponsored by several organizations.13Corrigan K. Ryan R.H. New reimbursement models reward clinical excellence.Healthc Financ Manage. 2004; 58: 88-92PubMed Google Scholar Moreover, structural changes in delivery of services, such as chronic disease management, and technological innovations, such as physician order entry and decision support, have been espoused as valuable tools in improving quality and safety for hospitalized patients.14Ofman J.J. Badamgarav E. Henning J.M. et al.Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review.Am J Med. 2004; 117: 182-192Abstract Full Text Full Text PDF PubMed Scopus (235) Google Scholar, 15Bates D.W. Leape L.L. 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Quality of care and quality of training a shared vision for internal medicine?.Ann Intern Med. 2004; 140: 927-928Crossref PubMed Scopus (9) Google Scholar Although it is widely accepted that training in these skills is needed, medical educators and program directors struggle with how and when to incorporate such training into the current time-constrained service requirements of an internal medicine residency.23Ogrinc G. Headrick L.A. Mutha S. Coleman M.T. O'Donnell J. Miles P.V. A framework for teaching medical students and residents about practice-based learning and improvement, synthesized from a literature review.Acad Med. 2003; 78: 748-756Crossref PubMed Scopus (154) Google Scholar These time constraints for internal medicine residents, or the duty hour regulations set forth by the Accreditation Council for Graduate Medical Education (ACGME), are contributing to the difference between training and practice. To meet these duty hour requirements, teaching hospitals were forced to adopt creative staffing solutions such as night float systems and hospitalist-led teaching and nonteaching services.24Fletcher K.E. Saint S. Mangrulkar R.S. Balancing continuity of care with residents' limited work hours defining the implications.Acad Med. 2005; 80: 39-43Crossref PubMed Scopus (61) Google Scholar, 25Saint S. Flanders S.A. Hospitalists in teaching hospitals opportunities but not without danger.J Gen Intern Med. 2004; 19: 392-393Crossref PubMed Scopus (36) Google Scholar Both of these solutions can potentially compromise the ability to present residents with a balanced set of options for a career in internal medicine practice. Float systems can increase time spent in inpatient settings at the expense of subspecialty elective and outpatient ambulatory experiences.26Trontell M.C. Carson J.L. Taragin M.I. Duff A. The impact of the night float system on internal medicine residency programs.J Gen Intern Med. 1991; 6: 445-449Crossref PubMed Scopus (34) Google Scholar This impairs informed career decisions, particularly due to the premature timeline of most fellowship applications.27Clayton C.P. Battinelli D.L. Landenson P.W. et al.Halfway toward healing a broken system fellowship recruitment in internal medicine.Am J Med. 2004; 117: 69-71Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Increased use of hospitalists may also affect career selections of internal medicine physicians-in-training.28Hauer K.E. Wachter R.M. Implications of the hospitalist model for medical students' education.Acad Med. 2001; 76: 324-330Crossref PubMed Scopus (40) Google Scholar Although studies suggest that hospitalist-led services can lead to improved teaching, concerns remain over the substitution of hospitalists for traditional general internists and subspecialists, which limits the overall exposure of trainees and medical students to mentors in these areas.29Hunter A.J. Desai S.S. Harrison R.A. Chan B.K. Medical student evaluation of the quality of hospitalist and nonhospitalist teaching faculty on inpatient medicine rotations.Acad Med. 2004; 79: 78-82Crossref PubMed Scopus (41) Google Scholar, 30Chung P. Morrison J. Jin L. et al.Resident satisfaction on an academic hospitalist service time to teach.Am J Med. 2002; 112: 597-601Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 31Wright S. Wong A. Newill C. The impact of role models on medical students.J Gen Intern Med. 1997; 12: 53-56Crossref PubMed Scopus (311) Google Scholar, 32Hollander H. Response to the effect of hospitalist systems on residency education re-incorporating medical subspecialists.Acad Med. 2001; 76: 555-556Crossref PubMed Scopus (16) Google Scholar This concern is not unwarranted as the number of hospitalists is growing at a time when interest in general internal medicine is low.33Wachter R.M. Hospitalists in the United States—mission accomplished or work in progress?.N Engl J Med. 2004; 350: 1935-1936Crossref PubMed Scopus (60) Google Scholar, 34Moore G. Showstack J. Primary care medicine in crisis toward reconstruction and renewal.Ann Intern Med. 2003; 138: 244-247Crossref PubMed Scopus (93) Google Scholar Finally, the training-practice gap has seriously jeopardized interest in internal medicine among medical students. As medical students rotate on their internal medicine clerkship, they are influenced by residents who are overworked and overburdened by caring for complex patients in systems that have not been updated to reflect the current practice of internal medicine.35Whitcomb M.E. Cohen J.J. The future of primary care medicine.N Engl J Med. 2004; 351: 710-712Crossref PubMed Scopus (76) Google Scholar, 36Schwartz M.D. Linzer M. Babbott D. et al.Medical student interest in internal medicine. Initial report of the Society of General Internal Medicine Interest Group Survey on Factors Influencing Career Choice in Internal Medicine.Ann Intern Med. 1991; 114: 6-15Crossref PubMed Scopus (105) Google Scholar Furthermore, with escalating student debt, medical students are drawn to careers that offer fixed hours and competitive compensation, such as radiology, ophthalmology, anesthesiology, and dermatology.37Lee B.Y. Hecht T. Volpp K. Lifestyle as a factor in medical students' career choices.JAMA. 2003; 290: 2941Crossref PubMed Scopus (4) Google Scholar, 38Dorsey E.R. Jarjoura D. Rutecki G.W. Influence of controllable lifestyle on recent trends in specialty choice by US medical students.JAMA. 2003; 290: 1173-1178Crossref PubMed Scopus (557) Google Scholar, 39Association of American Medical CollegesAAMC Medical Student Education Debt and Resident Stipend Fact Cards. 2003Google Scholar The first step in reconciling the training-practice gap is to define the current practice models of internal medicine. It is only after an adequate definition of internal medicine practice models is put forth that physician teachers can recognize and correct the deficiencies in residency training. For the most part, it is recognized that internal medicine practice has evolved to support 3 model practitioners: general internists, hospitalists, and subspecialists.40Larson E.B. Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine. Abstract health care system chaos should spur innovation: summary of a report of the Society of General Internal Medicine Task Force on the Domain of General Internal Medicine.Ann Intern Med. 2004; 140: 639-643Crossref PubMed Scopus (51) Google Scholar General internists are internal medicine physicians who specialize in the care and management of adult patients with chronic and complex medical conditions. In this role, they often provide services targeted for prevention, health maintenance, or diagnosis and management of chronic medical conditions. They are also considered providers of primary care or care that is designed to be accessible, comprehensive, coordinated, continuous, and accountable.41Institute of MedicineDivision of Health Manpower and Resources Development. A Manpower Policy for Primary Health Care: Report of a Study. National Academy Press, Washington, DC1978Google Scholar General internists may care for their patients in hospital or office settings, ensuring continuity of care for their patients. Although this model is still quite common, the utility of generalists who care for patients in both the outpatient and inpatient setting has come into question.42Rodney W.M. Hahn R.G. Impact of the limited generalist (no hospital, no procedures) model on the viability of family practice training.J Am Board Fam Pract. 2002; 15: 191-200PubMed Google Scholar Increasing inpatient time of predominantly outpatient-oriented internists is associated with decreased job satisfaction and higher rates of burnout.43Saint S. Zemencuk J.K. Hayward R.A. et al.What effect does increasing inpatient time have on outpatient-oriented internist satisfaction?.J Gen Intern Med. 2003; 18: 725-729Crossref PubMed Scopus (20) Google Scholar Internists' dissatisfaction could inhibit recruitment of students into generalist careers.44Wetterneck T.B. Linzer M. McMurray J.E. et al.Work life and satisfaction of general internists.Arch Intern Med. 2002; 162: 649-656Crossref PubMed Scopus (105) Google Scholar Recruitment of internal medicine residents into generalist careers is also problematic. The ambulatory practices of internal medicine residents often occur at teaching hospitals, characterized by inadequate support and staffing to care for a cohort of chronically ill patients with multiple medical problems and inadequate coverage.45Burke W. Baron R.B. Lemon M. Losh D. Novack A. Training generalist physicians structural elements of the curriculum.J Gen Intern Med. 1994; 9: S23-S32Crossref PubMed Scopus (20) Google Scholar Due to lack of adequate time and exposure to outpatient medicine, the current training system does not prepare internal medicine residents for routine procedures and problems in ambulatory practice.46Wiest F.C. Ferris T.G. Gokhale M. et al.Preparedness of internal medicine and faculty practice residents for treating common conditions.JAMA. 2002; 288: 2609-2614Crossref PubMed Scopus (84) Google Scholar, 47Wickstrom G.C. Kolar M.M. Keyserling T.C. et al.Confidence of graduating internal medicine residents to perform ambulatory procedures.J Gen Intern Med. 2000; 15: 361-365Crossref PubMed Scopus (52) Google Scholar Hospital medicine has emerged as one of the fastest growing fields in medicine. However, this rapid increase in the number of hospitalists is being met with increased skepticism. An ongoing debate regarding the importance of continuity for safe patient care and the role of the primary care provider in inpatient settings has challenged the field.48Sox H.C. The hospitalist model perspectives of the patient, the Internist, and internal medicine.Ann Intern Med. 1999; 130: 368-372Crossref PubMed Scopus (48) Google Scholar, 49Auerbach A.D. Davis R.B. Phillips R.S. Physician views on caring for hospitalized patients and the hospitalist model of inpatient care.J Gen Intern Med. 2001; 16: 116-119Crossref PubMed Scopus (17) Google Scholar, 50Schroeder S.A. Schapiro R. The hospitalist new boon for internal medicine or retreat from primary care?.Ann Intern Med. 1999; 130: 382-387Crossref PubMed Scopus (40) Google Scholar In addition, concerns over burnout and longevity of careers in hospital medicine remain a threat to ensuring a stable workforce in this relatively new specialty.50Schroeder S.A. Schapiro R. The hospitalist new boon for internal medicine or retreat from primary care?.Ann Intern Med. 1999; 130: 382-387Crossref PubMed Scopus (40) Google Scholar However, trainee interest and the economic demand for hospitalists ensure that this model is a key part of the health care delivery system of the future.51Levinson W. Linzer M. What is an academic general internist? Career options and training pathways.JAMA. 2002; 288: 2045-2048Crossref PubMed Scopus (23) Google Scholar Although it is recognized that training of internal medicine residents favors the accumulation of expertise in caring for hospitalized patients, it is important to acknowledge that many core competencies of hospital medicine are not emphasized in resident education. For instance, hospitalists often serve as consultants in perioperative medicine and surgical co-managers, leaders of quality improvement and patient safety initiatives, educators of physicians-in-training, and liaisons to administration in hospitals.52Wachter R.M. Goldman L. The hospitalist movement 5 years later.JAMA. 2002; 287: 487-494Crossref PubMed Scopus (326) Google Scholar For these reasons, it is important that exposure and training in these additional skills is present in the training of future hospitalists. The subspecialist in internal medicine is the clinician-consultant, receiving referrals from generalist and other primary care providers to address a specific issue or question in either inpatient or outpatient settings. Recent data suggest that subspecialists are often in a better position to deliver primary care for certain populations of patients who interact more frequently with subspecialists, such as nephrologists for dialysis patients.53Rosenblatt R.A. Hart L.G. Baldwin L.M. et al.The generalist role of specialty physicians is there a hidden system of primary care?.JAMA. 1998; 279: 1364-1370Crossref PubMed Scopus (157) Google Scholar, 54Fryer Jr, G.E. Consoli R. Miyoshi T.J. Dovey S.M. Phillips Jr, R.L. Green L.A. Specialist physicians providing primary care services in Colorado.J Am Board Fam Pract. 2004; 17: 81-90Crossref PubMed Scopus (13) Google Scholar In addition, data suggest that although a quarter of subspecialists treat patients outside of their specialty, care for certain diagnoses may be suboptimal.55Weingarten S.R. Lloyd L. Chiou C.F. Braunstein G.D. Do subspecialists working outside of their specialty provide less efficient and lower-quality care to hospitalized patients than do primary care physicians?.Arch Intern Med. 2002; 162: 527-532Crossref PubMed Scopus (43) Google Scholar Therefore, ensuring competency in health care maintenance and recognition and treatment of routine medical diagnoses is crucial for subspecialists serving as primary care providers to these disease-specific populations. This issue is particularly important in light of recent debates regarding maintenance of internal medicine certification for subspecialists and the high value placed on this certification by the public.56Brennan T.A. Horwitz R.I. Duffy F.D. et al.The role of physician specialty board certification status in the quality movement.JAMA. 2004; 292: 1038-1043Crossref PubMed Scopus (251) Google Scholar Every effort should be made to define a set of core skills in internal medicine for these subspecialists and develop an appropriate certification process to evaluate and ensure competency in these skills. It is important to note that the location of future practice (academic vs private, rural vs urban, etc) also influences the skill sets required for internal medicine physicians-in-training. Academic practice, for instance, requires educational or research contributions for advancement. On the other hand, private practice, either in groups or independently, requires extensive knowledge of the business side of medicine, with a focus on productivity and cost-effective care. Nevertheless, these various practice models, even with distinct features and threats, are all united by the same core residency training. In models of patient-centered care that emphasize efficient disease management, it is essential that all physicians-in-training obtain a working knowledge of these practice models and their interface with each other.57Bodenheimer T. Wagner E.H. Grumbach K. Improving primary care for patients with chronic illness.JAMA. 2002; 288: 1775-1779Crossref PubMed Scopus (2218) Google Scholar In addition, all internal medicine physicians-in-training will need to acquire core skills in cross-cutting areas, such as quality improvement, safety, communication, and cost-effectiveness. Core internal medicine training can be tailored to address these issues and showcase a proportionate sampling of patient care in all of these domains. In addition, this core internal medicine training can accentuate a key attraction of internal medicine for medical students, the diversity and flexibility of available career paths to meet the needs of individual learners. It is equally important to note that attempts to further differentiate these models earlier from the core internal medicine training may preferentially favor training certain types of internists at the expense of others. For instance, a 2-year core training program followed by a 2-year subspecialty fellowship in cardiology would lower the cost of specialization at a time when interest in generalist practice is already a concern. Training must reflect practice.58McPhee S.J. Mitchell T.F. Schroeder S.A. et al.Training in primary care internal medicine residency program. The first ten years.JAMA. 1987; 258: 1491-1495Crossref PubMed Scopus (51) Google Scholar Although practice models in internal medicine consist of 3 different models, the current training system is largely focused on training physicians who are proficient in the care of complex medical inpatients. Furthermore, the required residency continuity clinic experience is often characterized by caring for a patient panel of high disease-burden, with limited time and resources spent on the academic resident clinic experience. Although teaching institutions recognize the need for general internists, they do not place a priority on teaching physicians-in-training the skills necessary for outpatient practice. Given the focus on quality, safety, and technological innovation, it is imperative that internal medicine residency experiences include initiatives and curricula that ensure competency in these domains. Interestingly, a major recommendation that demands resolution of the training-practice gap comes in the form of the ACGME core competency in systems-based practice.59Accreditation Council on Graduate Medical EducationAccreditation Council on Graduate Medical Education Outcome Project. 2004Google Scholar Systems-based practice is defined as an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Under this rubric, residents are expected to understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice, know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources, practice cost-effective health care and resource allocation that does not compromise quality of care, advocate for quality patient care and assist patients in dealing with system complexities, and know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance. Proficiency in systems-based practice requires residencies to ensure that physicians-in-training understand all practice models of internal medicine in today's environment. Beyond generalist, hospitalist, and subspecialist practice, other distinguishing characteristics of these models that deserve attention in training include the differences between rural and urban practice, academic and private practice, and clinical-research and clinical-educator pathways within academic practice models. The authors recommend that all residents not only learn about these various practice models but also are afforded the opportunity to work with an internist who specializes in each of these practice models. Furthermore, proficiency in systems-based practice depends not only on understanding current practice models but also the judicious use of resources to provide high-quality care. This includes but is not limited to educating residents on the use of information technology to manage a practice, formal education on cost-effectiveness of diagnostic procedures and therapies, human resources management including effective use of physician extenders, and principles of quality improvement and patient safety. To close the training-practice gap, internal medicine training must provide a balanced allocation of time for each practice model and the additional education in the use and understanding of tools to deliver high-quality, safe, and effective patient care. Given the heavy reliance of teaching hospitals on internal medicine physicians-in-training for provision of inpatient care, this will most certainly require the divorce of service obligation from education in internal medicine residencies. A major barrier to achieving this goal is the current financing of graduate medical education, which is linked to care provided in hospitals with little provision for reimbursement for out-of-hospital educational activities.60Eisenberg J.M. Financing ambulatory care education in internal medicine.J Gen Intern Med. 1990; 5: S70-S80Crossref PubMed Scopus (27) Google Scholar, 61Kassirer J.P. Redesigning graduate medical education—location and content.N Engl J Med. 1996; 335: 507-509Crossref PubMed Scopus (53) Google Scholar, 62Anderson G.F. Greenberg G.D. Wynn B.O. Graduate medical education the policy debate.Annu Rev Public Health. 2001; 22: 35-47Crossref PubMed Scopus (12) Google Scholar To meet the financial needs of such a proposition, the authors advise that leaders of medicine, including program directors and chairs, administrators of teaching hospitals, and financiers of medical education, convene a special meeting to open the dialogue and address the budgetary implications of such an issue. It is only then that the features and design of an appropriate training model can be determined. Many groups have begun to examine how training reform can accurately address the training-practice gap in internal medicine. The concept of extending residency training to adequately incorporate the time for mastery of core skills has been recently suggested.40Larson E.B. Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine. Abstract health care system chaos should spur innovation: summary of a report of the Society of General Internal Medicine Task Force on the Domain of General Internal Medicine.Ann Intern Med. 2004; 140: 639-643Crossref PubMed Scopus (51) Google Scholar However, without careful and planned attention to revising the content of this training to represent the practice models of internal medicine, extending training length appears premature and likely detrimental to student interest in this career. The authors are most encouraged by the Residency Review Committee in Internal Medicine's recommendation for pilot projects to improve training, by addressing some of these issues with a move to a more outcomes-driven training process.63Goroll A.H. Sirio C. Duffy F.D. et al.A new model for accreditation of residency programs in internal medicine.Ann Intern Med. 2004; 140: 902-909Crossref PubMed Scopus (83) Google Scholar However, without adequately addressing the dissolution of the service obligation from the educational mission, the authors do not feel that programs can make use of this unprecedented regulatory latitude to explore and pilot the best possible solutions for training. The authors feel the training-practice gap must be recognized and addressed in a thoughtful, practical fashion with internal medicine physicians-in-training and recent graduates as integral parts of the ultimate solutions. Although it will take time, with constructive discussion and cooperation from all vested parties in internal medicine, we will not only improve internal medicine training but also the care of the patients to whom we are responsible. The authors would like to acknowledge the support and contributions of Gregory Rose, MD, Margaret Fang, MD, Shamita Shah, MD, Patrick Young, MD, Sara Wasserbauer, MD, Ross Downey, MD, Joel Garcia, MD, and Joseph Lim, MD, who served with us as members of the American College of Physicians Council of Associates in 2003–2004. The views presented are those of the individual authors and may not reflect the policy of the American College of Physicians. Response OneThe American Journal of MedicineVol. 118Issue 6PreviewAPM invited leaders in academic internal medicine—including representatives from the Alliance for Academic Internal Medicine (AAIM), American Board of Internal Medicine (ABIM), and the Residency-Review Committee for Internal Medicine (RRC-IM)—to respond to this commentary's suggestions for improving internal medicine training in the 21st century. Representatives from AAIM and ABIM responded to the commentary, while RRC-IM declined the invitation. Full-Text PDF Response TwoThe American Journal of MedicineVol. 118Issue 6PreviewResponse Two: Full-Text PDF