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American Board Internal Medicine

To determine whether sectional development in pulmonary and critical care medicine influences medical house officers' (HO) interests and knowledge about respiratory medicine, we reviewed HO performance on the American Board of Internal Medicine (ABIM) certifying examination during 4 years before and 5 years after reorganization of our section. After major changes in the program and introduction of new educational opportunities, HOs more often selected pulmonary consultation electives (68.6% vs 47.8%; p=0.009) and entered pulmonary fellowships after completion of residency training (12% vs 3%; p=0.047). Total ABIM examination score did not change, but performance on its respiratory disease component improved from a median national percentile score of 48.5% (1986 to 1989) to 80.0% (1990 to 1994) (p=0.0365). In relation to other specialty component scores, the rank of the respiratory disease percentile improved from the lowest specialty score to the highest. ABIM examination scores correlated with the cumulative faculty effort directed toward HO teaching (r=0.70; p=0.04) and the total number of clinical teachers (faculty and fellows) interacting with HOs (r=0.73; p=0.02). Academic development in pulmonary/critical care faculty has an important influence on medical HO interests in and knowledge of that discipline. Plans for the future structure of academic pulmonary/critical care sections must take into account this impact on the training of generalists. Although institutional priorities, resources, and shifting external forces will define how, where, and by whom respiratory medicine will be taught, an appropriate number of faculty members and sufficient commitment of their time to HO education must be preserved.

Abbreviations: ABIM=American Board of Internal Medicine; FTE=full-time equivalent; HO=house officer; MICU=medical ICU

With increasing emphasis on general medical training, the staffing and mission of university-based specialty programs are being reassessed.(1),(2),(3),(4),(5),(6),(7),(8),(9) There is little information about the current impact of specialty training during residency on the interests and knowledge of general internal medicine house officers (HOs). Although the effects of service and educational functions of pulmonary/critical care faculty on the training of specialty fellows are under scrutiny, little is known about their impact on the training of generalists. A major reorganization of the pulmonary/critical care section at our medical center provided an opportunity to determine whether section development of faculty and teaching has any impact on internal medicine HOs. We reviewed their performance before and after reorganization and found that specialty section development influences HO interest in and knowledge about respiratory medicine.

MATERIALS AND METHODS

We reviewed medical HO interests, plans for postgraduate training, and performance on the American Board of Internal Medicine (ABIM) certifying examination during 4 years before (1986 through 1989) and 5 years after (1990 through 1994) reorganization of our pulmonary/critical care section.

Background and Educational Interventions

Beginning in 1989, the reorganization of our pulmonary/critical care section included the following: appointment of a new section chief; designation of a clinical director with primary educational responsibilities; recruitment of new faculty (increase from 3 to 6 clinical faculty); protection of time for the faculty's nonpatient care functions (increased from 0 full-time equivalents (FTE), to 2.4 FTE; expansion of the fellowship program (from 0 to 1 fellows to 6 fellows); recruitment of basic scientists (from 0 to 4 PhD investigators); and development of basic science and clinical research programs. The increased protection of faculty time encompassed not only their educational functions, but also the section's expanded research activities.

Structural and staffing changes were accompanied by multiple new opportunities for HO instruction and sectional prioritization of its teaching commitments: there was an increased frequency of didactic and case-based instruction, a new weekly multidisciplinary chest conference, and improved clinical electives (pulmonary consultation service, including ambulatory care experiences). Other initiatives included new research electives for HOs; implementation of a preventive pulmonary academic award focused on a curriculum promoting respiratory health; delineation of a written curriculum for pulmonary rotations, including core learning goals; increased pulmonary faculty participation in morning report; and increased pulmonary faculty involvement in departmental administration (including the house staff executive committee). The medical ICU (MICU) rotation was a required and popular experience for HOs both before and after expansion of our section, and was not a component of the new elective rotations described.

Outcome Measures

To assess HO interests in pulmonary/critical care medicine, the numbers of HOs who selected the pulmonary/critical care consultation elective, HOs electing the research opportunities, and HOs entering pulmonary fellowship training were determined from Department of Internal Medicine records for the periods before and after pulmonary/critical care section reorganization. The number of publications in respiratory medicine (excluding those written during subsequent fellowships) that were first-authored by HOs during their residency training was also recorded and compared.

To assess HO knowledge of respiratory medicine, the summary reports of performance on the ABIM certifying examination were reviewed, including the number of HOs taking the examination, their composite and overall performances (expressed as percentiles compared with examinees from other programs nationwide), and their performance in the area of respiratory disease (noncore medical content). In addition, the rank order of performance in respiratory disease knowledge was compared with that of other components (ie, other medical specialties) of noncore medical content.

Each faculty member's estimated annual teaching effort was tabulated from the departmental faculty time record. (These estimates had been recorded prospectively, independent of data regarding HO ABIM performance.) The total time contributed to teaching by each faculty member was derived by calculating the product of the faculty member's percent teaching effort and the total time on clinical service. The total sectional teaching effort (expressed as percent FTE) was determined from the sum of the personally estimated efforts of all clinical members of the section.

Table 1--Markers of Medical House Staff Interest in
Pulmonary/Critical Care

The improved examination performance correlated with an increase in the total faculty commitment to HO education as estimated from the total percent effort dedicated to teaching (Fig 3). In addition, HO examination performance correlated with the total number of clinical teachers (ie, the sum of clinical faculty and fellows) within the Section (Fig 4).

DISCUSSION

Despite the primary importance of the educational mission of university-based medical training programs,(11),(12),(13),(14),(15) extensive faculty effort, and imposing financial costs of providing appropriate residency training across the breadth of medicine, there is little objective documentation of effects of subspecialty contributions to general medicine training programs. Recently, academic pulmonary specialty programs have been threatened on multiple levels.(1),(2),(3),(4),(5),(6) There are widespread concerns regarding a possible surplus and maldistribution of pulmonary/critical care specialists, increased departmental priorities to train larger numbers of primary care practitioners, and preparations for inevitable reductions in overall funding for graduate medical education because of the impact of managed care and other interacting economic factors. In response to these uncertainties, strategies euphemistically described as "down-sizing" or "right-sizing" programs have been implemented. Clearly, the roles of academic pulmonologists and other specialists are being redefined.(2),(7),(8),(16),(17),(18) During this period of rapid, profound change, the current observations have particular relevance.

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Teaching Makes a Difference

Reorganization of the pulmonary/critical care section at our institution was associated with a sustained increase of general medical HO interest in this aspect of internal medicine. Moreover, following the increase in the number, quality, and diversity of learning opportunities offered by the reorganized section, HO knowledge of respiratory medicine increased as measured by their performance on the ABIM certifying examination. It is not established whether enhanced HO interest and knowledge of respiratory medicine would either result in their more optimum treatment of patients with respiratory problems or detract from their performance in other areas. With increased emphasis on primary care (and associated practice opportunities), it is also unclear whether the changes seen at our institution will be sustained. As HOs, for a variety of compelling incentives, increase their selection of more general, rather than specialty-oriented career tracks, the content, context for, and implementation of respiratory medicine curricula will change further. More information defining the curricula that assure experiences for optimum training of generalists and their acquisition of essential competencies in specialty areas is necessary.

Although it seems obvious (and, to subspecialists, appealing) that expansion of our section might have had a causal relationship to our HOs' interests and improved cognitive performance, we cannot exclude the effects of other unmeasured internal and external factors. Because of multiple possible interacting influences on medical education, our findings are more accurately characterized as an association. The extent to which they reflect more pervasive national trends or unique predispositions of our HOs is unclear. During the period described, there was an increase in practicing pulmonary/critical care specialists, and it remains possible that our institutional changes reflected a general rise in specialty popularity and not merely effects of sectional development.

Who Will Teach?

The multifactorial nature of curricular changes and new learning opportunities does not permit delineation of a single cause of improved HO performance. These data suggest that there is a threshold effect of specialty faculty number and allocation of their effort for educational activities and are consistent with previous associations of better overall resident performance on the ABIM certifying examination with a higher full-time faculty/student ratio and increased resident time spent on consultation service and ambulatory care experiences.(19),(20) The need for a critical nucleus of committed faculty is obvious to academic pulmonary/critical care clinicians attempting to balance the time demands of providing optimum care to exceedingly ill patients and meeting other service functions, while maintaining effective teaching roles and research productivity. We are unaware, however, of previous documentation of these effects on general HO specialty interest and knowledge.

In addition, the presence of the role models offered by a thriving fellowship program appears to have a measurable beneficial impact. Although improved HO cognitive performance was associated with expansion of our pulmonary/critical care fellowship program, this finding does not represent either a justification or a recommendation for increasing the size of any fellowship program. The roles of fellows in a section's educational mission will clearly change in the future, as the anticipated national reduction in funded specialty training positions is realized. Our fellowship program was expanded to meet a combination of sectional research, education, and service goals unique to our center; local priorities and allocated resources will determine a variety of workable institution-specific responses.

With continuing uncertainties regarding what the future will pose for academicians, institutions have varied considerably in their strategies, depending on local resources and priorities. Some centers have made no changes in their HO educational programs, awaiting future clarification, while others have eliminated all but the service functions of some specialty faculty, relegating the teaching of respiratory medicine to primary care clinicians. Thus, the current observations are of interest not only to current subspecialists and academic chest clinicians. As general medical training, and, in particular, that in respiratory medicine, becomes extended increasingly to ambulatory, community-based settings, the important roles of nonspecialists in this activity should become more widely recognized. It remains possible that general internists with effective teaching skills and knowledge in pulmonary disease would have a similar, but perhaps more cost-effective curricular impact. We believe that the personal commitment of a true mentor, without regard to specialty orientation, is essential. Although the means for assuring appropriate emphasis on education in respiratory medicine will necessarily vary among institutions, retention of the educational component supersedes political or specialty alignments. It is likely that in many settings, appropriate training in some aspects of respiratory medicine can be achieved by well-trained, dedicated, nonspecialist mentors. We believe that role models' active participation in clinical and basic science research provides an added dimension to the instruction that they provide. In this regard, the HO's perceptions of the expertise, as well as the commitment, of the clinician-teacher has a major impact. As alternative approaches for addressing these educational priorities are developed,(21) each will require critical, objective evaluation. Quality, as well as cost-effectiveness, must be maintained.

Where Will Teaching Occur?

With inevitable alterations in the number and structure of pulmonary/critical care training programs, it is likely that innovative approaches to MICU staffing and other respiratory training experiences will evolve, and that several strategies will derive from institution-specific needs and driving forces. Organizational structures may include not only services left "uncovered" by HOs, but also management by full-time, in-house faculty intensivists, and increased use of well-trained physician extenders. Because of its high educational yield, the MICU will probably retain an important position in most university-based medicine training programs, but this time allotment in the curriculum will be balanced increasingly with the appropriate expansion of more general inpatient rotations and, in particular, extended ambulatory experiences.

Since the initial phase of program development described in this report, we have "capped" the number of critical care rotations that can be elected by HOs, to assure that all receive an appropriate distribution of experiences without an inordinate emphasis on critical care. Expansion of meaningful instruction in the ambulatory setting was one component of our sectional reorganization and continues in accordance with departmental curricular goals. This pulmonary rotation has become the most frequently requested among outpatient electives selected by HOs. This shift in locale of respiratory specialty teaching from traditional inpatient to ambulatory sites imposes further challenges and opportunities for faculty.

Who Will Pay?

The increase in faculty number and protection associated with our HOs' improved cognitive performance represents an economic commitment that may not be feasible in the future. Addressing research and educational, as well as service, needs was an important reason for our section's expansion, but the approach to this dilemma is an unresolved issue confronting all academic centers. Who will teach, and the ultimate source of funding for medical education and research have not yet been defined. The economic burden of teaching has received particular emphasis.(22) Typically, teaching is not acknowledged explicitly as a line-item expenditure (or priority), but rather an assumed and, generally, an untaught function that is merged with numerous other faculty activities. Recent analyses at our institution indicate that education is supported primarily by clinically generated revenues (W.F. Hazzard and K.M. Calloway, unpublished data, 1996). The focus on cost reductions that dominates ongoing transitions to managed-care modes threatens and, in many instances, may abolish such basic support of HO training. The impact on clinical faculty can be disastrous, as multifaceted roles, expectations, and self-images clash with fiscal realities. Many may contract their teaching activities to meet expanding patient care responsibilities (at lower compensation), or attempt to maintain previous teaching functions during extra, essentially unsubsidized hours. These general conflicts may be accentuated for the pulmonary/critical care physician, for whom the particularly high volume, acuity, and unpredictability of illness of inpatients, needs and expectations of patient's families, scheduling demands of procedures, and increase of outpatient activities simultaneously impact on teaching time. These unique demands may not be truly appreciated by the administrators who must coordinate and pay for these efforts.

Prospective Study Is Needed

Our observations of improved HO performance may not be of great surprise for persons experienced in academic medicine, but it is remarkable how little documentation exists regarding the education of generalists about respiratory disease. During this period of national change, objective monitoring of effects of medical curricular interventions becomes all the more important. Many anecdotal impressions and proposed solutions, while seemingly clear-cut and logical, have not yet been appraised. This report of our descriptive, longitudinal experience does not represent a controlled study. Prospective, controlled investigations of alternative curricular strategies using appropriate outcome measures of educational quality and effectiveness are essential, but will prove especially difficult to perform in the current rapidly changing environment.

CONCLUSIONS

Our observations strongly suggest that plans for reorganization of departments of medicine in response to changing residency training priorities must take into account the educational impact of their specialty programs. As staffing needs for university-based pulmonary/critical care faculty become better delineated, their impact on the effective training of generalists and on specialty fellows must be considered. In a recent statement of the American Thoracic Society, educational functions were included as important components of the future role of pulmonary and critical care medicine physicians in the American health-care system.(18) Despite the powerful forces that favor radical changes in university-based programs, these observations underscore the need for a cautious approach to assure that such vital functions are not only maintained, but also nurtured.

During what is a crisis-oriented, survival mode of operation at many institutions, it is increasingly difficult to maintain appropriate emphasis on the primacy of medical education and research.(11),(13),(23) These activities that differentiate the academic center from "leaner," more cost-efficient institutions focused entirely on delivery of patient care can present major short-term disadvantages. Ultimately, however, these fundamental scholarly missions represent defining strengths that will determine their survival. Maintaining focus on the central academic mission will present further challenges and will require innovative curricular responses.(6),(9),(11),(12),(13),(21),(24) Some paradigms for future medical education, as well as research and service functions, may blur or abolish traditional departmental or sectional organizational structures, but the need for meaningful instruction in respiratory medicine will remain. Institutional priorities, resources, and shifting external forces will define how, where, and by whom respiratory medicine will be taught, but an appropriate number of faculty mentors and sufficient commitment of their time to education must be preserved.

FOLLOW-UP COMMENTS

Following the review and acceptance of the current report, the ABIM examination results for the class of medicine HOs completing residency training in June, 1995 became available. Although this group maintained similar performance on the critical care component of the examination compared to previous HO classes, performance on the respiratory component declined markedly. As noted by the ABIM, the new reporting format does not permit direct comparison with the performance results of previous years. Nevertheless, a lower overall performance for this class is of concern in light of the previous striking improvements we had observed. It was all the more noteworthy that these differences had occurred in the absence of any recognized changes in the respiratory medicine curriculum.

Review of the experiences of this class of HOs suggested shifts in their interests and aspirations. Fewer had elected the pulmonary consultation service rotation during residency years when compared to previous classes. In addition, fewer of the residency program graduates were electing specialty training, seeking general medicine practice opportunities instead. These trends are accentuated among our current HOs. Even fewer upper level residents have elected pulmonary rotations for the current academic year. If, in the past, 85% of HOs completing our medicine residency program sought specialty fellowship training, 85% of current second-year HOs are planning careers as general internists. These findings suggest a very powerful impact of shifting HO goals in response to external factors, underscore the rapidity which HO performance and career interests are changing, and document the importance of continuous monitoring of the content and outcomes of specialty curricula.

ACKNOWLEDGMENTS: The authors thank Betsy Burkleo, Program Administrator, Internal Medicine Residency Program, Bowman Gray School of Medicine, and Patricia Boggs, Grants Accounting Technician, for their assistance in compiling these data; Julia Rushing, Department of Public Health Sciences, for statistical consultation; and Maxine Davis for preparation of the manuscript.

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