Demystifying Medicine One Month at a Time

Tag: medical training

Competence

I train doctors.

In my role as a residency program director, I have three major responsibilities:

  1. Recruiting: find and hire medical school graduates.
  2. Curriculum: set educational standards to produce well-qualified internists.
  3. Accreditation: comply with national professional norms and requirements.

Regarding #2, the goal is to have trainees demonstrate competence as doctors at the end of the three year training period (‘residency’). Ideally, they acquire it in steady, graded fashion at distinct mileposts along the way, so that teaching faculty know that residents are making adequate progress and will flourish as independent doctors.

How do professions measure and determine competence? In medical training, residency programs are subject to regulations provided by “Residency Review Committees” which are empowered by a national accrediting body. Those committees come for periodic site visits to inspect our training environment and make sure that we’re following best practices (and the rules…).

It’s up to us to comply with their rules, but we have leeway in interpreting them so that there can be innovation in how we implement our educational models.

Over the last fifteen years, the national governing body was able to choose six “core competencies” that defined competence for doctors of all specialties. Regardless of what kind of medicine you practice, there should be fundamental attributes that all doctors share, right?

Those six competencies are:

  • patient care (duh)
  • medical knowledge (also duh)
  • interpersonal skills and communication (hey, I kinda like that…)
  • professionalism (for sure, right?)
  • systems-based practice (huh?)
  • practice-based learning & improvement (I think you lost me on these last 2)

Give yourself an exercise: Now that you know the domains of competency, how would you evaluate learners in those domains?

Perhaps unsurprisingly, medical educators began resorting to numeric grading scales to evaluate residents in each of these domains. This allowed for quantification of residents’ performances, and a better ability to document both interval progress and ultimate competence.

The problem became that different faculty members interpreted the grading scales differently. Grade inflation starting making nearly everyone look the same, as far as their evaluation numbers were concerned. Asked to define what makes a competent physician, faculty responded along the lines of Supreme Court Justice Potter Stewart, who famously quipped about the hard-to-define-concept of obscenity “…I know it when I see it…”

Voila, welcome to the Next Accreditation System (‘NAS’). Program Directors like me across the country are currently struggling to implement this new system, with a goal of allowing more detailed analyses of learners’ performances. Another goal of the new system is to allow more freedom and flexibility in educational innovation by making reporting requirements more frequent but less onerous (hey-will that work?) to keep educators’ eyes more fixed on teaching and training than on evaluating and reporting. [I’m imagining that in the near-term, there will be a lot of the latter. I hope the former is not diminished…]

The new system is predicated on developmental milestones that lead doctors to become competent in a range of entrustable professional activities (“EPAs”). These EPAs map to the original six competencies which I shared with you above.

Got it?

At a recent national meeting discussing these changes and strategies for handling them, one colleague likened these new mandates to “repairing the airplane while flying it…”

No one ever said that change is easy. Best for us to embrace it and make it a learning opportunity.

The Magic Curtain

It’s graduation time again…..so I’m reposting this essay about transitions:

Hail, graduates!

After the first day of medical school, my mother called to ask me how it went. Then she threw in a kicker:

“I have a small rash I want you to look at.”

What the heck did she think I learned in one day?

I now know is that she was giving me an early lesson in boundaries:

I had crossed some magical line into MD-land, where I’d be expected to answer any question and have an opinion on all parts of the body and all medications, herbal supplements, chemicals, diets, beauty products, and the latest studies written about in newspaper articles (people read actual newspapers back then).

No matter that I’d had one day of the Krebs cycle, and nothing to show for it. I was now an almost-doctor!

Persnickety guy that I am, I really got frustrated when my Mom sent her friends in my direction, too. “I’m not a doctor, I just play one on TV,” became my go-to line to deflect their unwanted medical questions.

Things changed even more dramatically when I started internship.

My first day on the wards, I took over the care of Mrs. Manganelli, an unfortunate woman in her midfifties afflicted with severe multiple sclerosis (MS). This is a disease that wreaks havoc with the connections between nerves, and nerves to muscles, making things we take for granted like swallowing, walking and breathing very difficult. It also affects “toileting.”

Mrs. Manganelli (not her real name) had been admitted for severe constipation. Her MS had made her intestines barely able to move food and the resultant waste products along their course. An x-ray confirmed that her colon was “FOS” (full of stool, or a less nice word we somtimes use).

My supervising resident and the patient’s nurse gave me a strange look, with big eyes and a smile I mistrusted, telling me that “disimpacting” was the intern’s job.

I was scared to admit that I didn’t know what disimpacting was, but their looks told me it wasn’t pleasant.

To hide my ignorance, I asked what “tools” I’d need for the job. The resident pointed his finger at me, and the nurse handed me a chux, those ubiquitous blue pads that are all over hospitals to place under patients and clean up messes.

Then I understood: I was going to be making and cleaning up a mess from poor Mrs. Manganelli.

“I don’t want to be a doctor,” I thought to myself, in response to this form of hazing. “This is going to be a long and awful year.”

Mrs. Manganelli, apparently used to being disimpacted because of her illness, rolled onto her side (with help) and assumed the position.

Using a gloved finger and lubricant, I found what we would technically call “copious amounts of soft brown stool in her rectal vault.”

Her disease meant she had nearly no sphincter tone, so once I was able to initiate the flow of poop out of her bottom, it started coming out on its own. Lots of it.

A heaping pile.

And as gross as this story is, there are a couple of interesting facts and lessons I took from it.

Mrs. Manganelli felt about a million times better after being disimpacted. It was really remarkable both to see how dramatic her improvement was, and that I’d had a direct hand (so to speak) in making her feel that way.

When my family wanted to hear about my first day of internship, I proudly related some of the details of what I’d been through, thinking they’d find it amusing, or at least fodder for some storytelling.

Their reactions told me that I’d crossed over. Never again would I be able to share unfiltered details from my world. They couldn’t handle the truth.

So now, for better and worse, I live behind a magic curtain of people’s expectations and perceptions.

Like Mr. Gorbachev, I hope to tear down this wall.

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