How the ACGME and ABA are infantilizing resident training
Not long ago, my patient in a complex thoracic case developed progressive bradycardia followed by a malignant-looking multifocal atrial arrhythmia that didn't generate any blood pressure.
“Get out some epinephrine!” I said to my resident, who was standing closer than I was to the drug cart. The resident quickly drew up a milligram of epi, but then paused. I could almost see the thought bubble overhead: “Should I print out a label? Put a tamper-proof cap on the syringe?”
The resident – perhaps spurred on by the look in my eyes – made the right call, pushing epi immediately into the I.V. line and not stopping first to clean the injection port with alcohol for 15 seconds. The patient responded right away with return of sinus rhythm and a blood pressure consistent with life.
This brief but intense drama led me to ponder (not for the first time) whether the protocols and rules that infuse our days are improving safety or leading to paralysis when decisions must be made. Sometimes you have to act as you think best, accepting the possibility that your action may be vulnerable to criticism.
Even if you follow the protocol today, tomorrow it may change. Wearing masks all the time at the start of the COVID pandemic was considered a bad idea – until it wasn't. On average, 20% of the recommendations in clinical practice guidelines don't survive intact through even one review – on the next updated version, they're downgraded, reversed, or omitted (JAMA 2014;311:2092-100).
Today's resident education process isn't helping residents face the inevitable ambiguity of medical decision-making. No wonder residents get rattled when they find that one attending does things far differently from another. The ACGME and ABA are turning residency training into an infantilizing experience. Residents are used to studying to the test, and on the test there's only one right answer.
Anesthesiology trivial pursuit
I don't envy residents today. When I peer over their heads in the OR to see what they're looking at on the computer screen, it's often a multiple-choice question in preparation for the ABA basic exam, which looms over their first two years like an executioner's axe. Never once has the question had any relevance to the patient or the case. The question itself seems to be part of an anxiety-ridden trivia game, geared toward testing the ability to prep for the test, not the gain of medical knowledge with any connection to patient care.
“Today's resident education process isn't helping residents face the inevitable ambiguity of medical decision-making. No wonder residents get rattled when they find that one attending does things far differently from another.”
In an era where rote memorization has lost favor in medical education, replaced by “problem-solving” and group learning, why do these multiple-choice questions still exist? Does anyone actually learn anesthesiology from doing them? Can't residents end up confused by reading three or four wrong answers for every correct one?
There's a disconnect between watching residents struggle with today's arcane multiple-choice questions, and thinking about residents as “adult learners” who should have some say in how they acquire an essential foundation of knowledge in anesthesiology.
I'm told that medical education is moving from pedagogy – where the teacher is the instructional leader, and learning is motivated by external pressure – to andragogy, which “reimagines the teacher as a mentoring facilitator, guiding adult students toward collaborative assignments” (J Educ Perioper Med 2020;22:E638). Yet it doesn't look that way on the day-to-day level, certainly not during the first two years of residency when their futures hang on passing one written exam.
The recognition of residents as adult learners also doesn't fit with the ACGME's decision to track resident progress by attempting to measure “KSA” – knowledge, skills, and abilities – across multiple “domains” (asamonitor.pub/2KSRF2m). Some of the domains are so squishy that they defy measurement – especially the ones concerning personal interactions, professionalism, and ethics.
If a resident is not already an ethical adult who takes responsibility and has empathy toward other human beings, resident education won't correct defects of character that were fixed in place before kindergarten. Our job isn't to raise children. They're supposed to be raised by the time they start medical school. If not, we should question the admission process that let them in.
Technology can inform, not make, good decisions
Most residents are intelligent adults who are intrinsically motivated to study and learn by a love of medicine and a desire to help patients. The immediate availability of technology, in the form of smart phones and electronic decision support, can provide invaluable support to the human brain, making memorization less critical. Protocols and policies can benefit everyone when intelligently applied to decrease avoidable error.
Yet Siri and Alexa will never have all the answers, and protocols change. How frail is too frail? Should the patient with a drug-eluting stent continue taking aspirin or stop it before surgery? Should the patient with a history of penicillin allergy receive an alternative to cephalosporins that may not be as effective against surgical site infection? Does every difficult airway require awake fiberoptic intubation? Often the best answer is, “It depends.”
The ability to make good decisions in the moment is dependent on having a knowledge base and the judgment to apply it appropriately. The human brain has an astounding ability to integrate information and to choose a sound course of action in the face of conflicting or incomplete data inputs.
Sadly, the game of anesthesiology testing, as played today, doesn't guide the way to integrative knowledge. Residency training is losing sight of the fundamental twin goals of medical education: transmitting knowledge, and teaching – by case study and example – the wisdom and art of practicing medicine. We must find better ways to educate the anesthesiologists of tomorrow and prepare them – like the adults they are meant to be – for the complexity of decisions ahead.