Internal Medicine Residency Training Research Articles

The Declining Number and Variety of Procedures Done by General Internists: A Resurvey of Members of the American College of Physicians

A survey of general internist members of the American College of Physicians (ACP) in 1986 found that they did a large number and variety of procedures in their practices. Since then, changes in the practice of medicine, regulatory requirements, and availability of subspecialists may have affected the number and type of procedures done by internists. To determine the number and types of procedures currently done by general internist members of the ACP compared with 1986. Mailed questionnaire. National probability sample of general internists. Respondents to a national survey of 2500 general internist members of the ACP who were similar in characteristics to those who participated in the 1986 survey. Of the 1389 questionnaires that were returned, 990 were from general internists who had completed the survey. Responses to questions about procedures done and practice characteristics. The number and variety of procedures done by general internists has decreased dramatically. On average, the percentage of general internists doing each procedure now is less than half of that in 1986. The average number of different procedures done in practice decreased from 16 in 1986 to 7 in 2004. As in the 1986 survey, the number of procedures related strongly to personal and practice characteristics. Internists who practice in smaller towns and smaller hospitals do twice as many procedures on average as those in larger cities and larger hospitals. The number and variety of procedures done by internists also increased with greater time spent in total patient care. The number and type of procedures were determined by self-reporting, not direct observation. Both the number and variety of procedures done by general internists have decreased considerably since 1986. As in the 1986 survey, general internists who practice in smaller cities and smaller hospitals and those who spend more hours in patient care perform more procedures. Recommendations and practices for internal medicine residency training in procedures should be reexamined in light of these changes.

Do Residents Benefit from Participating in Internal Medicine Interest Groups? A Study of Resident Perceptions from Two Institutions

For more than a decade, primary care residency training programs have struggled to attract graduates of U.S. medical schools. Internal medicine (IM) interest groups (IMIGs) have been widely instituted to foster student interest in careers in IM. Residents can participate in many IMIG activities. Studies have not assessed the benefits gained by resident participants in such groups. A questionnaire was sent to residents at two IM residency training programs that contribute to IMIG activities at one medical school. Both participating and nonparticipating residents were included. The questionnaire was completed by 44 of 58 IM residents (76% response rate; 25 participants and 19 nonparticipants). Free-text advantages reported were teaching (n=6), mentoring (n=8), and leadership (n=5) opportunities, staying current in IM (n=3), encouraging students to enter IM (n=6), and improving resident morale (n=6). Likert-scale responses were higher for participants than for nonparticipants for all questions; nonparticipants also reported that involvement in IMIG activities is beneficial for residents. Statistically significant results were seen for questions regarding the following: improves resident morale, fosters leadership opportunities, is a valuable experience, and feeling qualified to participate. Residents perceive that participation in an IMIG confers significant benefit, providing additional justification for conducting these interest groups.

Are Commonly Used Resident Measurements Associated with Procedural Skills in Internal Medicine Residency Training?

BackgroundAcquisition of competence in performing a variety of procedures is essential during Internal Medicine (IM) residency training.PurposesDetermine the rate of procedural complications by IM residents; determine whether there was a correlation between having 1 or more complications and institutional procedural certification status or attending ratings of resident procedural skill competence on the American Board of Internal Medicine (ABIM) monthly evaluation form (ABIM-MEF). Assess if an association exists between procedural complications and in-training examination and ABIM board certification scores.MethodsWe retrospectively reviewed all procedure log sheets, procedural certification status, ABIM-MEF procedural skills ratings, in-training exam and certifying examination (ABIM-CE) scores from the period 1990–1999 for IM residency program graduates from a training program.ResultsAmong 69 graduates, 2,212 monthly procedure log sheets and 2,475 ABIM-MEFs were reviewed. The overall complication rate was 2.3/1,000 procedures (95% CI: 1.4–3.1/1,000 procedure). With the exception of procedural certification status as judged by institutional faculty, there was no association between our resident measurements and procedural complications.ConclusionsOur findings support the need for a resident procedural competence certification system based on direct observation. Our data support the ABIM’s action to remove resident procedural competence from the monthly ABIM-MEF ratings.

Simulation for Training Internal Medicine Residents in ACLS – What did we learn?

Simulation for Training Internal Medicine Residents in ACLS – What did we learn?

The research rotation: competency-based structured and novel approach to research training of internal medicine residents

BackgroundIn the United States, the Accreditation Council of graduate medical education (ACGME) requires all accredited Internal medicine residency training programs to facilitate resident scholarly activities. However, clinical experience and medical education still remain the main focus of graduate medical education in many Internal Medicine (IM) residency-training programs. Left to design the structure, process and outcome evaluation of the ACGME research requirement, residency-training programs are faced with numerous barriers. Many residency programs report having been cited by the ACGME residency review committee in IM for lack of scholarly activity by residents.MethodsWe would like to share our experience at Lincoln Hospital, an affiliate of Weill Medical College Cornell University New York, in designing and implementing a successful structured research curriculum based on ACGME competencies taught during a dedicated "research rotation".ResultsSince the inception of the research rotation in 2004, participation of our residents among scholarly activities has substantially increased. Our residents increasingly believe and appreciate that research is an integral component of residency training and essential for practice of medicine.ConclusionInternal medicine residents' outlook in research can be significantly improved using a research curriculum offered through a structured and dedicated research rotation. This is exemplified by the improvement noted in resident satisfaction, their participation in scholarly activities and resident research outcomes since the inception of the research rotation in our internal medicine training program.

97: 12-Lead Electrocardiogram Interpretation Skills of Senior Medical Students Entering Emergency Medicine, Family Practice, and Internal Medicine Residency Training Programs

Electrocardiogram (ECG) interpretation is an important clinical skill for senior medical students (MS) entering emergency medicine (EM), family practice (FP), and internal medicine (IM) residency programs. Research shows senior MS have deficiencies in ECG interpretation and that these skills do not change over the final year of medical school. However, little information is available describing these skills among senior MS entering these programs. This study aims to describe how residency aspiration impacts ECG interpretation skills.

Are Internal Medicine Residency Programs Adequately Preparing Physicians to Care for the Baby Boomers? A National Survey from the Association of Directors of Geriatric Academic Programs Status of Geriatrics Workforce Study

Patients aged 65 and older account for 39% of ambulatory visits to internal medicine physicians. This article describes the progress made in training internal medicine residents to care for older Americans. Program directors in internal medicine residency programs accredited by the Accreditation Council for Graduate Medical Education were surveyed in the spring of 2005. Findings from this survey were compared with those from a similar 2002 survey to determine whether any changes had occurred. A 60% response rate was achieved (n=235). In these 3-year residency training programs, 20 programs (9%) required less than 2 weeks of clinical instruction that was specifically structured to teach geriatric care principles, 48 (21%) at least 2 weeks but less than 4 weeks, 144 (62%) at least 4 weeks but less than 6 weeks, and 21 (9%) required 6 or more weeks. As in 2002, internal medicine residency programs continue to depend on nursing home facilities, geriatric preceptors in nongeriatric clinical ambulatory settings, and outpatient geriatric assessment centers for their geriatrics training. Training was most often offered in a block format. The mean number of physician faculty per residency program dedicated to teaching geriatric medicine was 3.5 full-time equivalents (FTEs) (range 0-50), compared with a mean of 2.2 FTE faculty in 2002 (P<or=.001). Internal medicine educators are continuing to improve the training of residents so that, as they become practicing physicians, they will have the knowledge and skills in geriatric medicine to care for older adults.

How Do Internal Medicine Residency Programs Evaluate Their Resident Float Experiences?

We surveyed the nation's internal medicine residency training program directors to determine the range and frequency of existing methods by which float experiences are evaluated. We sent questionnaires to the program directors of all 396 internal medicine residency training program sites in the country. Information requested included program characteristics, months devoted to float experiences in each year of training, and the location and purpose of the rotation. Program directors were also asked to choose among descriptors characterizing the evaluative process. There were 139 responding programs (39%), 134 with data that could be aggregated. Responding programs were similar to all programs nationally in the distributions of size and university sponsorship. Overall, 76% of programs employed a night float for any period of time, and 71% currently had one, on average for 6.7 years. Mean months of float experience during residency was 2.4 months, significantly longer in programs that were not university based. Float experiences were evaluated in 89% of those programs who employed them, with ten different methods reported. University-based programs were significantly less likely to use chart review as a method of evaluation, but no other differences in methodology were significant. Float rotations are common among internal medicine residency training programs. Evaluative methods vary, but one or more are applied in the vast majority of programs.

Personal growth and its correlates during residency training

To explore the characteristics of and factors associated with personal growth during residency training. In 2003, 359 house officers on 7 internal medicine residency training programmes in the USA were surveyed about their training experiences and issues related to their personal growth. Factor analysis and internal reliability testing were used to develop a 'personal growth scale'. Logistic regression models were then used to identify independent associations between individual variables and 'high' versus 'low' personal growth scores. A total of 281 house officers (80%) responded. The personal growth scale had a Cronbach's alpha of 0.81. Factors that were independently associated with achieving high amounts of personal growth during residency training included: agreeing that reflection is important during residency training (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.1-7.4); being male (OR 2.6, 95% CI 1.4-4.5); being non-white (OR 2.2, 95% CI 1.3-3.9); having a strong desire to develop personally and professionally (OR 2.2, 95% CI 1.1-4.1), and feeling highly supported by one's programme director (OR 2.1, 95% CI 1.2-3.9). Independent predictors of scoring below the median on the personal growth scale included feeling emotionally isolated at work (OR 0.4, 95% CI 0.2-0.7) and noting that negative or disappointing experiences had been powerful (OR 0.4, 95% CI 0.2-0.9). Disparate amounts of personal growth occur among trainees during residency training. Residency programmes interested in promoting personal growth among their trainees may wish to focus on modifiable factors that are associated with personal growth, such as fostering supportive relationships and encouraging reflection.

Residents’ Perceptions of a College Health Clinic to Train Internal Medicine Residents in Adolescent and Primary Care Internal Medicine

Purpose To assess internal medicine residency graduates’ perception of the value of a college health clinic in providing adolescent medicine and general primary care training to internal medicine residents. Methods An 11-item questionnaire was sent in mid-2004 to all physicians who had received training at a college health clinic during their internal medicine residency program. Variables examined included time in the clinic and current practice characteristics. In addition, the physicians were asked to compare their residency college clinic with their continuity clinic in the following educational areas: care of the adolescent patient, diagnosis and management of primary care conditions, coding, practice modeling, and overall learning experience. Results There was a response rate of 71% (30/42). Respondents reported that 31% of their current patients had conditions seen at the college health clinic. The college clinic was felt to be better than the continuity clinic in preparation for the office practice of general internal medicine; the care of the adolescent patient; the diagnosis and management of illnesses such as upper respiratory infections, urinary tract infections, and eating disorders; modeling an effective and efficient office practice; and as an overall learning experience. Ninety percent of respondents recommended continuing the use of a college clinic as part of the educational experience for internal medicine residents. Conclusion Internal medicine residency training programs should consider using college health clinics to provide adolescent medicine training and training for the practice of primary care medicine.

Effects of internal medicine residency training in AIDS care in Taiwan

Having contact and interacting with HIV/AIDS patients has long been recognized as a means for improving AIDS-related knowledge and attitudes among physicians and hence for increasing their intention to provide AIDS care. To investigate the impact of one-month residency training in an AIDS inpatient unit on internal medicine residents, this quasi-experimental, pre-post, two-group study, conducted from April 2000 to April 2001, used questionnaires. At follow-up, residents who received training in the AIDS unit (experimental group) were significantly more knowledgeable about HIV/AIDS, had more positive attitudes and greater intention to care for HIV-infected patients than residents who did not receive this training (control group). Results suggest that a one-month AIDS residency training intervention can effectively enhance residents' HIV-related knowledge, attitudes and intention to care for patients infected with HIV.

Achieving Housestaff Competence in Emergency Airway Management Using Scenario Based Simulation Training: Comparison of Attending vs Housestaff Trainers

<h3>Study objectives</h3> To evaluate a teaching protocol comparing a critical care attending to a housestaff team in training medical interns in initial airway management skills using a computer-controlled patient simulator (CPS) and scenario-based simulation training (SST). <h3>Design</h3> Prospective, randomized, controlled, unblinded trial. <h3>Setting</h3> Internal medicine residency training program in an urban teaching hospital. <h3>Participants</h3> Forty-nine starting internal medicine interns in July 2003, all of whom had been certified in advanced cardiac life support in June 2003. <h3>Interventions</h3> All interns were tested and scored with a CPS while responding to a standardized respiratory arrest scenario. Random allocation to either training by a single experienced teaching attending or by a housestaff team occurred immediately following testing. All interns were retested using the same scenario 6 weeks following the initial training, and their clinical performance of airway management was scored during actual patient events throughout the year. <h3>Measurements</h3> Initial airway management was divided into specific scorable steps. For each intern, individual step scores and total scores were recorded before and after training. For 10 consecutive months following training, intern airway management scores were recorded for actual patient airway events. <h3>Results</h3> All starting medical interns demonstrated poor initial airway management skills. SST was effective in improving these skills, both on retesting with the patient simulator and in actual patient situations. Interns trained by a housestaff team performed as well as interns trained by the attending. <h3>Conclusions</h3> SST is effective in training medical interns, and the results are equivalent whether the training is provided by an experienced teaching attending or by a housestaff training team.

Physician Familiarity With Diagnosis and Management of Hypertension According to JNC 7 Guidelines

Physician knowledge of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines is unknown and may contribute to the prevalence of uncontrolled hypertension. Our objective was to determine physician knowledge of JNC 7 guidelines and whether online instruction could improve knowledge. A pretest served as baseline knowledge, and comparison with a post-test after completing an online didactic demonstrated improvement in knowledge. Participants included 1280 physicians at 45 internal medicine residency training programs. Average baseline knowledge of six concepts of hypertension was 51.2%. Attending physicians performed better than trainees on some but not all concepts (p<0.05). Third-year post-graduate trainees performed better than first-year trainees on some but not all concepts (p<0.05). Knowledge increased significantly on all concepts after completing the curriculum (p<0.05). The authors demonstrated that physician knowledge of JNC 7 guidelines is poor but can be improved by an online curriculum. Further study is needed to determine the impact of physician education on clinical outcomes in individuals with hypertension.

Mentoring Matters: Mentoring and Career Preparation in Internal Medicine Residency Training*

Mentoring Matters: Mentoring and Career Preparation in Internal Medicine Residency Training*

Redesigning Training for Internal Medicine

The American College of Physicians supports the need for reform throughout the continuum of training in internal medicine. Today's internists must have the necessary knowledge, skills, and attitudes to meet the challenges of an expanding body of medical knowledge and a rapidly evolving system of health care delivery. Suggested priorities for undergraduate medical education include redesigning curricular experiences to afford students earlier and more exposure to career opportunities in internal medicine, improving ambulatory education, exposing students to outstanding faculty role models in internal medicine, and incorporating educational experiences during the fourth year that optimize its value and relevance to the student's future career plans in internal medicine. Internal medicine residency training should remain a 3-year experience, with a component of core education common to all trainees and a component of customized training in the third year targeted toward the resident's career goals. Residency programs should be designed around educational rather than institutional service needs. The ambulatory component of training requires substantial reform in its structure, sites, content, and timing. Team-based models should be used both for patient care and for flexibility in design of residency training. Better faculty models must be developed that build on the concept of a "core faculty," improve the rewards for teaching faculty, and provide appropriate faculty development focusing on a necessary set of educator competencies.

Mentoring Matters: Mentoring and Career Preparation in Internal Medicine Residency Training*

Journal of General Internal MedicineVolume 21, Issue 4 p. A‐4-A‐4 Free Access Mentoring Matters: Mentoring and Career Preparation in Internal Medicine Residency Training* First published: 03 May 2006 https://doi.org/10.1111/j.1525-1497.2006.00346_1.x Address correspondence and reprint requests to Dr. Ramanan: Director of Faculty Development, Center for Health Education, Long Beach Memorial Medical Center, University of California, Irvine, 2801 Atlantic Avenue, Long Beach, CA 90806 (e-mail: rramanan@memorialcare.org) AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Abstract Mentoring is associated with career satisfaction and enhanced development of expertise. Given recent reports of burnout and stress during residency, we conducted a survey of Internal Medicine Residents to examine mentoring relationships and perceived career preparation. 93% of residents described the importance of mentoring, but only half identified a mentor. Few interns and underrepresented minority residents identified a mentor. Mentored residents were more likely to describe excellent career preparation. We identified qualities of mentoring and barriers to finding a mentor. We encourage educators to re-examine the critical role of mentoring during residency training, and to facilitate the development of mentoring relationships. Volume21, Issue4April 2006Pages A‐4-A‐4 RelatedInformation

Announcement

ANNOUNCEMENTSAnnouncementPublished Online:01 Apr 2006https://doi.org/10.1152/ajprenal.00005.2006MoreSectionsPDF (40 KB)Download PDF ToolsExport citationAdd to favoritesGet permissionsTrack citations ShareShare onFacebookTwitterLinkedInEmailWeChat Dr. Peter Igarashi has been named the 2006 Carl W. Gottschalk Distinguished Lecturer of the American Physiological Society (APS) Renal Section. Dr. Igarashi will deliver the lecture, entitled “Transcriptional mechanisms of renal cystogenesis,” on Sunday, April 2, 2006, during the Experimental Biology Meeting in San Francisco, California. Dr. Igarashi will also be honored during the Renal Dinner on Tuesday, April 4, 2006.Dr. Igarashi received his B.S. degree with Highest Honors from the University of California, Riverside, in 1978. He attended medical school at the University of California, Los Angeles, earning the M.D. degree in 1981. After internship and residency training in Internal Medicine at the University of California, Davis Medical Center, he completed a nephrology fellowship at Yale University School of Medicine (1984–1987). During this period, he received research training in the laboratory of Dr. Peter S. Aronson. Dr. Igarashi accepted a faculty position as Assistant Professor of Medicine at the Yale University School of Medicine in 1987 and was promoted to Associate Professor in 1992. He moved to the University of Texas Southwestern Medical Center in 1999 as Professor in the Department of Internal Medicine and Chief of the Division of Nephrology. In 2000, he was named the Robert Tucker Hayes Distinguished Chair in Nephrology, in Honor of Dr. Floyd C. Rector, Jr. He has published more that 45 peer-reviewed manuscripts, 5 book chapters, and 9 review articles. Dr. Igarashi has served on several study sections, advisory committees, and editorial boards, including the American Journal of Physiology-Renal Physiology, and he is currently Associate Editor of the Journal of the American Society of Nephrology.Dr. Igarashi's research focuses on kidney development, kidney-specific gene regulation, and polycystic kidney disease. He has been working to define the genetic pathways that regulate normal kidney development and to identify alterations in the pathways that are responsible for cyst formation in polycystic kidney disease. In particular, his studies are probing the roles of hepatocyte nuclear factor-1β and renal cilia in the pathogenesis of cyst formation. This work uses a combination of biochemical and genetic approaches in transgenic, knockout, and conditional knockout mice to identify and characterize the transcription factors that regulate clinically relevant genes.The APS Renal Section's Distinguished Lectureship Committee was composed of Pamela K. Carmines (Renal Section Chair), P. Darwin Bell (Renal Section representative to the APS Joint Program Committee), Jeff M. Sands (Editor, American Journal of Physiology-Renal Physiology), and Douglas C. Eaton (APS President). Download figureDownload PowerPointThis article has no references to display. Download PDF Previous Back to Top Next FiguresReferencesRelatedInformation More from this issue > Volume 290Issue 4April 2006Pages F946-F946 Copyright & PermissionsCopyright © 2006 the American Physiological Societyhttps://doi.org/10.1152/ajprenal.00005.2006History Published online 1 April 2006 Published in print 1 April 2006 Metrics Downloaded 61 times

Mentoring matters. Mentoring and career preparation in internal medicine residency training.

Mentoring during the early stages of a career has been associated with high career satisfaction and may guide development of professional expertise. Little is known about mentoring experiences during residency training. Our purpose was to describe mentoring relationships among internal medicine residents, and to examine the relationship between mentoring and perceived career preparation. We designed and administered a mailed survey to all interns and residents enrolled in the five independent Internal Medicine Residency Training Programs affiliated with Harvard Medical School. We examined the development of mentoring relationships during residency training, and measured satisfaction with mentoring and with perceived career preparation. Of the 329 respondents (65% response rate), 93% reported that it is important to have a mentor during residency, but only half identified a current or past mentor. Interns [adjusted odds ratio (AOR) 0.3 (95% confidence interval (CI) 0.2, 0.5)] and underrepresented minority residents [0.3 (0.1, 0.7)] were significantly less likely to establish a mentoring relationship than their peers. Mentored residents were nearly twice as likely to describe excellent career preparation [1.8 (1.1, 3.1)]. Our findings demonstrate the importance of mentoring to medical residents, and identify a relationship between mentoring and perceived career preparation. We also identify a relative lack of mentoring among interns and underrepresented minority residents.

Internal medicine residency training in Turkey

Medical school entrance depends on passing a central examination that is given annually by the National Selection and Placement Center. Undergraduate medical education takes 6 years. About 5000 students graduate from medical faculties annually. The central exam necessary for residency training is given by the National Selection and Placement Center. A Specialist Training Regulation regulates residency training. Internal medicine residency training takes 4 years and includes inpatient and outpatient care in wards and rotations. Residents prepare a dissertation that is used in the evaluation of residency competency. At the end of the residency period, residents who have been successful in previous evaluations take an oral exam followed by a written exam, which lead to their certification in internal medicine. Residents' scientific knowledge and skills are assessed by a jury consisting of five people, four from the same department and one from the equivalent department in another training institution. The title of specialist is granted after a certification exam given by training institutions and approved by the Ministry of Health. Internists are mainly employed in state hospitals, which are under the Ministry of Health. Subspecialty areas in internal medicine include gastroenterology, geriatrics, endocrinology, nephrology, hematology, rheumatology, immunology, allergology, and oncology. The training period for a subspecialty is 2 years. A substantial effort is being made all over the country to improve regulations and health care service delivery. These changes will also affect the residency training and manpower planning and employment of internists.

Reforming internal medicine residency training. A report from the Society of General Internal Medicine's task force for residency reform.

The structure, process, and outcomes of internal medicine residency training have concerned the profession for over 20 years.1–9 Over the last decade the initiative to move to outcomes-based education redefined the competencies physicians should obtain during training.10,11 The core principle of outcomes-based education is the objective demonstration that a graduating trainee, whether from medical school or a residency, possesses the knowledge, skills, and attitudes necessary to progress to the next stage of his or her professional career.12,13 The Accreditation Council for Graduate Medical Education (ACGME) and the Institute of Medicine (IOM) have defined core competencies for physicians shown in Table 1.10,14 While both the ACGME and IOM provide a framework for the desired outcomes, medical educators bear the burden of designing the structures and processes to achieve them.15 Table 1 Comparison of the IOM and ACGME Competencies Educators face several key challenges in redesigning residency programs. First, residency programs must prepare trainees for a variety of general internal medicine and subspecialty careers. Second, the settings and resources for residency training are highly heterogeneous. Third, an aging and increasingly diverse population, combined with rapidly expanding medical information and procedural technology, challenges all internists to acquire and maintain the knowledge, skills, attitudes, and performance necessary to provide high-quality care within their chosen discipline.16,17 Finally, growing public dissatisfaction, substantial health care disparities, increased acuity but shorter lengths of stay for hospitalized patients, new work hour requirements, increasing medical student debt, and changing student demographics and lifestyle concerns further complicate residency reform.18–25 To provide recommendations for residency reform. The Society of General Internal Medicine (SGIM) convened a task force consisting of physicians representing a broad range of views within general medicine, expertise and experience in clinical education, and who represented internal medicine organizations outside of SGIM (Appendix 1). The task force focused on reform in 5 specific areas: ambulatory education, inpatient education, residency curriculum, health disparities, and life-long learning skills. To prepare this report, 4 subcommittees performed literature reviews that guided a prospective, systematic process to develop the final recommendations. The guiding principles, task force timeline, and the specific findings of the 4 subcommittees can be viewed at http://www.sgim.org. We acknowledge this report cannot cover all important aspects of residency training. The task force enthusiastically welcomes comments from other educators and internal medicine specialty organizations. Only through active collaboration and serious dialogue can we improve residency training.