Residency Program: Objective Criteria for MUSC’s Program
Guest: Dr. Harry Clarke – Urology Services, MUSC
Host: Dr. Linda Austin – Psychiatry, MUSC
Dr. Linda Austin: Dr. Harry Clarke is Associate Dean for Graduate Medical Education at MUSC. Dr. Clarke, in this podcast, let’s talk about a very interesting new development in residency which concerns objective criteria for advancement. Tell us about that?
Dr. Harry Clarke: Well, first of all, residents pay a lot of money to go to medical school. They get into huge debt, and the amount they get paid during residency training is really pretty low, so for them to retire their debt is very difficult. So, residents are starting to vote with their feet, so to speak, as to what training programs they’re willing to sign up for. And, it’s been noticed that, say, something like cardiothoracic surgery, which normally has five years of general surgical training followed by three years of cardiothoracic surgery, has not been as popular lately; compared to previous years.
A lot of this is thought to be just the economic constraints that this puts people in. That and, also, plastic surgery, and a lot of the other surgical subspecialties, are looking towards reducing the number of total years that it takes to train by combining their program into one. Say, in plastics, rather than having five years of general surgery and then two or three years of fellowship, it’s a straight plastics program that’s six years in total. The same is going on here in Cardiothoracic. They’re experimenting with having a complete program where the residents enter as cardiothoracic surgeons, and then go through in six, rather than seven, years to complete their training.
This makes sense because you can get out and start practicing, and then retiring the debt that you have. One of the examples that I use, being in Urology, is, why does a resident need to do five or six years of urologic training, and be a chief resident in Urology if, in fact, they’re going to do a two or three-year fellowship in Pediatric Urology, and then never treat adults? They could probably get the economy of losing one of those years as a chief resident in adult urology and just go straight into pediatrics.
So, that’s the one point. The other point is one that’s being mandated by the federal government as well the overseeing body, such as JCAHO (Joint Commission on Accreditation of Healthcare Organizations), for objective criteria for what residents and, in fact, faculty are, or not, allowed to do on credentialing. For example, for a resident to do a lumbar puncture or to put in a central venous catheter, they have to have hospital credentials to do that. So, if a family member says, Does Dr. So-and-So have credentials to put my grandpa’s line in?, they have to be able to pull that up on the computer and show, yes, in fact, they do; they’re credentialed to do it.
So, that leaves us to struggle with arranging to have these credentials for people, and to determine what the training needs to be before we allow people to have credentials: Is an individual taught how to do this once or twice; five or ten times? At what point does the attending faculty sign off on these privileges? We’ve come to protocol on that. And all of the procedures that the residents do in the hospital are now credentialed and they’re not done without supervision, unless the resident has those credentials signed off on and can be looked up on the computer. In similar fashion, we’re trying to make objective criteria for advancement in each of the training programs, and for each of the rotations, in the program.
This is easiest to look at in terms of an example with laparoscopic surgery. We have laparoscopic trainers, and we can have the residents go through and show proficiency in these before they work with laparoscopic equipment at the bedside in the operating room. And this is an excellent way to get objective criteria for advancement in this area.
Dr. Linda Austin: It sounds very interesting and very exciting, but also quite challenging to think through the details of that; very different from the days where you just kind of showed up in residency and did your thing for few years, and you were done, and that was about it.
Dr. Harry Clarke: Certainly. And that’s the challenge. Because, for me, it might take five or ten practice cases in order to become proficient at something, while someone else may be able to do it in just one or two. So, that brings up the point that I brought up initially about the timeframe of the finite structure of a residency being four, five, or six years. For some individuals, if they can accomplish these goals in a shorter timeframe, they should be allowed to advance sooner. Whereas, for others of us, it may take us a little bit longer, but that doesn’t mean that the individual is any less qualified. We’re just making sure that they have these qualifications before advancement.
Dr. Linda Austin: Now, we have a very sophisticated simulation lab here, at MUSC. Is that utilized in residency around these particular skills?
Dr. Harry Clarke: Yes, it is. As a matter of fact, it’s headed by Dr. John Schaefer, and there’s been a lot of very interesting and exciting work in training the hospital teams, including the code teams, for resuscitating patients. And it’s been shown that those residents and staff, who go through this training, do far superiorly in providing this care than those that have not gone through this. This is being rolled out for the residents to train in as well in terms of a specific laparoscopic training and other training modules that they have.
Dr. Linda Austin: For those who have never seen the simulation lab, I have to give a verbal description of it. You really have to see it to appreciate it. But, there are, I believe, 80 simulated dummies, some of which are, for example, a woman in labor and delivery, somebody in the operating room. Some of them are, let’s say, arms on which you can practice drawing blood and so forth. And these are computer-controlled, so the instructors can simulate by putting different criteria into the computer, and can simulate any illness they want. And then the trainee, or students, can work on these dummies. But one of the advantages, of course, it that you can simulate illnesses that the resident may not have gotten to see in the luck of the draw, so you can really expose the residents to a much broader range of disease conditions.
Dr. Harry Clarke: Exactly. And, in fact, some of these conditions are so rare that some of the attendings, say, in the pediatric emergency room have never seen these things. And, yet, when they go through these training sessions, they’re probably more proficient than someone who may see one of these, say, in 15 years or so to treat.
Dr. Linda Austin: Dr. Clarke, thanks so much for telling us about this.
Dr. Harry Clarke: Thank you.