Ágoston Kecskés

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January 11, 2012

Blog Entry #7: Changing habits of practice

            In my previous post, I started headlong into a tirade against Bowen et al.’s article[1] on the transformation of internal medicine residency education in the ambulatory setting. In this post, I continue my tirade.

The aforementioned two claims – that internal medicine residents spend less time training in ambulatory medicine than internists do in practice, and that ambulatory medicine differs significantly from inpatient medicine - seem to be the only driving forces motivating this literature review. Yet the authors find that “substantial changes in ambulatory education are needed” and that, as per the authors’ discussion, these changes should not be limited to simply increasing the amount of time residents spend in the ambulatory setting. Many, if not most, of the authors’ recommendations go well beyond (and tangential to) remedying a perceived discrepancy between training and practice in internal medicine. It feels almost as if the authors’ hypothesis was formulated after the data was collected.

The authors at least mention the argument that “residents might benefit from training tracks tailored to their career plans, so that residents bound for careers as hospitalists would focus on hospital-based training.” This argument raises the question of why the authors did not bother looking into the mismatch between total times spent in residency training versus practice settings per individual instead of on a national level. It would seem incumbent on the authors to ensure at the very least that it is not by design that some residents are not receiving ‘adequate’ amounts of exposure to the ambulatory setting. Instead, the authors conclude that “the core of internal medicine training at the residency level should include a more robust exposure to continuity practice regardless of the resident’s future career choice.” This statement neither is intuitive nor flows from the authors’ findings. More saliently still, it stands in isolation of any cost-benefit analysis. As a result, it could be merely an expensive cop-out. As long as the authors do not have to foot the bill, how could more training possibly be a bad idea? Later in the article, the authors curtly mention that “financial pressures may limit available resources, including faculty time or clinical space.”

In contrast to the rest of this study, the authors’ limitations section is a breath of fresh air. The limitations of this study are so substantial, in fact, that it would seem more appropriate to list them before the results than after the discussion. Of note, the authors admit that most of their recommendations are drawn not from their findings but from “discussions with experts and knowledge of learning theories.” It would seem this paper could have been written without findings of any kind.

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[1] Judith L. Bowen et al., “Changing habits of practice,” Journal of General Internal Medicine, http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1497.2005.0248.x/abstract; accessed 9 January 2012.