Wednesday, January 15, 2014

The Never Ending Residency

The January issue of Anesthesiology highlights changes in anesthesiology residency training that are about to be implemented. And it is not good news for future residents. Because the American Board of Anesthesiology somehow feels that residents are struggling tremendously once they are in private practice, it has decided to begin a protocol called the Objective Structured Clinical Examination. It is basically a series of milestones and simulations that residents must master before they can graduate from residency and become board certified starting in 2017.

After torturing new anesthesiologists for decades with the Oral Boards examination, the ABA is reassessing the actual usefulness of the exam in predicting the competency of the examinees. They have come to the conclusion that Boards Parts 1 and 2 only test a doctors ability to know the disease process and knows how to deal with it. What they are looking for now is any insight into whether a doctor can show how he will treat the problem and actually does it. Thus the new milestone and simulation requirements.

They justify this additional approach to residency teaching by first pointing fingers at Israeli and United Kingdom training programs. The Israeli Board of Anesthesiology has its doctors go through five different simulation stations: trauma management, resuscitation, OR crisis management, mechanical ventilation, and regional anesthesia. The UK authorities have its residents go through a gantlet of sixteen simulations, including communications skills and X-ray interpretations.

But before residents even make it to the simulations, they must first successfully complete their programs, which has become extremely complex. According to the ABA, residency directors have categorized 25 milestones that the residents must achieve before they are allowed to graduate. And here's the kicker: the residents may be stuck in a state of purgatory if they are unable to pass through all the milestones.

It is assumed that not all residents will progress through training at the same rate. Some will show extreme competency in under the three years that are currently required and might be able to finish early. Meanwhile others may be slower to reach the same levels and need more time to finish residency. The authors acknowledge that this sets up a difficult situation for fellowship training programs as new fellows may start their training at almost any month of the year. And they caution that program directors should not stigmatize a resident who may be on his fourth or fifth year of residency training.

But is that really possible? If there is an anesthesiology resident who is going through a CA 5 year because he just can't seem to complete that last milestone even though he has shown his capabilities with everything else, won't there be a natural tendency for the educators and other residents to look down on him? Can a residency really suggest to the lagging resident that he should go into something else after all the time invested just because of some arbitrary milestone developed by those sitting up in their ivory towers thousands of miles away?

Lastly, these new milestones raise the troubling question of how much training is too much. Is the ABA suggesting that thousands of anesthesiologists it has certified in the last century are somehow not good enough and pose a danger to patients? This was before my time, but if I recall correctly, anesthesiology training used to take only two years instead of the current three. Plus they only had to take their certification exams once and never have to be bothered with it again. Is the ABA saying these doctors who received their board certifications with half the training of current residents able to magically demonstrate their clinical skills without going through the series of milestones and simulations that are going to be enforced on new trainees?

I am so glad I finished my training over a decade ago. I couldn't imagine the tediousness of residency today, with its checklist method of training physicians. In the ABA's earnestness in graduating the perfect doctor and anesthesiologist, they possibly are forcing residents to go through a Groundhog Day of repetition until they get their skill set completed as determined by some committee. Somehow I don't think that makes for better physicians, just better test takers.

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