Will Any Road Get You There? Examining Warranted and Unwarranted Variation in Medical Education

Eric S. Holmboe, Jennifer R. Kogan. (2022). Will Any Road Get You There? Examining Warranted and Unwarranted Variation in Medical Education  Academic Medicine. 2022 Aug; 97(8): 1128–1136.

Summary

In this narrative article, Drs Holmboe and Kogan eloquently articulate many of the challenges of unifying a growing and evolving medical education system in the United States. While medical schools and residency programs advertise their uniqueness and distinguishing features, and some of these features do indeed offer a benefit to the learner, it is imperative that trainees are given the broad range of knowledge and skills that will allow them to practice in their desired specialty and clinical setting efficiently and effectively. In this article, the authors identify a number of sources of ‘unwarranted variation' in clinical training and begin to address how overseeing bodies, individual institutions, and even the trainees themselves can help minimize the negative impact these variations can have on the education of clinicians.

Interview

AD: Can unwarranted variation in training experiences be an even greater challenge in some specialties/programs/areas relative to others?

EH: Unwarranted variation exists across all specialties, yet the magnitude of the variance is still unknown. One would hypothesize that more variation is likely the larger the specialty and number of programs, along with the number of settings and where they're located. For example, even within Family Medicine, one urban program may focus on underserved communities and another on wealthier populations. A program's location is going to change the nature of who you care for and therefore what you experience as a trainee. Medicine is not like riding a bike – there are so many variables to consider for training.

AD: Why aren't accreditation and certifications enough to prevent unwarranted variance in training? What else can be done?

EH: Accreditation and certification certainly help but there's limits to what they can do before they become constraining in ways that are counterproductive. There's always a tension between specifying requirements versus making sure there's space for improvements and customization. It's important to ensure we're defining the key outcomes and requirements to reduce variation upon graduation and creating homogenous requirements. Trainees must take ownership of this as well - each trainee, especially as they move to a new location or new setting or new job, must understand their current strengths and abilities, but just as importantly, where the gaps are and where they didn't get sufficient experience. That'll help ensure their continuous professional development supports a journey to expertise.

AD: What does this mean for a trainee that's trying to choose the program that's best for them?

EH: It's critical to consider your future career path when deciding between programs. There has to be clarity around the purpose of your experience in preparation for what you're training for. If you see your career leading to work in a certain setting or with a certain patient population, then you should seek training that aligns with that experience. Your preferences or career may change over time, but identifying your purpose early will help ensure you're gaining relevant experiences. Additionally, consider how Learners are taught in each program. For example, programs with more group discussion and collaboration fosters distributed cognition in clinical reasoning, which can lead to better outcomes. Group discussion not only lowers the risk of diagnostic errors, but also reduces unwarranted variation in training and ensures that Learners can determine the best way to approach a variety of situations.

AD: What does this mean for training programs and how they're structured? For example, the ACGMEs 2021 requirement changes for Internal Medicine set a minimum of 10 months of outpatient time for trainees across the 3 year residency, but this can cut into ICU time. Is there an ideal balance?

EH: While there may be utility in specific clinical experiences, we have to be clear about the purpose of each rotation in reference to the desired outcomes. If I am going to be exclusively an outpatient internist, then what is the purpose of ICU training and how much do I need? How will ICU training make me a better outpatient internist? It'd be ideal to design the third year of residency using competency-based medical education principles to prepare them for their chosen career pathway.

Blog Post Author

Dr Alexander Davies is a chief fellow in Pulmonary and Critical Care Medicine at the University of Maryland Medical Center. He completed his medical school training at SUNY Downstate followed by a combined residency in Internal and Emergency Medicine at the University of Illinois, Chicago where he also served as a chief resident. His primary passions are early resuscitation of critically ill medical ICU patients, the palliative care of patients with end-stage obstructive lung disease, and trainee education from the student to resident level, especially in the intensive care setting.

Twitter: @daviesalexander

Article Author

Dr Eric Holmboe currently serves as the chief of Research, Milestones Development and Evaluation at the ACGME. He is also holds Adjunct Professor of Medicine roles at Yale University, the Uniformed Services University of the Health Sciences, and the Northwestern University Feinberg School of Medicine.  He previously served as the Associate Program Director for the Yale Primary Care Internal Medicine Residency Program and as the Director of Student Clinical Assessment for the Yale School of Medicine. Before joining Yale in 2000, he served as Division Chief of General Internal Medicine at the National Naval Medical Center. He also previously served as a medical student clerkship director and residency training officer at the Portsmouth Naval Medical Center.

His research interests include interventions to improve quality of care, outcomes-based medical education across the continuum, and methods in the assessment and evaluation of clinical competence. His professional memberships include the American College of Physicians, where he is a Master, the Society of General Internal Medicine, and the Association of Medical Education in Europe. He is an Honorary Fellow of the Royal College of Physicians in London and the Royal College of Physicians and Surgeons of Canada. He is also an Honorary Fellow of the Academy of Medical Educators in Europe.

Twitter: @boedudley