It's been a busy beginning to 2014. The week after our EMRA Board of Directors retreat for strategic planning, I traveled to Chicago for the biannual Council of Review Committee Residents (CRCR) meeting. The CRCR is composed of residents from every specialty accredited through the ACGME, so instead of focusing on things important to individual specialties, the CRCR works on making a global impact. A 30,000-foot view, if you will.
The sentiment was set by the chairman, who opened with, “Our work here is to change the landscape of our profession.” The major group exercise for this meeting was a discussion on progressive independence and appropriate oversight. I was placed in the hospital-based subgroup along with representatives from radiology, genetics, nuclear medicine, and pathology – who knew nuclear medicine had an RRC? Through spirited discussion, we came to a few absolutes.
First, a “one-size-fits-all” approach to how medical education is provided does not work. Several members voiced concerns about too much or too little supervision in residency training, but none of them are emergency physicians. I couldn't help but wonder; can you generalize your own anecdotal experiences to an entire specialty?
Second, the Milestones should be a bridge for faculty to gauge how much independence a resident has earned – part of the spirit in the formation of Milestones. We were all in agreement that the faculty should have this outcomes-based data at their fingertips, so they can know in which areas residents need more supervision. Billing and reimbursement implications aside, shouldn't the goal of residency training be to have minimal oversight with appropriate supervision, earned over time? The consensus concern from the group was that, in the near future, a fellowship may be required to prepare you for independent practice. I think we can all agree that if the first time a surgeon performs a nephrectomy by himself, or an emergency physician manages multiple patients alone, occurs after residency graduation, it won't be in the best interest of our patients.
The final issue the council agreed upon was that our culture of education must become more transparent. This might be achieved through honest feedback provided to attendings, and the expectation of timely, useful feedback in return. The days of “good job” as feedback must move to extinction. You should never be blindsided by your quarterly, or six-month, evaluation because “everyone told me I was doing fine.” It's hard to improve if you don't know you are not performing up to expectations.
It was apparent during the CRCR meeting that emergency medicine has earned a great deal of respect from its peers in a relatively short time. As I think about the pioneers of our specialty, like Drs. John Wiegenstein, Ron Krome, and George Podgorny, I believe they would be proud that we have taken a leadership role with the development of Milestones and the Next Accreditation System (NAS). In these times of change and relative uncertainty, as we attempt to stand on the shoulders of the giants in emergency medicine, EMRA is at the forefront advocating for our members.
| Topic | Consensus Results |
| Transition from residency to independent practice: Understanding the business side of medicine | 86% (18/21) |
| Progressive independence and appropriate oversight | 81% (17/21) |
| Patient Safety: Revisiting duty hours with respect to patient ownership and accountability | 62% (13/21) |
| Patient Safety: Transitions of care and handoffs | 62% (13/21) |
| Resident Well-Being: Mental health | 43% (9/21) |
| Resident Well-Being: Finances and planning for the future | 43% (9/21) |
| Reducing length of training, with reference to outcome-based assessments | 43% (9/21) |
| Incentivizing teaching among academic faculty | 38% (8/21) |
| Patient care in the age of of the EMR: Optimizing use of technology | 29% (6/21) |
This table was developed from a brainstorming session at our meeting in September. It represents the issues in graduate medical education the council thought were most important. The council and emergency medicine share a lot of the same angst about what the future holds for medical education.