Response to Internal Medicine Residency Redesign

Abstract

Horwitz et al1Horwitz R.I. Kassirer J.P. Holmboe E.S. et al.Internal medicine residency redesign: proposal of the Internal Medicine Working Group.Am J Med. 2011; 124: 806-812Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar are to be congratulated on their efforts to address improving Internal Medicine (IM) residency training and their recommendations to improve residency education. Most specifically, we would like to comment on the issue of mastery of the physical examination and bedside teaching. Horowitz et al1Horwitz R.I. Kassirer J.P. Holmboe E.S. et al.Internal medicine residency redesign: proposal of the Internal Medicine Working Group.Am J Med. 2011; 124: 806-812Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar comment on producing physicians who are masters of but not slaves to technology, and no doubt, proficiency in basic skills such as the physical examination are essential to achieve this. Many commentators, such as Verghese,2Verghese A. Horwitz R.I. In praise of the physical examination.BMJ. 2009; 339: b5448Crossref PubMed Scopus (68) Google Scholar have lamented the decline of the role of the physical examination in the training of doctors, which seems to have been replaced by an over-reliance on modern technology. Indeed, this concern has led to the creation of the “Stanford 25,” a core set of physical examination skills in which trainees should be adept.2Verghese A. Horwitz R.I. In praise of the physical examination.BMJ. 2009; 339: b5448Crossref PubMed Scopus (68) Google Scholar, 3Stanford School of MedicineStanford initiative in bedside medicine.http://medicine.stanford.edu/education/stanford_25.htmlGoogle Scholar We believe there is a burning desire amongst trainees to develop and harness these skills to allow enhanced patient care and more focused use of modern technologies. Nair et al,4Nair B.R. Coughlan J.L. Hensley M.J. Student and patient perspectives on bedside teaching.Med Educ. 1997; 31: 341-346Crossref PubMed Scopus (108) Google Scholar over a decade ago, found that medical students overwhelmingly (77%) enjoyed bedside teaching and were not overly anxious at the bedside. McMahon et al5McMahon G.T. Marina O. Kritek P.A. Katz J.T. Effect of a physical examination teaching program on the behavior of medical residents.J Gen Intern Med. 2005; 20: 710-714Crossref PubMed Scopus (17) Google Scholar also have demonstrated that physical examination skills courses can improve frequency of the physical examination in practice whilst also delivering increased confidence in teaching these skills to junior medical staff. In any potential redesign of residency training, therefore, physical examination training and development of basic skills learned in medical school at the bedside must take a central role. There are, of course, barriers to bedside teaching on the part of both learners and teachers, which may include perceived discomfort to patients but more importantly, as discussed by Janicik,6Janicik R.W. Fletcher K.E. Teaching at the bedside: a new model.Med Teach. 2003; 25: 127-130Crossref PubMed Scopus (89) Google Scholar there also can be unease from medical educators, which can be overcome by workshops teaching them important skills. In summary, ongoing discussion in this important area and development of methodologies to enhance the residency training experience are welcome and should be embraced by institutions striving to produce quality physicians to serve our patient population. Internal Medicine Residency Redesign: Proposal of the Internal Medicine Working GroupThe American Journal of MedicineVol. 124Issue 9PreviewConcerned with the quality of internal medicine training, many leaders in the field assembled to assess the state of the residency, evaluate the decline in interest in the specialty, and create a framework for invigorating the discipline. Although many external factors are responsible, we also found ourselves culpable: allowing senior role models to opt out of important training activities, ignoring a progressive atrophy of bedside skills, and focusing on lock-step curricula, lectures, and compiled diagnostic and therapeutic strategies. Full-Text PDF