Although they have endured four years of lectures, exams, and national standardized tests, new medical school graduates entering residency training are often "unable to carry out even the most routine duties," physician Pauline Chen writes in the New York Times' "Well" blog.
Observers have long attributed the notorious "July effect"—the month when first-year residents begin work at a hospital and medical error rates may increase—to rookie interns themselves, Chen notes. However, a recent shift in how doctors and residency programs are accredited has shifted the way many medical educators view the issue.
Starting in 1999, accrediting groups began studying how to better assess the competency of young doctors based on the belief that too much importance was placed on time spent in training and not enough on quantifiable clinical skills. The groups introduced a set of "competencies" to gauge the preparedness of new doctors, but in doing so, they found that medical schools and residencies were working in siloes, emphasizing skill sets that weren't always relevant to the training programs.
Chen writes that the most "glaring" example of this lack of standardization is the transition between medical school and internship. Though many medical schools require senior medical students to complete "sub-internships"—a one-month stint as an acting intern—few structured the prerequisite around common goals or input from the directors of residency programs. Moreover, the emphasis placed on hands-on experience during sub-internships often varies widely by program.
What skills should new interns have in July?
Medical educators in some of the smaller service lines like surgery, family medicine, and obstetrics and gynecology were the first to hold conferences and conduct surveys to create specialty-specific goals for new interns. Last year, the Association of American Medical Colleges assembled a panel that put forth a list of general skills that medical students should master ahead of residency, like conducting a physical exam, recognizing clinical emergencies, and obtaining informed consent for procedures.
According to a study in the journal Academic Medicine, educators in the largest specialty—internal medicine, which attracts a third of medical students—are following suit. Leaders in internal medicine recently distributed a questionnaire to their colleagues at residency training programs asking what skills were necessary for students starting internships. Nearly 300 program directors responded, and "while their answers were not entirely surprising, the degree to which they agreed was," Chen writes.
A majority of respondents said that new interns on the first day should know when to request help, how to communicate well with nurses, and how to manage their time. Only 5% of program directors believed that new interns should have more medical knowledge or procedure experience before starting work.
"With so much agreement, you might wonder why it has taken us so long to coordinate our education and training," says Steven V. Angus, lead study author and program director of the internal medicine residency program at the University of Connecticut School of Medicine. "But we educators had this silo mentality and were thinking, 'I know what my job is, and someone else can deal with what happens to the students before or after,'" he adds.
The current push to improve training is the largest collaboration undertaken between internal medicine educators in medical schools and residency programs, Angus told Chen. The overwhelming response to the questionnaire also may be a sign that old attitudes are changing. "We're stepping out of our silos and talking a lot more now, and most of us are embracing the change because we know it will be better for our students and for the patients they care for," he says (Chen, "Well," New York Times, 4/24).