Can We Get Graduate Medical Education Right?

“We are great at generating new knowledge, but bad at implementation.”

James B. Battles, PhD
Social Science Analyst for Patient Safety
Agency for Healthcare Research and Quality
Harvard IOM Conference presentation, June 18, 2010


I loved this quote when I first read it in an excellent white paper entitled, Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety”. It is a well-written review regarding many of the issues and challenges that lie ahead in graduate medical education (GME). Over the years I have heard many, including myself, express dismay at the ability of our profession to generate new ideas yet fail to see those practices turned into universal action across care sites–but never so simply put as Battles articulated. Having had the great pleasure of knowing Dr. Battles through the years, it didn’t surprise me that this eloquent quote came from him.

Over the past decade, research and outcomes studies have shown us what we need to do to improve the safety and quality of care for our patients. Be it misaligned financial incentives, lack of internal resources, competing time constraints, or a lack of strong leadership that fails to make safety and quality top priorities, we continue to struggle with the implementation of proven best-practices at the bedside…things we know work.

Can the same Jim Battles quote now be said for graduate medical education? As shared in my previous post, “Graduate Medical Education: Value Based Reimbursement…”, in December, 2008, the Institute of Medicine (IOM) issued a report entitled “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety”.  In 2010, the Accreditation Council for Graduate Medical Education (ACGME) Board of Directors responded by approving new requirements for residency programs, including updated standards for resident duty hours, education, and supervision. These new standards were implemented on July 1, 2011. In line with many of the IOM’s recommendations, the new ACGME standards required residency programs to:

  1. Tailor supervision standards for different levels of training, particularly greater supervision for first-year residents
  2. Ensure competence in structured handover processes
  3. Incorporate clinical quality improvement and patient safety into resident learning
  4. Provide safe transportation and/or sleeping facilities for fatigued residents
  5. Adjust workload according to patient severity and resident training
  6. Improve oversight of compliance with duty hour limits


Following the release of the new standards, Dr. Nasca the current CEO for the ACGME, was quoted in a perspective piece published in the New England Journal of Medicine (September 30, 2010). In it, he highlighted “the important role of the IOM report in ‘solidifying the ground on which GME programs will move forward to adjust duty hours, provide closer supervision to residents, and improve the quality of care by making it safer.’” Program directors would now be held accountable in ensuring that their residents:

  • Participate in identifying system errors and implementing potential systems solutions.
  • Work in interprofessional teams to enhance patient safety and improve patient care quality.
  • Are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs.

Some say the ACGME requirements are not enough. The white paper cited above was the result of a conference entitled, “Enhancing sleep, supervision, and safety: What will it take to implement the Institute of Medicine recommendations?” Twenty-six stakeholders participated in the invitation-only roundtable discussion and included quality improvement experts, medical educators and hospital administrators, consumers, regulators, sleep scientists, policy makers, a resident physician, and a medical student. The group also included two members of the IOM committee that produced the “Sleep, supervision and safety” report. The conference was structured around the 10 major recommendations made by the IOM. The expert panel concluded:

Given that resident physicians comprise almost a quarter of all physicians who work in hospitals, and that taxpayers, through Medicare and Medicaid, fund graduate medical education, the public has a deep investment in physician training. Patients expect to receive safe, high-quality care in the nation’s teaching hospitals. Because it is their safety that is at issue, their voices should be central in policy decisions affecting patient safety. In September 2010 the ACGME issued new rules to go into effect on July 1, 2011. Unfortunately, they stop considerably short of the Institute of Medicine’s recommendations and those endorsed by this conference…it is clear that policymakers, hospital administrators, and residency program directors who wish to implement safer health care systems must go far beyond what the ACGME will require.

The new ACGME requirements are clearly a big step in the right direction. However, I have been continually surprised through my recent travel and speaking engagements across the country at the number of residency program directors, designated institutional officers (DIO’s), quality/safety directors and C-suite leaders who are still unaware of the new ACGME requirements, or the newCLER (Clinical Learning Environment Review) program that now uses unannounced site visits to assess the GME learning environment of each sponsoring institution and its participating sites. Many residency program directors who have heard of the new programs cite lack of institutional support needed to address the new requirements–they know what they need to do but don’t have the support or resources to implement what they need to do.

Here’s hoping Dr. Battle’s quote doesn’t also prove to be true in GME.

First posted on Educate the Young on 02/24/2013

David Mayer, MD
David Mayer MD is Vice President of Quality and Safety for MedStar Health and is responsible for overseeing the infrastructure for clinical quality as well as for designing and directing systemwide patient safety and risk reduction programs for MedStar and each of its entities. Dr. Mayer founded and has led the Annual Telluride International Patient Safety Roundtable and Patient Safety Student Summer Camp for the last eight years. He regularly presents and writes on topics related to quality and patient safety for Educate the Young, and has received grant funding from the United States Department of Education, the Agency for Healthcare Research and Quality, and the Anesthesia Patient Safety Foundation.


  1. Medical students and resident physicians are a sharp bunch given heavy incentives by the need to survive severe sleep deprivation, school debt, and other pressures. I’d have to guess that with whatever practices they eventually develope reflect precisely what our health care system rewards. Physicians largely ignore practice standards across the board, and will continue to do so exactly as long as they benefit from such decisions. Physician leaders can continue to pretend to self-regulate their training and practice with meetings, PR, papers, and voluntary suggestions, or they can take some responsibility and get to work actually doing so. The longer they pretend, the more prestige their profession will continue to lose, and the more control over its own work it will lose over time. This once very powerful profession has already fallen considerably in very little time; ask any doc how much time they spend begging for insurance approval for routine deicsions. The financial & practical consequences of this massive industry have become far too large for medicine to survive as the last cottage industry able to ignore the modern world.

  2. The essential problem in the health industry is not ability to implement knowledge: the worst problem is one of priorities. Long ago health industry leaders essentially abandoned health outcomes or care quality as major priorities. At every managerial and regulatory level, including biomedical research, profits have long ago become the top priority, with a thin veneer of PR indicating otherwise. We fail to implement practices that either hurt the bottom line or fail to improve it, and we have seen powerful efforts to ensure that all billing and other incentives maintain these prioriites. Even idealisitic Obamacare does far more to grow the industry than it does to attack corruption, waste, and profiteering. We will see ongoing efforts to ensure health care remains among the most profitable industries in America, regardless of outcomes, with relatively minor exceptions to maintain appearances for public consumption.


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