Teaching old dogma with new tricks and technology: educational paradigm shifts in graduate medical education.

Introduction

Huge changes are occurring in medical education across the continuum of physician training. Advanced understandings of adult learning theory, an explosion of scientific information, and new tools and technology both in medicine and in education are driving these transitions. Furthermore, a transforming culture of medical practice represented by increased patient autonomy, health-professional teamwork, and advances in health-care reform are effecting change. In addition, we must acknowledge the shifting generational values of those entering our educational programs and support their articulated values that continue to promote service but also stress work–life balance. There is a striking difference in values between the baby boomers, who are teaching and supervising Gen Y (also known as Millennials), our students and trainees. Each generation can be defined by certain general characteristics (Table 1).[1] Appreciating these differences and supporting each other's values are key to a favorable learning climate.

Table 1

Characteristics of the generations

	Traditionalist	Baby boomer	Gen X	Gen Y or Millennial
Year of birtha	1925–1945	1946–1964	1965–1980	1981–2000
Notable events	WW II	Space exploration, the “counterculture”	Vietnam War, Watergate, rise/fall of the Cold War, mass media	Persian Gulf War, Internet, multiculturalism
Attributes	Veterans, loyal, follow rules	Driven, question authority, optimistic	Latch-key kids, independent	Structured, team player
Work is	An obligation	An adventure	Difficult and challenging	A means to an end
Leaders/teachers	Respect them	Replace, challenge them	Ignore them	Leaders and teachers must respect us
Other	Do the right thing Clear gender roles	Workaholics Value experience over expertise	Do not believe in “paying your dues” Work success defined by competence	Happy without having it all Hardworking, but desire balance

Gen, generation; WW II, World War II.

Variations of the year intervals appear in the literature.

Changes in education are seen across all aspects of medical education. Current medical students are voting with their feet, not showing up for lectures, and demanding technology-assisted educational tools. Although promoting more active learning, in concert with adult learning theory, the undergraduate medical curriculum has flipped the classroom, incorporated team-based learning, and is fostering interprofessional education.[2] Continuing Medical Education (CME) has also undergone a remarkable transformation, branching out from the more traditional (and previously predominantly pharma-supported) large audience programs to a menu of choices including web-based learning and point-of-care options. Maintenance of certification is currently the source of much controversy,[3] but a positive focus for continuing medical education is quality- and value-based clinical care.

Perhaps the transformations in graduate medical education (GME) reflect the greatest degree of change, which have been implemented in a fairly rapid fashion, largely dictated by accrediting agencies. GME has been in the forefront of educational principles in medical education, having established the six areas of core competencies developed as part of the Outcome Project that began in 1998. These include patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication.[4] The concept of competency is one that befits the training of future physicians, requiring excellence and setting the bar high for this responsible and privileged role. This notion is also consistent with the transforming generational values, with younger generations valuing competency in contrast to the boomers who appreciate experience over expertise. Competency sets the threshold for the knowledge and skills necessary to safely and proficiently perform a task. It is not defined by time immersed in learning or by numbers (e.g., of procedures), but rather by the demonstration of expertise.[5]

The Accreditation Council for Graduate Medical Education (ACGME) has implemented the Next Accreditation System (NAS) with several components (Table 2) and many new educational terms reflecting the key features of the NAS (Table 3).[6]

Table 2

Components of the NAS

Component	Description
Data collection	ADS
	• Statistics • Structure and resources of the program • Scholarly activity • Teaching responsibilities
	Board pass rates
	Clinical experience
	Trainee survey
	Patient safety
	Faculty survey
Semiannual milestone data	Program directors must complete the required reporting milestone document for each fellow
10-year program self-study	Self-study will lead to a site visit
CLER visit	Not linked to accreditation
	Institutionally based and not tied to a specific program
	Focus on six areas:
	• Patient safety programs • QI initiatives • Transitions in care • Supervision • Fatigue mitigation/duty hours • Professionalism

ADS, Accreditation Data System; CLER, clinical learning environment review; NAS, Next Accreditation System; QI, quality improvement.

Table 3

Terminology used in GME

Terms	Definition	Specific applicability to gastroenterology
Milestones	Significant point in development; defines a floor for competence; does not eliminate the need for aspirational goals	The end goal in training a GI fellow is to ensure the trainee is ready for unsupervised and independent practice. Milestones denote specific points in development toward that goal
Curricular milestones	Behavioral objectives defining knowledge, skills, attitudes, and behaviors that are granular and used for curricular development and assessment	At the current time there is no consensus of curricular milestones in GI, but each EPA developed by the societies have detailed objectives for knowledge, skills, and attitudes
Reporting milestones	Knowledge, skills, attitudes, and other attributes for each of the ACGME competencies that describe the development of competence from an early learner up to and beyond that expected for unsupervised practice; must submit to ACGME twice annually per trainee	There are 22 subcompetencies for the core IM residency reporting milestones. All IM subspecialties have 23 subcompetencies (addition of one for scholarship). This is the required reporting documentation for the ACGME
Competence	Knowledge, skills, and attitudes must be acquired and applied for a favorable outcome	In GI, this can relate to the acquired knowledge, skills, and attitudes for cognitive decision-making as well as for skill-based procedures
Competency	Observable quality requiring integration of multiple components of knowledge, skills, attitudes, and values	This is particularly important related to procedures where the number of procedures performed cannot be indicative of competency but rather observable ability to perform the procedure independently
EPAs	Professional tasks/activities that define that specialty. It is the core of the profession that a patient or another provider would use to identify what constitutes a particular role	There are 13 EPAs developed by a multi-society effort for GI Fellowship training

ACGME, Accreditation Council for Graduate Medical Education; EPA, entrustable professional activity; GI, gastroenterology; GME, graduate medical education; IM, internal medicine.

Modified from Rose et al.[10]

Milestones are a prominent feature of the NAS and are intended to develop highly competent practitioners to provide state of the art care with accountability to the public. Similar to the milestone markers that denote distances on a highway, educational milestones represent significant points in development and identify progressive outcomes as trainees advance in capability. Reporting milestones have been developed for internal medicine and the internal medicine subspecialties with a requirement to assess fellows biannually.[7, 8] Milestones are intended to provide transparent expectations for the trainee and the program director; they also foster self-directed learning, promote development of assessments linked to exactly what needs to be evaluated, and provide a framework for feedback.

There are two additional features within this educational paradigm: curricular milestones and entrustable professional activities (EPAs), neither of which are current requirements of the NAS. Curricular milestones represent specific objectives that are, by definition, granular and can be used to direct curriculum development and assessments. EPAs are defined tasks or responsibilities associated with a professional role that an individual is trusted to perform independently and without supervision, once competence has been achieved.[9]

EPAs for Gastroenterology Fellowship Training were developed through a multi-society effort[10] (Table 4). These EPAs delineate the tasks that define the profession of gastroenterology and hepatology, and incorporate the work of the previously published core curriculum.[11] A detailed toolbox accompanies this project along with additional educational supportive materials, for each EPA including specific objectives, links to ACGME competencies, suggestions for assessments, and a description of the implication of entrustment.[12] Assessment is a key component in competency-based education; perhaps the greatest challenge for gastroenterology program directors is to identify the best evaluation tools for the reporting milestone requirement. This is an area for continued development for gastroenterology educators.[13]

Table 4

EPAs for Gastroenterology Fellowship Training

1. Manage common acid peptic-related problems 2. Manage common functional gastrointestinal disorders 3. Manage common gastrointestinal motility disorders 4. Manage liver diseases 5. Manage complications of cirrhosis 6. Perform upper and lower endoscopic evaluation of the luminal gastrointestinal tract for screening, diagnosis, and intervention 7. Perform endoscopic procedures for the evaluation and management of gastrointestinal bleeding 8. Manage biliary disorders 9. Manage pancreatic diseases 10. Manage common GI infections in non-immunosuppressed and immunocompromised populations 11. Identify and manage patients with noninfectious GI luminal disease 12. Manage common GI and liver malignancies, and associated extraintestinal cancers 13. Assess nutritional status and develop and implement nutritional therapies in health and disease

EPA, entrustable professional activity.

Why all of these changes? Did not the boomers turn out just fine? Let us consider this in an open-minded context. Just a couple of questions can demonstrate the examples of the rapidly changing landscape of science and practice: (1) Where is the endoscopic teaching attachment? It is hard to believe that the first videoendoscopes were introduced in the early 1990s. Current fellows and anyone completing fellowship in the past 15 years have probably never seen a teaching attachment; and (2) Are you kidding, a bacteria causes ulcers? Helicobacter pylori is a noted paradigm shift discovery from the 1980s. Many of us began our training in medicine without thinking of this relationship, and as the correlation evolved, we were incredulous at first. Such innovations and discoveries were made not that long ago and many who trained before these changes are still engaged in the practice of gastroenterology. As we expect a future of continuing rapid advances, our focus must evolve to the key competencies of information retrieval skills and lifelong learning strategies. The ability to recognize what one knows and to acknowledge one's own knowledge gap with the know-how to address that gap becomes the essential competency.

We are also dealing with an aging patient population and aging physicians in practice. These demographic truths, along with altered expectations from patients (boosted by television, movies, the media, lifestyles, and technology), require new approaches. We expect to see technology applied to greater degrees in medicine with smartphones and other perhaps yet-to-be-developed technologies advancing the communication between practitioner and patient and between interprofessional colleagues.[14]

We are not entirely ready for these changes. How are we shifting old educational paradigms to account for these changing accreditation requirements and the advancing capabilities in gastroenterology and in medicine related to technology?

Perhaps we should examine the prerequisites for training. Is it really necessary to have 14 years after high school to train a gastroenterologist? Who are the teachers? How do we assess our trainees to be sure they are ready? How do we evaluate them after training to be sure their skills are up to par for their practice? As we examine these issues, we also need to consider whether there should be alternative training for cognitive vs procedure-based roles; we need to define the team leader (is it going to be the MD?) as our current trainees will be practicing in a team-based environment and provide skill training to our fellows for leadership training. And finally, we need to seriously address whether it is necessary to train everyone in all of the sub-subspecialties in gastroenterology and hepatology such as motility, hepatology, pancreatobiliary, and nutrition, and if so, to what degree.

The art and science of medicine are transforming. Our trainees need to prepare not only for the practice of gastroenterology tomorrow but also for practice in 30—or more—years. The challenge for us—across the spectrum of ages, training, experience, expertise, and practice type—is to first of all, embrace change. We need to prepare for change, answer the above pending questions by thinking outside the box and—just as we did with H. pylori—we need to be courageous in discarding old dogma in efforts to accept new paradigms.