A new model for internal medicine residencies, stressing education but reducing trainee workload, markedly increased satisfaction among interns, residents, and the attending physicians training them, according to a report.
The new residency approach was designed to increase trainees' opportunities to pursue subjects in depth, engage in reflection, spend more time with patients, and interact more with teachers and mentors—in short, to make internal medicine residency “an educational experience rather than an exercise in technical training,” said Dr. Graham T. McMahon of Brigham and Women's Hospital, Boston, and his associates.
In a direct comparison with the existing internal medicine residency program at a community teaching hospital affiliated with Brigham and Women's, the new model met many leading recommendations for graduate medical education reform without negatively affecting patient care.
The Integrated Teaching Unit (ITU) model included a reduced clinical workload and decreased call frequency for the trainees. Each ITU training team consisted of two attending physicians—one a hospitalist and the other an internist or specialist—who had been rated as superior in teaching ability. Each team supervised two residents and three interns.
Dr. McMahon and his colleagues said that bedside teaching was enhanced by the participation of both attendings, who were compensated for their extra time, as well as by the multidisciplinary nature of the instructors.
The researchers assessed the 1-year experience of two ITU teams that cared for 1,892 medical inpatients and two regular (control) residency teams that cared for 2,096 medical inpatients. Trainees spent time on both ITU and regular residency teams. The regular training teams were made up of multiple attending physicians who volunteered to participate.
In the ITU program, trainees spent twice as much time (20% of total time vs. 10% compared with controls in the regular program) pursuing educational activities such as self-directed learning, didactic sessions, and conferences. They spent significantly less time (37% of total time vs. 45% compared with controls) doing “indirect” patient care such as reviewing charts, writing notes, and entering orders.
The two groups spent a similar amount of time at the bedside, but ITU trainees “had a significantly lower patient census, meaning that the time they spent per patient at the bedside was greater (by almost 50%),” the investigators wrote.
Residents and interns reported significantly higher satisfaction with their training in the ITU program, saying that they learned more new skills, received more feedback from attendings, and participated in more patient follow-up than those in the regular program. They reported that they used the additional time in their workdays for reflection and self-appraisal.
Attending physicians also reported the ITU model was closer than the existing model to their teaching ideal. Not only were their teaching skills well used, they said, but also they learned from their teaching teammates.
Trainees and attendings reported liking the increased exchange of ideas, the deeper insights into clinical thinking, and the mix of teaching styles that the dual-attending supervision allowed.
Patient responses on surveys of their satisfaction with their hospital experience and with their physicians did not differ between the training styles. There also was no significant difference in rate of hospital readmission within 30 days, cause of death, or ratings on 11 measures of quality of hospital care.
“Our study shows that an educationally centered program, constructed to address the educational needs of trainees, can be successfully introduced without adversely affecting the quality of care,” Dr. McMahon and his associates said (N. Engl. J. Med. 2010;362:1304-11).
In an editorial, Dr. Kenneth M. Ludmerer of Washington University, St. Louis, said the comparison in the study “clearly demonstrates” the benefits of a rich learning environment. The study “helps to point out where our priorities in residency education should be,” he said (N. Engl. J. Med. 2010;362:1337-8).
Dr. Ludmerer added that the study could not assess all patient benefits with the ITU model, but those plausibly include “the traditional hallmark of good care,” physician thoroughness. In this context, the word does not mean ordering every test, he said.
“Rather, it means paying attention to detail, being careful, not missing things, and not jumping to conclusions. It is reasonable to hypothesize that residents who have the time to be careful will order fewer unnecessary tests and procedures, use resources more efficiently, and make fewer avoidable mistakes,” he noted.
Disclosures: Dr. McMahon and his associates reported no financial conflicts of interest.