Berkowitz Sabbatical Report - School of Medicine

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Kenan Sabbatical Leave
Lee Berkowitz, MD
Medical Education at the University of Oxford
July- December 2010
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In the academic year 2010-2011, I was awarded a Kenan sabbatical leave from the University of
North Carolina at Chapel Hill. I chose to go to the University of Oxford to investigate their methods and
philosophy about medical education. This report summarizes my experience. The report is divided into
the following sections:
I.
Introduction – Getting to Oxford: First Impressions
II.
Sabbatical Beginnings
III.
The Role of the Faculty
IV.
Postgraduate Medical Training in the UK
V.
Undergraduate Medical Training in the UK
VI.
The National Health Service
VII.
National Organizations in the UK That Impact Medical Education
VIII.
Internal Medicine and its Specialties in the UK
IX.
Summary
X.
Next Steps
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A number of people helped me in this endeavor and I want to take this opportunity to thank
them. Marschall Runge, MD, PhD, the chair of the Department of Medicine, nominated me for the
sabbatical and provided continued enthusiastic support throughout my leave from the department. Paul
Chelminski, MD, served as program director in my absence, working with Michele Lowe, program
administrator, Jill Tichy, MD, Krista Fajman, MD, and Ryan Sanford, MD, all chief residents, to keep the
residency running smoothly. Also Krista Fajman, MD, graciously saw my continuity patients. In Oxford,
Professors Peter Ratcliffe and Alastair Buchan served as my sponsors. Their assistants, Pramodi Majithia
and Catherine King graciously helped with my orientation and with the scheduling of many meetings.
Finally, and most importantly, my wife, Sandra Freeman, MD was a daily source of support and
inspiration, truly my anchor in this adventure.
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I.
Introduction- Getting to Oxford; Initial Impressions
On June 29, 2010, I arrived in Oxford to begin a sabbatical at the University of Oxford in the
Nuffield Department of Clinical Medicine. Getting to Oxford was the culmination of almost a year’s
work. It began in August, 2009, with an inquiry to the chairman of the Department of Internal Medicine
at Oxford, Peter Ratcliffe, about a possible sabbatical to study medical education in the United Kingdom.
My reasons for choosing Oxford were as follows:
1. Postgraduate training in the UK is restricted to 48 hours per week. With pending reductions
in work hours for residents in the US, I thought that by understanding their system(s) I could
bring back valuable lessons on how to restructure our residency.
2. Oxford University’s Department of Medicine is a research-oriented department like UNC’s. I
wanted to learn how their faculty balanced their time between the different missions of the
medical school and the Department of Medicine.
3. Internists in the UK are consultants to primary care doctors. I wanted to learn how this
affected training in internal medicine.
4. Oxford is a university town like Chapel Hill. I thought the similarity would help in the
transition to living in a foreign country.
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I received an enthusiastic response from Professor Ratcliffe and also from Professor Alastair
Buchan, the Head of Medical Sciences, to serve as sponsors. I then applied to UNC for a Kenan leave. My
proposal (Attachment 1) contained 7 areas of focused research:
1. The rules of accreditation
2. The interface between residents and faculty
3. The role of the National Health Service
4. Internal Medicine as a consultative discipline
5. The Internal Medicine education community
6. Evaluation of residents
7. Competency-based training
For each area my goal was to understand the UK system and to compare it to the one(s) in
place in the US.
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In December, 2009 I was informed that my proposal was accepted and funded for the Fall
Semester, 2010(Jul-Dec). In the next 6 months I arranged for coverage for clinical and academic duties.
My department was very supportive, in particular Marschall Runge, the Chair. I also had to secure a
place to live in Oxford. My original idea was to live as a visitng fellow in one of the colleges at Oxford. I
applied for several fellowships. I was elected as an Honorary Member to the Senior Common Room at
Magdalen College, which gave me privileges to dine in college and to tutor the medical students of
Magdalen, but this did not include housing. My other applications were not successful, so I rented an
apartment close to the City Centre of Oxford.
I had never been to Oxford. I had visited London and Cambridge as a tourist many years before
so I arrived with no real sense of what life in Oxford would be like other than that depicted in the
literature I read by C.S. Lewis, P.D. James, and Colin Dexter, author of the Inspector Morse series. My
first impressions were unsettling. The City Centre was not a subdued set of streets populated by Oxford
Dons strolling in their academic regalia. Rather the streets were teaming with tourists from all over the
world. I also expected to be able to walk in the beautiful grounds of the colleges. However, I soon
discovered that the colleges were shut off from the streets of Oxford by imposing walls and gates,
guarded by porters. Open campus areas so prevalent in Chapel Hill were not to be found in Oxford.
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II.
Sabbatical Beginnings
After moving in to my apartment, I began my sabbatical with a series of meetings at the John
Radcliffe Hospital. The John Radcliffe Hospital, known as the JR, is one of the main hospitals of the
Oxford University Medical Center. Its predecessor was the Radcliffe Infirmary situated in the City Centre.
The Radcliffe Infirmary was opened in 1770 and has an important and colorful history. It was here that
the first patient in the world received penicillin and also where William Osler rounded as the Regius
Professor of Medicine. As the medical school grew the Radcliffe Infirmary became too small to support
the clinical enterprise so the JR was built in 1972 at a site approximately 2 miles from the main campus.
All clinical departments moved there right away except Neurology, Neurosurgery, and Psychiatry. In
2007 a further addition to the JR allowed these 3 departments to move to the JR and the Radcliffe
Infirmary was closed. The Radcliffe Infirmary is an impressive piece of Georgian architecture, fitting with
the colleges of the University. In stark contrast is the JR hospital which is a set of rectangular buildings
made from white cement block with no distinguishing features.
As I walked into the lobby of the JR Hospital for the first time I felt like I had taken a step back to
the 1970’s. There were a few rows of chairs for visitors and a reception desk that were all well worn.
There was nothing warm or comforting in the space. Although the hospital was smoke-free there was
still the smell of stale tobacco. The hallways were also somber with drab white paint and dull tile floors.
The wards were very plain. Patients were mostly in 4-bed wards with partitions. There was a paucity of
computers and there were chart racks containing paper charts for each patient. There were just a few
health care professionals including nurses, CNA’s, and ward personnel. Like my arrival into Oxford, I was
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taken aback by the contrast between what I was used to in the US compared to what I was seeing at the
JR.
My first meeting was with Alastair Buchan, the head of the Division of Medical Sciences. His
position is the equivalent of a dean of a medical school without oversight of the teaching hospitals. Dr.
Buchan is a neurologist with a special interest in stroke. We talked mostly about the health care system
in Oxford and its relationship to the National Health Service (NHS). He provided me with a lot of
background reading material. He also made me aware of the most recent NHS plan which places the
majority of health care funding in the UK in the hands of the general practitioner. He was not certain
how this would affect the academic medical centers of the UK but did raise the idea of trying to gain
more control of medical training for the University akin to the experience in the US. Professor Buchan
was familiar with post-graduate training in the U.S., having done some of his training in New York.
My second meeting was with Peter Ratcliffe, chair of the Department of Medicine. I learned that
the department has over 800 members and is focused predominantly on research. Peter was trained as
a nephrologist and continues to be active clinically. He also has a major research program studying the
molecular pathways associated with hypoxia. From the outset he did display a real interest in the
educational mission of the department from the medical students all the way to the faculty level.
Both Professor Ratcliffe and Prof. Buchan were gracious in offering to set up meetings with other faculty
members to gain more perspective on the medical education system at Oxford.
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III.
The Role of the Faculty
Over the next several weeks, I met with a variety of faculty at the medical center. These
included specialists and generalists, involved in both clinical care and research. Their formal title is
“Consultant”, equivalent to the term “Attending” in the US. Each person was talented and
dedicated. All were well published and expert in their field. Many carried out research on an
international level. As I met with them I tried to understand how they balanced research activities
and clinical care.
Clinical Activities
First, I explored time in the hospital serving as the consultant physician for the teaching services.
The faculty I interviewed all spent several months a year doing this, the exact time depending on other
responsibilities. Their role was very limited compared to the responsibilities of an attending in a US
teaching hospital. They saw patients on admission and the next day, but then would not see them for
several days, relying on the judgment of the trainees to call if there were issues in the interim. The
patients had no difficulty with this type of oversight. The consultants did some teaching on rounds but
did not have designated teaching times with the trainees assigned to them. The consultants also were
not required personally to do documentation of their clinical work. On rounds one of the trainees wrote
a daily note and in it stated that the consultant had seen the patient. This attestation was sufficient for
the NHS.
Second, I investigated what consultants did in the outpatient setting. Most consultants had
several clinics per week seeing patients with trainees present. For subspecialties the trainees did most of
the work and then presented to the consultant. Documentation was done by the trainee.
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Finally, I looked into other clinical commitments. Consultants attended a main departmental
conference weekly where interesting patients were presented. Scattered throughout the week were
other lectures.
My impression of these activities was that it was less interruptive than the clinical activities of an
attending in the US and therefore more time could be devoted to individual research efforts.
Research Activities
In many of my individual meetings with faculty the discussion about their research was where
they displayed the most enthusiasm. Some were involved in clinical research and some in basic research.
Mostly this was funded by the NHS but there are other funding sources including the Medical Research
Council and the Wellcome Fund. The faculty go through extensive training to reach this position,
including training in internal medicine for 3 years, subspecialty training for 5 years and research training
to obtain a D Phil which is another 3 years minimum. Many faculty are age 40 as they start their faculty
position. Most were not aware that the training for academic faculty in the US is much shorter and
thought that all of time they invested was necessary to be successful. This type of training obviously
selects for those who are willing to undergo sacrifices and are not in a hurry to reach the position of a
consulting physician. My overall impression was that they were satisfied with their careers and did not
see themselves changing directions or moving to another institution. Their work routines included 4050 hours per week. They traveled frequently to meetings and conferences, both in the UK and in Europe.
Some traveled more extensively but this was a minority of the faculty.
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Salary
All of the faculty I met with were employees of the National Health Service (NHS). Their salaries
were based upon years of service and some merit bonuses. The range was £100,000 to
£150,000(£1=$1.6). I learned from these faculty members that salaries in all disciplines in the NHS are
paid at the same level. There is no distinction based the field of practice including those who are doing
highly specialized work like neurosurgeons or cardiothoracic surgeons.
Faculty can also earn private monies for work done outside of the NHS. Fees are determined by
the local community of practicing physicians. Most of the faculty I interviewed were not engaged in this
type of work.
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IV.
Postgraduate Training in the UK
With some sense of the role of faculty, I then moved on to the center of my research, the training of
postgraduates in Internal Medicine. The structure of the training is as follows:
1. The Foundations Program
All graduates of UK medical schools spend their first 2 postgraduate years in this program.
Students can list preferences for where they are assigned to do their Foundation years but it is not
as well organized as the NRMP. The first year (F1) is the equivalent of a rotating internship with 6
month blocks of surgery, internal medicine, and other disciplines. The second year (F2) continues
with 3-6 month block rotations, again a mixture of different disciplines. These 2 years include both
inpatient and outpatient training. The trainees are evaluated by mini-CEX’s and more formal
observed exercises kept in an electronic learning portfolio. Included in this are assessments of
behaviors, case-based discussions, direct observations of procedural skills, a procedure log book,
and teaching assessments. At the end of the each year there is a comprehensive review. There are
also national examinations sponsored by the Royal College of Physicians. There are 2 written parts
and an observed examination called PACES (Practical Assessment of Clinical Examination Skills). The
first part is taken after one year of training and then next 2 parts at the end of the Foundations
program. Passing the first exam allows one to be registered by the General Medical Council of the
UK as a practicing physician.
The Foundations Programs are organized in the UK by geographic deaneries which are
usually not affiliated with medical schools. There is a head of the deanery and Foundation
Program directors for each site. The deanery receives the funding for the F1 and F2 positions
through the NHS and the deanery decides how many positions go to each specialty.
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2. Specialized Training
These years directly follow the Foundations years. For Internal Medicine there are 2 years of
general training followed by specialist training. The first 2 years. ST1 and ST2 are in-patient based
and follow a set of competencies much like the ACGME. End- of year assessments are mandatory to
proceed with training. The specialized training beginning in the 3rd year goes on for a minimum of 3
years and a maximum of 5 years, depending on the specialty. Like the Foundations program, there
are national examinations for these segments of training, sponsored by the Royal College of
Physicians.
I observed a number of trainees at all levels. The Foundation Level 1 trainees were functioning
at the level of an advanced US medical student or beginning resident. They had some ownership of
patients but not to the extent seen in the US. In part this lack of ownership was created by the work
hour rules in the UK which allow a maximum of 48 hours per week of training (see below.)Their daily
work was largely to write notes on rounds, order tests, and arrange discharges. They did perform
phlebotomies and sometimes had to transport patients. They attended several hours of core lectures
per week as part of a didactic curriculum. They admitted patients once every 4 days. The Foundation
Level 2 trainees supervised the Level 1 trainees and shared in the work assigned to the Level 1 trainees.
They attended the same core lecture series and were under the same work hours regulations.
The ST 1 trainees held a similar position to a PGY2 or PGY 3 resident in the US. They led the work
rounds and directly interfaced with the consultant. They had oversight of the plan of care and rounded
with the team when the consultant was not present. It was his/ her responsibility to contact the
consultant with any emergent issues on the service. The ST 2 trainee was in the position of an advanced
resident or chief Resident in the US.
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ST 3 trainees are equivalent to first year subspecialty fellows in the US. ST trainees beyond the ST 3
year continue as the equivalent of advanced fellows in US training programs.
As I observed the trainees and the consultants, I was struck that 3 factors drove the entire
process. First is the definition of the role of an internist in the UK. The essential part of this is that an
internist in the UK is a consultant, not a general practitioner. All patients in the UK have a general
practitioner to provide primary care and preventive care and only when there are questions or
complications does the internist get involved. On rounds the discussion was focused on these types of
issues and the goal of a hospitalization was to return the patient to the care of the general practitioner.
Continuity of care and follow up by the internist team were not built in to the care of plan. Curricula for
Internal Medicine reflect this philosophy. The Royal College of Physicians begins its overview of general
internal medicine by describing the practice as dealing with “… patients admitted as emergencies,
patients with multiple disorders, patients referred to outpatient clinics for investigation and diagnosis,
and patients referred by specialist services-as outpatients or urgent inpatient referrals.” The Royal
College of Physicians has also developed the specialty of Acute Medicine within Internal Medicine to
specifically define a curriculum for managing acutely ill hospitalized patients. This is akin to the
hospitalist movement in the US.
The second factor driving the training experience is the work hours limits for trainees .As
mentioned previously, trainees can only work a maximum of 48 hours per week. This stems from
European labor regulations for all workers not just physicians. As a consequence, all daily activities were
shift-based and there was no overnight call and very little weekend call. Thus, the trainees were focused
on what they could accomplish in a 10-12 hour shift. They also had to plan for who would cover on their
days off. The end result was that they did not really follow their patients longitudinally.
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The third factor is the NHS. The NHS funds all postgraduate training in the UK. The NHS has
divided the UK into Deaneries as the overseers of the process. Each Deanery has a head physician and
administrators assisted by program directors. The NHS dictates the curriculum and the budget for each
deanery and in turn the number of positions to be filled. The Oxford deanery is responsible for 1500
trainees and has an operating annual budget of £66,000,000. The head of the Oxford Deanery has the
sole distinction in the UK of also having an appointment with the medical school
The trainees seemed very satisfied with this system and approach to patient care. They felt that
they were learning internal medicine well with adequate exposure to all of the main problems an
internist must be prepared to diagnose and treat. They did not feel that the work hours detracted from
this. They were somewhat surprised that trainees work 80 hours per week in the US. The consultants
also seemed satisfied with this system. Although many of them trained before the reduction in work
hours and took overnight call, they did not advocate for a return to that kind of system. The consultants
did not get involved in the coverage schemes. When they rounded they adapted well to working with
the members of the team present that day.
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3. Training Academicians at Oxford
Trainees at Oxford also have another training option if they are interested in an academic
career, called the Oxford University Clinical Academic Graduate School (OUCAGS.)
The leadership of the Medical Sciences Division at the University of Oxford created this special
pathway with a local perception as well as national perspective that fewer graduating physicians
were choosing careers in research.
The structure of this program builds on the NHS system of Foundation training and Core
training. Each trainee goes through the sequence outlined previously but in each year of training
there is protected research time under a research mentor. The goal is that each graduate of the
program has had enough basic training to be able to enter D Phil training, followed by fellowship
training. The program has both a medical and administrative director
The program initially received funding from the NHS is 2006 and began in 2009. To date,
approximately 80 trainees have been enrolled.
The program also puts on a number of academic programs each year designed to enhance the
research experience. These include lectures and poster sessions.
There are no other programs like OUCAGS in the UK, although many are considering instituting
programs like this based upon the success of the program.
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V.
Undergraduate Medical Training at Oxford
Oxford University also has a major program in undergraduate medical education. The program
begins with entrance to the medical school at age 18. Like US medical schools it is extremely competitive
to gain entrance to any medical school in the UK (Total 31.) The very best are admitted to Oxford. The
curriculum is 6 years, divided into a 3 years of pre-clinical study and 3 years of clinical study. Year 1 is
focused on normal structure and function and includes physiology, anatomy, pharmacology,
biochemistry, genetics, and sociology. There is also a course where students shadow practicing
physicians. In year 2, there is a mixture of normal structure and function and pathophysiology. Some
exposure to patients is included. The final preclinical year, Year 3, has more focused study in
neurosciences, genetics, infection and immunity, cell signaling, and cardiac and pulmonary physiology.
The students also engage in a research project. Students take a comprehensive examination at the end
of each year and at completion of the first three years earn a bachelor of medical sciences degree.
Teaching in these 3 years includes some classroom lectures, laboratory work, and small group tutorials.
The latter is a hallmark of the entire education system at Oxford University.
In brief, the tutorial system has a long history at Oxford and other UK universities. It is based on
the college system at Oxford. Oxford University is made up of 38 colleges, each with designated faculty.
In the early days of the University, most of the faculty and students lived in the colleges. The students
would be assigned to faculty and met with them 1-2 times a week as the main venue for their education.
Each student would then spend the remainder of their time in independent study to prepare for the
next meeting called a tutorial. Lectures in classrooms were a rarity in this system. Over time fewer
faculty chose to live in the colleges and there were the development of departments and classroom
instruction. However, the tutorial system still exists. Medical students are assigned and can live in the
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colleges of Oxford. Each college does have faculty from the medical school who meet with the students
in both the preclinical and clinical parts of the curriculum.
Years 4, 5, and 6 make up the clinical part of the curriculum. In Year 4, students work with
general practitioners in a community setting, and do some inpatient rotations in internal medicine and
surgery. There is also a course in laboratory medicine. Year 5 is comprised of rotations in pediatrics,
ob/gyn, psychiatry, neurology, neurosurgery, ent, ophthalmology, emergency medicine, pm&r,
geriatrics, palliative care, and dermatology. There is also a segment on primary health care. Year 6 has a
great deal of elective time plus assignment to a district hospital. There are final examinations at the end
of each clinical year including OSCE’s. At the completion of the sixth year the student is granted a BM,
BCh, Bachelor of Medicine and Surgery.
I met with a number of students in these latter years of the curriculum. On the inpatient
rotations I was struck with the peripheral role they played. Their day began at 9 am and ended in the
afternoon. They mostly observed and had no real patient responsibility. They did not admit and follow
patients and did not perform procedures. They had scheduled didactic sessions with assigned faculty
and were responsible for presenting topics related to the patients they saw on their rotations. They
were free on weekends. They did enquire about the responsibilities and experiences of US students
during their clinical training and were surprised at the differences in the amount of patient care and
work hours US students experienced compared to the UK system. The students I interviewed were
pleased with their training and felt that their didactic teaching time was the most beneficial aspect of
their clinical education. They were not concerned about the lack of time they spent with patients,
feeling that they would get this experience in the Foundations part of their training.
Through Magdalen College I also interacted with 6th year students, serving as a tutor. We
scheduled a number of sessions, some in small groups and some one-to one. I developed a series of case
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vignettes and had the students work through the exercises. To a person they were extremely bright and
understood principles of pathophysiology quickly. They were also eager to read more on each case
vignette independently. Finally they were very thankful for the meetings and took the initiative to
continue scheduling sessions. These tutorials were very enjoyable for me as well.
The financial burden for medical students in the UK is substantially less than in the US. Tuition
for each academic year is approximately £3,300. Living expenses add another £6,000 per year. I asked a
number of the students if they were in debt at the completion of medical school. Most were not, having
obtained scholarships or family support for their education. The lack of debt plus the salary equality of
practitioners in the UK allowed them more freedom in career choice; ie they were not driven to
specialty medicine like US medical students.
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VI.
The National Health Service(NHS)
In any of my meetings with faculty, postgraduate trainees or students, there was always a
discussion about the role that the NHS played in their careers. The following is a brief synopsis of the
NHS to help understand its function and its influence on academic medicine in the UK.
The NHS began in 1948 with the goal to provide health care to all citizens of the UK. It is funded
through taxation that amounts to approximately £ 2,000 per person. This is the only cost to
citizens of the UK for health care, regardless of their health care needs. The NHS is controlled by the
Department of Health with a cabinet-level Secretary of State for Health. All NHS activities are broken
down into 10 Strategic Health Authorities (SHA). These SHA’s are further divided into trusts for the
different health care needs. There is a primary care trust, an acute trust for hospitals, a mental
health trust, and foundation trusts for specialized local area care.
The NHS is the largest employer in the UK with 1,700,000 employees including 150,000
physicians. In 2009 its annual budget was £100 billion.
The centralization of health care allows the NHS to more directly set health care policy in the UK
compared to policies set by the US Federal Government. These policies determine guidelines for
clinical practice and for medical education. Some examples of how this is accomplished are:
1. Payments for physician services - Physicians in the NHS are paid based upon length of service
and experience, not by their specialty. This parity has resulted in a large work force of primary
care physicians.
2. Payment for physician training – By funding all postgraduate training, the NHS takes a proactive
role. It can examine the workforce and instruct deaneries to adjust the number of training slots
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per specialty based upon the need or oversupply in any specialty. The NHS also sets the
curriculum for postgraduate training and monitors it directly.
3. Payment for patient care – The NHS has a number of guidelines for patient care that must be
adhered to by NHS physicians and trainees. Included is the use of generic prescriptions, limits on
diagnostic tools and access to specialized procedures and surgeries
4. NICE – The National Institute for Health and Clinical Excellence- NICE was begun in 1999 as part
of the NHS. The main purpose of NICE is to advise the NHS about treatments and procedures by
reviewing the existing medical literature and seeking expert opinions. NICE also develops
indicators of quality practice that are rewarded in the NHS system. NICE is made up of centers
including the Center for Public Health Excellence, the Center for Health Technology Evaluation,
and the Center for Clinical Practice. The work is done by the formation of committees that
include NHS experts, other authorities, and patients. These committees work with NHS staff that
searches the Internet for evidence. The public may attend committee meetings.
All of the NHS policies are open to debate and criticism both politically and from the medical
community. Discussions that I observed were at the level of new policies, particularly whether
they were feasible or should be adopted. Once policy was set, there appeared to be broad
acceptance and uniform adherence. There was not optional adherence as is commonly practiced
in the US.
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VII.
National Organizations in the UK that Impact Medical Education
Although the main driver for the education and training of physicians in the UK is the NHS, there
are several other groups that are involved with education policies and the funding of training and
research.
1. The Medical Research Council (MRC) - The MRC is a government funded organization with the
mission “to improve human health through world-class medical research.” The MRC chooses the
research it supports independently. This includes funding scientists individually, funding
research centers in partnership with universities, and funding MRC research facilities. The MRC
also gives out training awards to post graduate students and fellows. In 2008-09, the MRC spent
£700,000,000 on research.
2. The Academy of Medical Sciences – This is a relatively new organization founded in 1998. Its
main activity is to produce papers and reports dealing with health policy and development. The
Academy consists of Fellows and a Council who produce the reports with staff support. The
Academy also puts on conferences on topical issues in medicine. Finally the Academy offers
some support for career development with a mentoring program and funding of special
projects.
3. The Medical Schools Council – This group has representation from all of the UK medical schools.
Its mission is to examine all aspects of medical education over the entire spectrum from medical
school to postgraduate training. The council puts on conferences related to these topics and
publishes a large number of reports annually.
4. The Royal College of Physicians (RCP) – The RCP represents practicing physicians throughout the
UK. Membership requires passing a 3 part examination that is taken during and at the end of
initial training (see Foundations program). This requirement exerts a strong influence on the
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training curricula in the UK. Beyond this, the RCP is involved in policy development for the NHS
and setting standards for clinical care and professionalism.
5. The Academy of Medical Educators – The Academy was established in 2006. Its main activity is
to accredit medical educators. The Academy has developed professional standards and
guidelines for curriculum development that are used throughout the UK. The goal of the
Academy is to accredit all medical educators by 2012. Other activities include developing
measurable outcomes for medical education, holding conferences, and publication of
newsletters.
There is no organization that independently accredits programs like the ACGME in the US.
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VIII.
Internal Medicine and it’s Specialties in the UK
Each subspecialty in Internal Medicine in the UK has its own society. Like their counterparts in
the US, these societies hold annual meetings, publish journals, have practice guidelines and offer
some grants for research. Many also have educational curricula for trainees. Some have partnered
with the Royal College of Physicians to develop certification examinations to be completed at the
end of specialty training.
There is no organization in the UK equivalent to the American College of Physicians that broadly
represents the field of Internal Medicine. There are international organizations that UK internists
participate in such as the International Society of Internal Medicine and the European Federation of
Internal Medicine.
There is also nothing in the UK like the Alliance for Academic Medicine and its constituent
groups.
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IX.
Summary
I am deeply appreciative that I was given the opportunity to take a sabbatical leave from the
University to advance my knowledge of medical education. I learned a great deal about a very different
approach to training in academic internal medicine. In this report, I have described my experience.
There are several dominant themes.
First is the notion that faculty have many different competing interests and responsibilities that
need to be prioritized to fit with the mission of their sponsoring institution. What I observed in Oxford is
the dominance of research productivity for faculty and how other responsibilities were configured
around this. I also saw the how this influenced the trainees working with the faculty.
A second theme is the influence of reduced training time on postgraduate medical education.
All aspects of training, including teaching time and time for patient care were developed to fit the work
hours. The more the work hours are reduced ,things that we value in our system like continuity of care
and the idea that trainees are responsible for patient care take lesser importance.
A third theme also related to postgraduate training in internal medicine is that training is
influenced strongly by the role of the internist in the health care system. The UK internist is a consultant
and therefore the trainees are seeking the knowledge base and skills to be competent as such. Trainees
do not learn about preventive care or primary care and do not follow patients in continuity clinics.
Regarding undergraduate education, the policy of admitting students at a much younger age
and incorporating typical undergraduate education in their medical school education results in a more
academic and didactic experience compared to the training of US medical students.
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A national health system impacts greatly on medical training, far beyond the reaches of
providing care for the nation’s citizens. Any change is health care policy needs to be examined for its
effects on training.
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X.
Next Steps
As I return to my duties at UNC, I now have an expanded view of medical education. I hope to
carry this perspective with me in ways to improve our program as well as others in the US. I plan to
share with others my opinions about the effects of reduced work hours in the UK and what is lost by
doing this. I hope this will make GME policy makers in the US hesitant to continue the trend of further
reductions.
The idea that the internist is a consultant is attractive to me. I think it is time to reinitiate the
debate in the Internal Medicine community about the role and definitions of an internist, particularly
the scope of the profession.
There is gaining momentum in the internal medicine education community in the US to adopt
competency-based training. Seeing it done well in the UK is further evidence that we should continue to
pursue this type of evaluation in our training programs.
There are national internal medicine societies in the UK but they do not seem to be as integral
to the discipline as they are in the US. There is therefore opportunity for collaboration between US and
UK internal medicine organizations to develop a more global approach to internal medicine.
~ 28 ~
Attachment 1
Sabbatical Proposal: Understanding Post-Graduate Medical Education in the Department of Medicine at
the University of Oxford
Lee R. Berkowitz, MD
Eunice Bernhard Distinguished Professor of Medicine, Department of Medicine
~ 29 ~
Introduction
My interest in a sabbatical In the Department of Medicine at the University of Oxford is to
compare and contrast graduate medical education in the United Stated and the United Kingdom. This
experience will help greatly in my current research which centers on developing a much-needed new
paradigm for residency education in Internal Medicine in the United States. If successful, this work will
restore the stature of residency training in Internal Medicine.
The need for change in our residency programs is driven by a number of factors that inhibit
effective training in Internal Medicine in the United States. First, the number of qualified and top
students graduating from US medical schools who choose internal medicine is small and has remained
low for at least 10 years. This results in program directors having to adjust curricula to compensate and
often remediate residents. A second problem is the excessive regulation of training from the
Accreditation Council of Graduate Medical Education (ACGME). This forces program directors to comply
with many rules that diminish the quality of their training programs. As an example, residents are
restricted in their work hours. These restrictions have created problems with continuity of care and have
caused a dilution of the training experience. Residents have also lost ownership of their patients. Yet,
programs can be placed on probation if there is not compliance with these rules. A third factor is the
role that faculty play in the training of residents. Faculty are increasingly fragmented into subspecialty
groups and spend the vast majority of their time obtaining and carrying out research. They are therefore
less accessible and willing to teach and mentor in departments of Internal Medicine. Finally, the expense
of training has come under scrutiny. Currently graduate medical education is largely funded by Medicare
with an annual cost of 9 billion dollars to the government. These monies and whether or not the
product, i.e. the physician work force, is adequate are being questioned by the US Congress.
~ 30 ~
With these observations, many people in the graduate medical education community in the US
feel that substantial changes need to be made in the residency training programs. Although this view is
commonly held, there has been little progress as to how this should be done.
The Department of Medicine at the University of Oxford has a long and distinguished history of
graduate medical education, done in the setting of a major university. Furthermore the funding of
patient care and medical education is substantially different compared to the United States. As we seek
to change what we do, I think we can learn a great deal from the program at the University of Oxford
and it is my goal on sabbatical to understand the system as well as possible.
Focused Areas of Research for the Sabbatical
1. The rules of accreditation in the United Kingdom- My understanding is that these are
substantially less restrictive compared to the United States with the exception of work hours. I want to
understand how medical educators in the Department of Medicine at Oxford feel about these rules and
how they are carried out. In particular, I seek to understand whether or not these rules enhance or
detract from the quality of training.
2.
The interface between the residents and the faculty- With many faculty devoted to
research, I wish to explore how time is allotted for teaching and supervising trainees and how faculty get
credit for their endeavors. Are there different faculty ranks based upon teaching, research, and
administration?
~ 31 ~
3.
The role of the National Health Service- I will examine how a single payer system affects the
experience of residents. Does it have any influence on career choice? Is there adequate funding for the
education mission of the department?
4.
Internal Medicine as a consultative discipline- In the United States, internists act as
consultants but also provide primary care. Would we be in a better position for recruiting students if we
adopted a model like that in the UK where internists are consultants? Would payments be different if
we adopted this model? I would also like to examine the curriculum used to teach Internal Medicine as a
consultative discipline.
5.
The Internal Medicine Education Community in the United Kingdom- This community in the
United States centers on the Association of Program Directors in Internal Medicine (APDIM). Does an
equivalent group exist in Great Britain and if so, what is its mission?
6. Evaluation of residents- The ACGME requires that residents be evaluated in 6 core
competencies: Medical knowledge, Professionalism, Patient care, Interpersonal and communication
skills, Practice-based learning and improvement, Systems-based practice. Even though these
competencies have been required for a number of years, they are poorly
understood and may or may not be adequate to evaluate residents. I would like to compare this system
to the evaluation system used in the Department of Medicine at the University of Oxford. I want to
examine how the faculty feel about the system in terms of its facility and accuracy. Also how much
direct observation by faculty is done in the Oxford system?
7. Competency-based training – Currently residency training in the United States is time-based. I
am chair of a national task force examining the possibility of switching to a competency –based system.
The curriculum at the University of Oxford contains many competency-based modules. A thorough
understanding of how this works will help significantly in the work of the task force.
~ 32 ~
Conclusion
The ability to spend six months understanding this very different and successful system will be
key to advancing my research on Graduate Medical Education change in the United States. The
subsequent contributions I can make should have benefits for our own program as well as others across
the country.
~ 33 ~
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