of the current educational challenges and incorporating innovations to improve PGME.
The work–education balance may be best addressed with a discussion about what constitutes work versus education (although, as mentioned earlier, a clear-cut delineation between the two concepts is unlikely to be forthcoming as they remain intertwined during residency). Some patient care tasks require little repetition to master or do not greatly improve a learner’s understanding of the practice of medicine, but they may constitute a reasonable part of a learner’s duties in providing patient care. The balance of work and education in PGME can be tipped in favour of education by using other health professionals (e.g., phlebotomists, EKG technicians, laboratory technicians) to perform some of the more routine tasks. Operating room assistants, wound care nurses and nurse practitioners – provides clear principle and recommendations on resident
duty hours, directions and best practices.
From a professional standpoint, patient care during residency ethically dominates the learning role, requiring learners to fit their educational needs into their patient care duties. However, residents have empowered themselves to influence their dual role by developing professional organizations that are able to negotiate for their rights as service providers, including for the unique educational needs that must be met while providing patient care. While this capacity to influence the system offers many advantages, there is a potential risk of conflict with the learner’s role as professional.
Although changing, many faculty members who teach PGME have historically had little or no formal training in either educational principles or the impact of a rapidly evolving health care system and changing learner demographics on program delivery. [See the Faculty Development Re-Imagined paper.]
Increasing professional responsibility, previously referred to as graded responsibility, for patient care is a cornerstone of the current definition of PGME; however, it must be implemented carefully if it is to be congruous with good educational principles, including CBME. Alongside increasing professional responsibility is the need for graded supervision, junior learners perform simple, mundane tasks where repetition may have little educational benefit since they are not often observed and evaluated. They “put in their time” until they are senior enough to be rewarded with the more complex, relevant, engaging patient care duties, coupled with ready access to or observation by a supervisor. Junior learners who are inexperienced and more susceptible to errors secondary to fatigue can pose patient safety issues if they are not properly supervised.3 In addition, there is a lack of flexibility in the current system, in that learners are unable to move through residency at a pace that matches their abilities. Given that the selection processes for medical school and residency are rigorous, most candidates are able to attain the skills taught in
whose domains of competence overlap those of junior trainees – can also help deliver patient care and can free the resident to devote more time to educationally rich activities. The addition of these professionals could also enhance PGME by providing training, direct observation, feedback and assessment, particularly for junior learners. Widespread adoption of physician extenders (as in the United States) may shift the spectrum of patient care that physicians currently provide – effectively narrowing the professional domain – so that junior trainees would become responsible for more complex care and would have a decreased volume of work overall.
The CanMEDS framework is a competency-based system of medical education. The Royal College has been adapting medical education in Canada to become more congruent with this framework. PGME may become more efficient in a CBME system where learners progress by demonstrating competence in a specific area of practice.6 As programs change to align themselves with CBME, there will be a more robust assessment of the educational value of patient care activities and how those activities help the resident achieve competency in specific areas. Programs will assign residents not by time on rotations but by the opportunities they can use to attain or improve competencies in a continuum of expertise toward independent practice. Training faculty to become better teachers and educators will also improve the learning and help address duty hour restrictions. Faculty development has a key role to play in ensuring that the resident’s needs as a learner are met throughout the course of residency training.7
There should also be a greater emphasis on residents “owning” their education by becoming better CanMEDS scholars and paying attention to the principles of adult education and lifelong learning. Residents who do so can then tailor their educational experience and maximize efficiency. To address some of the resident wellness issues, faculty development focused on emotional debriefings with residents should be considered as part of faculty training. These debriefings would continue to serve residents well as they move into practice and CPD activities.
In order to optimally train residents, PGME must organize residency training around the transitions that learners face as they enter residency and graduate into practice, providing graded education and responsibility along the way. [See the Continuum of Medical Education paper.] High-stress situations tax the ability of junior residents to learn and function (a key aspect of the ACGME report). Therefore, junior learners may require more attention, supervision and direction. However, they must slowly gain autonomy in their learning and patient care roles. Senior residents require less supervision than do their junior colleagues for routine procedures; however, important skills such as crisis management that are learned at the senior level still require supervision of some form. Senior residents also need to be given the opportunity to practise independently so that their performance can be assessed at the level of a junior consultant. The process of graded autonomy requires flexibility in training as well as the need to ensure that supervision changes appropriately over the course of residency.
BArrIerS to CHAnGe
The governance of PGME in Canada is highly complex. It involves medical schools, the hospital system, medical regulatory authorities, ministries of health (as payers), ministries of education, certifying colleges and the faculty who are also independent practitioners. This may lead to a situation of competing interests and expectations. With this reality in mind, a set of solutions that recognize this complexity will likely be required to address the tensions in the resident’s dual role.Traditional learning structures and policies have been built over many years on the assumptions that residents will be present in certain hospitals and will provide a relatively predictable amount of patient care. In some instances, the educational process was relied on to provide personnel for health care delivery, even linking training position allocation to the ability to provide adequate service and
Specialist physicians trained in environments that do not reflect the realities of community-based practice can be limited in their ability to practise outside a training environment and, as such, risk not meeting societal health needs. [See the Addressing Societal Health Needs
and Diversified Learning Contexts papers.] Ensuring that residents will be well equipped to practise in a variety of settings and that they have realistic expectations around work hours once they have graduated remain challenges that will require further debate and discussion.