From burnout to shortcomings in interprofessional training, everyone seems to agree that the resident experience is in need of improvement. But what would an ideal residency look like, and can that vision become reality? The American Medical Association (AMA) recently awarded $14.4 million to support eight projects from various institutions through its "Reimagining Residency" grant program in an effort to improve residency training. The projects will create new curricula and draw upon recent innovations to potentially reimagine this crucial time in young doctors' lives. We spoke with some of the grant winners and asked them to share with us how their work will change the future of medical training and what they think residency will look like halfway through this century. Lisa Willett, MD; and Stephen Russell, MD (The University of Alabama at Birmingham School of Medicine) In the 1950s, Dr Tinsley Harrison wrote in the introduction to Harrison's Principles of Internal Medicine that a physician needs "technical skill, scientific knowledge, and human understanding" to care for patients. In 2050, at the 100th anniversary of those words, we envision an innovative training environment for graduating residents to meet those goals. We aim for residents to gain cognitive and technical skills through competency-based training. Each resident should advance through training with personalized tailored feedback to improve based on directly observed skills. Resident advancement toward practice autonomy will be based on demonstrated expertise and not length of time in training. We aim for residents to gain scientific knowledge combining time-honored techniques with modern medical advances. Using a team approach centered on patients' needs helps improve patient outcomes and drives evidence-based decision- making. We aim for residents to gain human understanding by investing in the physician-patient relationship. Meaningful time in the presence of the patient brings meaning and purpose to this sacred encounter, ensuring that patients get the best possible care. Reimagining residency for 2050 is based on the fundamental principle that joy in medical practice is experienced with our patients as we serve their needs. In doing so, residents will find that they are not only meeting the needs of a modern health system but also meeting their own professional needs. The University of Alabama at Birmingham School of Medicine, Johns Hopkins University School of Medicine, and Stanford University School of Medicine were awarded an AMA grant for their project: The Graduate Medical Training "Laboratory": An Innovative Program to Generate, Implement, and Evaluate Interventions to Improve Resident Burnout and Clinical Skill. Catherine C. Skae, MD, DSc (Montefiore Medical Center, Albert Einstein College of Medicine) Because we can't predict how advances in technology or policy might change the practice of medicine in 2050, we don't really know what medical training will look like; however, we do know that the health of patients will always be impacted by social determinants of health (SDH). Thus, we can endeavor to change education in meaningful ways right now and into the future. We firmly believe that residency in 2050 will ideally incorporate rigorous curricula on SDH that encompass both concrete, specific needs—such as inadequate food and transportation needs—and complex structural underpinnings that are mostly responsible for health inequities. Recognizing and engaging SDH is an important strategy for healthcare systems to improve outcomes and reduce disparities. In the context of value-based care, healthcare providers increasingly are given a mandate to identify SDH and partner with community-based organizations to address their patients' health. SDH affect patients' clinical outcomes and well-being and can also be associated with higher health care costs. The importance of the physician's role in addressing SDH has been stressed by major national professional organizations. However, physicians are not formally trained to effectively respond. Our hopes for 2050 would ensure adequate training and changes in house officer behavior to improve patient outcomes. Embedding teaching in the clinical learning environment would support residents in building pragmatic skills to address SDH during patient visits and through interprofessional panel management activities such as team-based care approaches and quality improvement. Residents will integrate strategies such as awareness of and leadership in health system initiatives and advocacy to serve as change agents for underlying systemic etiologies of SDH. A cross-specialty curricular framework will allow medical schools and health care systems to efficiently scale high-quality training in SDH, thereby shifting the culture of residency training to meet the need for a physician workforce well versed in these skills. A high-quality curriculum in SDH honors the meaningful mission at the heart of physicians' work. Skills and confidence in addressing patients' SDH needs may positively impact work-related characteristics that affect physician burnout, such as a sense of value alignment with the organization's leadership, efficiency in teamwork, and reduced workplace chaos; and, as a result, improve physician wellness and professional fulfillment for faculty, residents, and graduates. Montefiore Medical Center was awarded an AMA grant for its project: Residency Training to Effectively Address Social Determinants of Health: Applying a Curricular Framework Across Four Primary Care Specialties. Brian Garibaldi, MD (Johns Hopkins University) Healthcare delivery has changed dramatically in the 100 years since Sir William Osler established the modern residency training system at the Johns Hopkins Hospital in 1889. Medical and scientific knowledge is expanding at an unprecedented rate, nearly doubling every year. Yet Osler would still recognize the basic structure of graduate medical education with its mix of classroom-based teaching and experiential learning through activities such as bedside rounds and clinical service. As our healthcare system has evolved, so too must the way in which we train the next generation of physicians . Predicting what residency training will look like in the next 25-30 years is difficult; however, current trends offer some insight into possible directions. The residency programs of the future must better prepare physicians to search for medical knowledge and to translate new information into bedside clinical medicine. Artificial intelligence (AI) will undoubtedly assist physicians in data synthesis, but physicians will need to use "human intelligence" to figure out how to apply that data to an individual patient. Roy Ziegelstein, MD, coined the term "personomics" to refer to this specific field of medicine whereby knowing the patient as a person (eg, their goals, aspirations, personal relationships, fears) directly impacts their treatment plan and response. Osler predicted this more than 100 years ago when he said, "The good physician treats the disease. The great physician treats the patient who has the disease." A pivot towards personomics will require a shift in the amount of time that trainees and physicians spend with patients. In current graduate medical training, some residents spend as little as 13% of their time in direct contact with patients and their families. This has led to a decline in bedside clinical skills and likely adversely affects the doctor-patient relationship. It also contributes to the alarming rise in physician and trainee burnout. In the future, AI will help to unload the burden of electronic health record documentation and free up time to spend with patients. We must be more intentional about cultivating the necessary skills for trainees to connect with patients and navigate shared decision- making when faced with growing amounts of data. We must also prepare trainees and patients for the inevitable and paradoxical uncertainty that comes with information overload. A return to a broader focus on the humanities in undergraduate and graduate medical training has been advanced by some as a means to prepare physicians to navigate these complex relationships and deal with uncertainty. In addition to focusing on personomics, residency training will likely have a renewed focus on traditional bedside clinical skills such as the physical examination. Groups such as the Society of Bedside Medicine and the Stanford Medicine 25 team are leading a growing effort to reinvigorate the practice of the bedside physical examination. This is a critical skill that has fallen by the wayside in recent years. In order for the power of AI in diagnosis to be realized, we must ensure that the data provided to the system are accurate. In order to adequately train residents in the bedside physical examination, we must be more intentional about assessing and providing feedback on these skills to physicians in training. Formative assessment programs such as the Assessment of Physical Examination and Communication Skills (APECS) will likely play an important role in bedside skills training. The current time-based model of graduate medical education will also likely change over the next 25 years. Interest is growing in competency-based training programs, whereby residents may be able to advance to the next stage of their career more rapidly if they demonstrate a certain level of proficiency. AI will create more discriminating metrics of clinical performance. Coupled with a renewed emphasis on direct observation and assessment, we will likely be able to individualize resident learning plans and tailor training in both content and time based on a specific resident's performance. Just as we use the scientific method to advance medical knowledge, we must apply the same principles to study and develop the best approaches to residency training. Programs such as the Reimagining Residency initiative are an important start to gather the objective data needed to inform system wide changes in graduate medical education. Our project will examine the impact of modifiable factors in the residency training environment (eg, time spent at the bedside, activities in the electronic health record, workload, patient complexity) on the important outcomes of resident wellness and clinical skill. The data we gather will allow us to develop and assess the impact of changes in residency program structure to improve these outcomes and, ultimately, the quality of patient care. Johns Hopkins University School of Medicine, The University of Alabama at Birmingham School of Medicine, and Stanford University School of Medicine were awarded an AMA grant for their project: The Graduate Medical Training "Laboratory": An Innovative Program to Generate, Implement, and Evaluate Interventions to Improve Resident Burnout and Clinical Skill. Grant Project Team Members from the University of North Carolina (UNC) School of Medicine Looking to the future of residency training, we anticipate that predetermined time constraints for graduation will be removed; instead, resident training will be completed as a set of core competencies is attained. We also anticipate a more connected approach to training across the continuum, which includes an integration of future residency sites during medical school and improved practice management training to prepare residents for success once they join the workforce. We also see an increased acknowledgement of the impact of burnout across the medical profession and anticipate a greater focus on wellness and programs that promote resilience and provide emotional support to residents during their training. Our Reimagining Residency grant will support the expansion of the Fully Integrated Readiness for Service Training (FIRST) program. Established in 2015, the pilot phase of the FIRST program provides students with the opportunity to participate in an accelerated and advanced curriculum; this allows students to complete medical school in 3 years and enter the UNC Family Medicine Residency Program followed by 3 years of practice support after graduation. Expanding this program to the additional specialties of general surgery, pediatrics, and psychiatry in the future will allow us to better serve the physician workforce needs of North Carolina. By offering a seamless transition between medical school, residency, and practice, we increase the likelihood that our students remain in North Carolina to practice and ensure they are best prepared to care for our state's diverse population. Additional programmatic elements of our grant include a focus on promoting an inclusive and positive clinical learning environment and increasing our focus on health systems science to produce physicians ready to achieve success in the ever-changing world of health care. UNC School of Medicine was awarded an AMA grant for its project: Fully Integrated Readiness for Service Training (FIRST): Enhancing the Continuum from Medical School to Residency to Practice. Grant Project Team Members from Oregon Health & Science University and University of California, Davis The California Oregon Medical Partnership to Address Disparities in Rural Education and Health (COMPADRE) aims to develop a robust education collaborative to provide more and better-trained physicians for underserved communities in the region. COMPADRE will bring together dozens of residency programs, health systems, and community health centers to train more students and residents from rural, urban, and tribal communities and equip these individuals for practice in their communities. By 2050, this bold initiative will result in development of a virtual regional campus to better locate medical education opportunities closer to vulnerable communities. Students will incur minimal educational debt and acquire their training closer to their home, using distance education technology and other modalities to remain connected with and learn from their communities. By 2050, undergraduate medical education will be directly linked to residency training, allowing for greater continuity and enabling learners to put down roots where they study. Student and residents will be supported by their local communities and engaged in a vast COMPADRE learning and wellness network. By 2050, the physician workforce will more closely reflect the diverse social, economic, and cultural identities of our nation. Most importantly, these physicians will have helped improve health in the region, serving as a model for other parts of the country affected by workforce shortages. Oregon Health & Science University and University of California, Davis were awarded an AMA grant for their project: California Oregon Medical Partnership to Address Disparities in Rural Education and Health (COMPADRE). Kalli Varaklis, MD, MSEd (Maine Medical Center) We envision a future clinical learning environment where graduate medical education is fully integrated into the patient care environment to better prepare residents for team-based care and interprofessional, collaborative practice. This new clinical learning environment will ensure that graduates and clinicians in all of the health professions will have proficiencies essential to the evolving practice environment, including improving patient outcomes, demonstrating systems-level competencies, interpreting an ever-increasing amount of information and data, and participating in quality improvement and population health initiatives as an interprofessional team. In the year 2050, we believe that residency and fellowship training will occur in an environment that values these principles: Full team involvement in care planning with scheduled interprofessional rounds to communicate one message to patients and families Patient and health care team cohorting Rapid- cycle quality improvement on individual units with full team engagement Team learning activities scheduled by and for the entire team A shift to teaching back to the bedside We envision this training model to be integrated into all inpatient and outpatient training settings as well as at rural training sites. We believe that the Maine Medical Center pilot, Interprofessional Partnership to Advance Care and Education (iPACE) can help meet these aspirational goals. We anticipate that our Reimagining Residency project will implement the core principles of iPACE in inpatient and outpatient settings, in diverse specialties, and in rural training sites, achieving the goal of redesigning the clinical learning environment to ensure that all residents in our programs are ready for interprofessional practice. Maine Medical Center was awarded an AMA grant for its project: Reimagining Residency: Ensuring Readiness for Practice Through Growing Interprofessional Partnerships to Advance Care and Education (iPACE). Source
