Graduate Medical Education in 2018 From the Perspective of a 1992 Intern

by Rick Musialowski Jr., MD, FACC, FASE

Richard Musialowski Jr., MD, FACC, FASE
Rick Musialowski Jr.
As the director of cardiovascular education at Atrium Health’s Sanger Heart & Vascular Institute, my primary role is the education of learners of many different education levels with exposure to inpatient and outpatient care. It became evident that the paradigm of medical education has shifted in parallel to the shifts of education and society in general.

There are still system-based methods, basic science and bedside decision-making, but the method of information transference and accountability is very different. There will be some regional variability as well as institutional nuance. As generational shifts have occurred, graduate medical education (GME) and the profession in general had to adapt.

Changes Over Time

I was an intern in 1992 under a traditional intern schedule. I decided my career in cardiology in the early morning hours as the intern covering the cardiac care unit (CCU) at Buffalo General Hospital. My first day as a resident was under the Bell Commission recommendations in New York.

GME began its metamorphosis. Technology was in its infancy in the 1990s. Some hospitals were just getting computers for basic lab access and the trip to radiology and the micro lab were the daily pilgrimages. Technology is now an essential part of every medical professional’s daily life. 

Embracing Change

According to the Association of American Medical Colleges (AAMC), 2016 is the first time that women have surpassed men as entrants to medical schools. American medical schools are embracing the needed diversity of its student body to serve the increasingly diverse population of the United States. Sensitivity to cultural differences, as well as concern for the learner’s quality of life and well-being, have emerged as an important part of their development. In the past, the nontraditional medical school candidate may have been the first to pursue a medical career or even the first of their family to graduate from college. Now, these candidates are the norm. The new, nontraditional students reflect the changes of American society, including diversity of race/ethnicity, religion, sexual orientation and disabilities.

‘A Fundamentally Different Delivery System’

GME has transformed into a fundamentally different delivery system. Previously, it was common to admit and follow the patient’s hospital course to discharge. The legislated changes in work-hour requirements cause fragmentation of patient care and the learning process. A greater effort is needed to assure full exposure to disease states while administering appropriate care and optimizing education.

Moreover, communication between residents is different today. Many different residents and advanced care providers (ACPs) will be involved in a patient’s care. This generation of learners are much better at digital communication about patient care, but the content and delivery are very different. A verbal sign-out of the past would be terse with heavy emphasis on duties to be completed. Today, the duties are discussed, but the discussion is more of a social interaction among the learners with many social aspects of the patients’ care as part of the sign-out.

The fragmentation also creates a different sense of ownership of patient responsibilities. The sign-outs are frequently passing different responsibilities to other learner colleagues as well as onto ACPs. The sense of ownership and responsibility is noticeably different than earlier years. It has become common to state in a daily note “new to me” as a disclaimer that the author may not know the full clinical details. As a result, documentation is more reproduction, instead of new contribution. The old paper charts required a newly created daily note, but the information was not as detailed. Hopefully, it was legible!

Rounding in the pre-technology era required that all pertinent data were written on the 3x5-inch index cards and quickly reproducible by looking and hoping you wrote it down while gathering data early that morning. I was not always fortunate to know what was needed, and rounds may stop to find my missing data point. Now, we can just open the electronic medical record (EMR) application on our phone without disrupting the flow of rounds. Current GME learners are excellent in data acquisition and collation. Their ability to lever technology reflects their generation. This is reflective in their bedside presentations in which large volumes of data are discussed, but integration and implementation seem of lesser importance. Offering a differential diagnosis often appears secondary to the presentation of data. It is also acceptable to search answers on smart devices on rounds, but integration on secondary questioning is incomplete and re-examination later in the day often shows lack of retention. It appears to be a function of fear of failure. Being wrong is worse than not knowing. I have contemplated banning phones on rounds.

‘Ghosted’ and Other Challenges Remain

Professionalism and quality patient care will always be a cornerstone of medical practice, but its meaning has also developed.

Recently, a student on rounds presented incorrect information and confidently presented wrong data. I corrected the student on rounds and explained the danger of such behavior. The student then disappeared for the rest of the day. That student essentially “ghosted” the teaching service and care for that patient, requiring another team member to take responsibility. That evening, the learner expected a phone call from me to discuss the occurrences of the day. That would have resulted in absolute failure of the rotation or worse under the old education system.

The unprofessional behavior of sexual harassment and bombastic behavior in the past was viewed as unprofessional behavior but often tolerated. Current professionalism has zero tolerance of such actions, which jeopardize patient care and workplace safety. Appropriately so!

‘Fear of Failure Needs to Be Eased’

In my opinion, the direction of medical education needs to have a much larger emphasis on information integration and critical thinking.

The use of simulation labs is increasing, which will facilitate real-time decision-making. Previously, knowledge was the sign of excellence. Professionalism was unconditionally expected.

I think the ability of critical thinking and professionalism will be the new sign of superiority and excellence. Knowledge is at our fingertips, but one cannot easily lever technology to critical medical analysis. At least not yet. I think protocolization of medicine may worsen this lack of critical thinking and retention. The point-and-click approach and super computer artificial intelligence may erode this even further. 

A fear of failure needs to be eased to allow the important development of critical thinking skills, but at what cost?

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Rick Musialowski Jr., MD, FACC, FASE, is director of cardiovascular education at Sanger Heart & Vascular Institute-Atrium Health Care System.