Medical Training in the US and UK [Re-release] (1 May 2024)

SPEAKER_03 0:00

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SPEAKER_05 0:31

Hello and welcome to our next episode. We're delighted today to have special guests, the Curbsiders team. So we've got with us today Dr. Matthew Water and Paul Williams, who are running the Curbsiders podcasts. And these are a series of podcasts on many interesting internal medicine topics. And we invite you to listen to them. With me today, I've got the Dr. Badget as well, whom you'll know from our clinical conversations. And I'll let everyone to introduce themselves.

SPEAKER_02 0:59

So hi, I'm Johnny Bargett, and I'm a TMC member. And again, guys, welcome to the podcast. And would you like to introduce yourselves? I would like Paul to introduce himself first.

SPEAKER_01 1:10

You're just trying to see how much depth I go into. So I'm Paul Williams. I'm delighted to be here. Thank you so much for having us and allowing us to talk. I am a clinician educator and outpatient internal medicine doctor in Philadelphia, Pennsylvania, uh in the United States. And I've been with the Curbsiders podcast almost from the very beginning, but not quite. I think one or two episodes away from the start. So I don't I don't count myself as an originating member, but there early on.

SPEAKER_00 1:31

You were pretty much there, Paul. I'm pretty sure I was talking to you on the phone and I'm like, yeah, I'm thinking about this podcast thing. And you're like, that's a great idea. And you were the first guest. So I feel like you were there from the start. But I'm Matt Watto, I also a clinician educator. I live and work in the Philadelphia area. I work for a residency program where I work with medical students and medical residents. And I see some of my own patients in outpatient clinic and spend way too much time on curbsiders, which is, you know, something I'm working on. But we will keep putting out episodes because overall, on balance, Paul, I think it's been pretty fun.

SPEAKER_02 2:04

Yeah. Yeah, absolutely. So it's great to have you guys. And basically, I think one of the things that I'd like to start with is just by asking you how did you get involved in podcasts? And how have you been able to create this repertoire of knowledge?

SPEAKER_00 2:21

I'm always going to defer to Paul here.

SPEAKER_01 2:24

The guy who just said he wasn't actually one of the founding members. But Matt should probably be telling this story, and I'll let you expand on this. But if memory serves, Matt and Stuart Brigham, another physician, were actually responsible for running an ambulatory curriculum where they were working together. And after some because some of the conversation they revised, it would translate well into the podcast medium. I think Matt credits me with introducing him to the idea of podcasts in the first place, which is just kind of absurd. So this was completely off my radar. I listened to comedy and movie podcasts, and we talked about that because that's the interest that Matt and I share. But he was smart enough to actually transfer sort of his morning report ambulatory curriculum format into a podcast format. And I can tell you sort of my entry into it is one of the first guests. They actually asked me about the sprint triangle, which I have no expertise in, by the way, but I did have 20 pages of handwritten notes that I referred to, and I thought a lot about it. And I can at least put together a sentence. So I was probably one of the first non-thrown-away podcasts that was recorded with the curbsiders. And then from there, we sort of built our cohort of experts and it just kind of snowballed from there. Does that reflect your memory, Matt?

SPEAKER_00 3:19

Yeah, that's a great summary. So, first of all, there was nothing I was obsessed with podcasts, and I was using them for learning about things like finance and I don't know, mindfulness, stuff like that at the time, whatever I was obsessed with at the time. And I thought a lot of what I enjoy about these interview shows could work for medicine and the medical podcast that exists at the time. Nothing sounded conversational, like it was just colleagues bouncing ideas off each other. So that's where it came from. And then when we found out we could make the work count twice and that it would be a win for the audience, it'd be a win for the guests who get to put their ideas out there and a win for us who would get to feel like we're taking better care of our patients and better able to teach. You know, it just all sort of went from there. And some of our first episodes, we we would cold email people and we would just say, Hey, I'm a big fan of this article you wrote, or I'm a big fan I heard you speak at this conference or on YouTube or whatever. And you know, people respond because turns out they weren't getting hundreds of emails a day offering them to come on podcast at the time. So found out we could record remotely and have all these great guests from all over the country, all over the world, really. And one of the reasons Paul wasn't involved from the start is because we thought, oh, well, Paul's in Philadelphia, we're in San Antonio, Texas, but we very quickly realized that even all of us in San Antonio didn't want to all go to the same house to record. So we just started recording remotely and Paul quickly joined. So that's kind of the genesis.

SPEAKER_05 4:37

That's great. Thanks so much for taking us for that journey. It's really inspiring. And so, how do you develop the content and the ideas? So you're telling us how it started all at the beginning. How do you work that now? So the curbsiders is an internal medicine podcast. How do you bring about the ideas? Is it all based on the kind of the research, the conferences you've been to? How do you know what the audience wants?

SPEAKER_00 4:58

You know, Paul, I think uh so I'll tell you our mission statement is we are looking for clinical pearls and practice-changing knowledge. And we, of course, feature a lot of bad puns. But Paul, why don't you tell them like some episodes you're working on right now and like how you chose those? Because I think that sort of speaks to how we think about things.

SPEAKER_01 5:15

Yeah, I think that's right. So from the start, the topics have always been the things that we feel like we don't have comfort with or things that we can learn more about. We always at this point choose topics that are of interest to us. And so, for instance, right now I'm thinking about working on say hematuria, which is not something that we've done before. It's just it's something I have a handle on, but not as strong handle on as I would like, or say chronic neck pain, which is something that we see in the outpatient office all the time, but we've not had a conversation about. So a lot of the times we'll choose topics based on something that we'd like to personally learn more about or areas that we feel like our audience would benefit from learning more about. So we've always put this show together with us in mind as the surrogate audience. And I think that's probably part of the reason for the success. So basically, in summary, our clinical topics are chosen by the things that we think are interesting or want to learn more about. And we hope that we're reflecting our larger audience.

SPEAKER_02 5:58

It's nice to know that your method is kind of similar to ours when we were first making this. We're kind of thinking in the same line of thought, and we're generally all within internal medicine training curricula. And we have training programs to accredit to, and so we have different presentations that we have to learn about and show evidence for. And we thought podcasts is probably one of the most accessible ways of obtaining that knowledge. But we're quite lucky in that we get feedback directly from the Royal College of Physicians of Edinburgh through our evening medical updates and our symposia. Do you get any written feedback through portals like that or sort of American Colleges of Physicians or your sponsors? Um, can you tell us a bit more about that?

SPEAKER_00 6:37

Well, we get a lot of unsolicited feedback from the audience. Now, actually, we do ask at the end of every episode for feedback. Sometimes we appreciate it more than others. If you've ever heard anyone in the public sphere, and I'm sure you've experienced this yourselves, but you could get probably 99% of the feedback we get is positive, but then you just get that one person that's just sort of complaining about some like little minute thing or criticizing us for the first 10 minutes of the show, you know, that sort of thing. And it's hard. But yeah, most of our feedback comes through social media, our website, or our email. And those are the main sources of feedback.

SPEAKER_02 7:12

I think the theme of feedback is so important because we've been doing a few episodes on clinical education. And has just recently released an episode on reflection, cognitive bias, and how we make decisions. And uh, do you want to talk a little bit about that?

SPEAKER_05 7:26

Yeah, so our main remit is to record podcasting on clinical topics as we discussed, but we do some non-clinical topics as well. So John is saying the one that's awaiting release is on cognitive bias and clinical decision making. And there was one of the renal physicians here in Edinburgh who did a master's degree in medical education and he concentrated on working and learning about cognitive bias and clinical decision making. I think it was fascinating as well, because whilst learning on about clinical topics, you bring together all those non-clinical aspects of training as well. And yeah, really enjoying doing this and trying to find from the audience what they like us to do. So we try and attract both undergraduate medical students, but also those in postgraduate training from the beginning of training till uh later years. I was wondering if that's a good transition because today we also wanted to talk about, of course, the curbsiders clinical conversations podcast, but also about training systems both in the UK and the US and do a bit of kind of contrasting and comparing because I think that would be very interesting for the audience to know. So we thought we'd kind of go a bit through the medical training process and you're all happy with that. Tell us a bit about undergraduate training in the US, and Joni and I can compare that to what happens in the UK.

SPEAKER_01 8:40

So, undergraduate training in the US, it's constantly evolving, especially in terms of the assessment. It's been fascinating to watch. Some of that has been prompted by COVID and some of that has been prompted by just sort of ongoing conversations. But essentially, and Matt, you'll you'll correct me if I'm wrong if I say something that is unclear, medical school where the medical training begins for the most part after you've done at least a bachelor's degree in something. And sometimes people will do their undergraduate training as a quote unquote pre-med. Sometimes they'll do sciences like biology and chemistry. And that tends to be fairly common, but it doesn't have to be. You just have to have enough background learning and have taken the right courses to undergo a big test known as the MCAT, where you have to at least know biology, chemistry, organic chemistry. I think some physics are in there. And there's a writing sample of memory serves. It's been about 27,000 years since I've taken it. So it's probably changed since that time. So you can major in film studies if you want, but you at least have to have at least the background that you can succeed on this test and do well enough to be considered for medical school. And then typically to be accepted to medical school, the requirements are evolving and changing as well. It used to be just, you know, good scores and you had to get good letters, then you were done. But I think a lot of schools are now looking more holistically who's going to become a good doctor. So what has been there, at least the institutions where I'm working in, they're actually interested. Have you done any volunteerism? Do you have a sense of service? What is your personal sense of mission to actually take care of patients? So now rather than just sort of the accomplishments that we tend to associate with success, now we're actually looking at the broader person, which I think is really by and large a really important and exciting thing. So you make it past that hurdle, you get into medical school, ideally after applying 20,000 places and are now doing a lot of interviews primarily through Zoom calls right now, thanks to COVID, and then also with the recognition that traveling is financially burdensome to a lot of applicants. And medical schools are also involving in terms of the way that they train. I should probably pause here actually before I get into actual medical school proper and see if there's any questions up to this point.

SPEAKER_02 10:18

So I think we have a similar sort of admission test you have to go through. And it's, I think was it the UK CAT, Anda? Although it might have changed. So it's the UK clinical aptitude test, sort of like a situational judgment test, but it's kind of looking at what your best response would be in a certain situation, but not necessarily the correct one, but the most appropriate response. But the tests are ever changing. I think one of the things I'm interested in is about how long medical school within the United States lasts. And are there any hurdles within that that you have to overcome before you match or get into the training center of your choices you were you were alluding to?

SPEAKER_01 10:56

Great question. So medical school is four years. What those four years look like will vary from medical school to medical school. Traditionally, in the past, it had been sort of two very clear, distinct preclinical years, then two years that were spent doing your clinical rotations. And that at some point during your final year of clinical rotations, then you're applying into your residency program of choice, whether that would be internal medicine or surgery or neurology or what have you. The evolution now has been the preclinical years have actually been foreshortened. There is more time spent actually in the clinical years. And in terms of the barriers and hurdles that you have to take, you're probably referring mostly to the United States medical licensing examinations. There are sort of three-step examinations. The first one is kind of a review of your basic sciences at the end of your first two years. The second is a clinical skills test, they call it, which is typically taken, I think I want to say in the fourth year. And then the step three is actually taken during your residency training. So to successfully practice medicine, you have to get through these three sort of large exams that generate a lot of anxiety. I think a question I'd like to ask you all is actually at one point in our very recent history, there was a clinical skills test that was required as well. So you would actually go and you would see standardized patients and you would, you know, write down your progress note and say what's your best plan and what your thoughts were. And that's actually recently been ki-boshed. It's been eliminated and is now part of the licensing requirements. So that is something that has been a recent change. And I'd be curious to know what those sort of look like in your system and if there's still a clinical skills component to it.

SPEAKER_02 12:13

Yeah, so we're actually in the progress of recording a podcast about this as a sort of separate stream. And it's called the PACES exam. So it's the member of the Royal College of Physicians PACES exam. So it's the objective structured clinical examination or OSCE. And usually it is done one or two years into your internal medicine training program. Although it can be done in theory prior to even entering that program. Some people choose to do these sort of after your in the UK, you have your foundation year program. So after you leave medical school, you go into foundation year, which is your training to achieve your GMC practice, your general medical counsel license, and then you're registered from a provisional license to practice to your full registration, which is essentially your ability to practice medicine. But after foundation year, you choose whether you're going to go into medicine or surgery or whichever specialty. And then you have two written exams. One is a basic science exam, another is a more sort of structured situational or scenario exam. And then the PACES exam is the clinical exam that you're referring to. And do you want to talk a bit about that?

SPEAKER_05 13:17

Yes, so examinations is that kind of clinical examination. So it's going through some restructuring at the moment. Well, it was meant to be coming in 2020, but because of the pandemic, there's been some changes there. Basically, it's an exam based on clinical stations. And the stations cover important internal medicine topics. So most of the specialties such as neurology, cardiology, gastrointestinal medicine, respiratory medicine. And these are all live stations. So you go in on the examination and you examine it, will be asked to examine a real-life patient. The patient you most commonly will have pathology. So you'll have to pick up the signs and discuss the findings with the examiner. So very quick, it's kind of trying to mimic clinical practice in a way. So you have to make decisions on the spot. And then as part of that, you also have a communication station where you are again interviewing the patient, doing a consultation of the patients, and usually that will be a delicate, challenging ethical situation, for example. The exam is changing. We've had some changes during the pandemic. We had to pause some diets, but also we've done some remote stations as well. Just going back slightly, so as John was saying, foundation is kind of the program we do following finishing medical school, and that gets you into the next stage of training. At the end of medical school in the UK, that varies according to medical schools where you are in the UK at which stage you do it, but you'll have also final exams, which will also usually include OSCE or clinical examination as well. And then also the situational judgment test as well, which will provide you with certain scenarios, and that's something we still do at the moment in terms of progressing towards training.

SPEAKER_00 14:52

Oh, I think I would have needed beta blockers to get through a PACES exam. This sounds terrifying.

SPEAKER_01 14:56

I'm fascinated by it. Like the use of actual pathology, I'm just envisioning being expected to find pathology on a fundoscopic examination and knowing what to do with it.

SPEAKER_05 15:04

Like all that just gives me exactly what I had in my exam. Yes. So I don't know I should say that, but I'm not sure I've touched it again.

SPEAKER_00 15:12

Someone with papilledema, you're just like, what the?

SPEAKER_05 15:17

Yeah, but we do we do kind of say joint corrective on wrong, but we do say that possibly around your PACES exam, that is the best of a clinical doctor you're going to be in internal medicine because there's such a breadth of everything you're learning for that.

SPEAKER_01 15:30

I was going to ask that question if that's okay. Do you feel like these are adequate assessments or are they fair in terms of the stages of training to actually help you become a doctor? The reason I ask is I feel like the step one test specifically is often maligned as having a lot of information that will then probably not be used for the rest of your lifetime, like the nuances of the Krebs cycle or glycogen storage diseases, where if you have that as a clinical interest, maybe it'll actually come up, but for the most people, by and large, it will not. So I there's some that may complain about that. In terms of the examinations that you all take, do you feel like they reflect the practice you'll ultimately be doing? And are they fair assessments of where you need to be?

SPEAKER_02 16:01

I think with the PACES exam, it's kind of that sort of milestone that you have to achieve before you can be let loose as a medical registrar, which is the I don't know what they call them, grade before and attending in America.

SPEAKER_01 16:13

The resident, yeah.

SPEAKER_02 16:14

The resident. And so to be able to run the hospital at night, to run the acute medical take, you need to have reached the standard where you're almost at that exam or have passed it. And that's kind of that marker of your ability to care for patients. Our curriculum in the UK has shifted more from a competency-based to a more of a capability-based curricula. So it's not focusing on whether you know how to manage someone with chest pain, but more managing the patient presenting the acute medical take with an undifferentiated symptom. So it's more about how safe you are with what level of supervision rather than what presentations you can manage. So that's kind of been the shift in the curriculum in the most recent years in the UK. And you have a bit more experience of that than than I do.

SPEAKER_05 16:56

Yes, certainly. So just to answer also on that question about the exam. So I think I'd agree with all Johnny says. But I think that preparation for that exam, because the way we prepare for it, you know, you of course you read the textbook, you try and go to courses, but ultimately what helped me was for a few months before that, after your clinical day, you would go with a group of peers who were going through the same process and you'd go around the wards in the hospital and examine patients, you know. And I think that is such a useful experience and will give you that preparation to go into your next stage of training, but also to have another kind of opportunity to revise all topics in internal medicine. So, yes, our curriculum has been undergoing some changes. So I'll go back a bit to talk about kind of what happens after foundation when you start internal medicine training. So, up to three years ago, isn't it, Johnny? We were doing a program called core medical training, which involved two years of rotation. We decided to go and train towards a physician specialty, two years of rotations around in internal medicine, and then after that, you would choose your specialist registrar training or residence program. That's now changed, and we move to an internal medicine training program. So we've got three years to start with for everyone, during which time you're expected to do those examinations that we just spoke about, and then after that, you follow on to the next stage of higher internal medicine training. When you choose a general medicine specialty, for example, cardiology or gastroenterology, you would combine that with training in general medicine at the same time. So when you become a consultant at the moment, you would dual a credit in those specialties. So that's more towards a shift of recognizing that we all deal with comorbid patients and we all should be able to manage those patients and manage their complex illness.

SPEAKER_01 18:49

Can I ask? And I'll stop asking questions, but I'm curious in terms of the mix of inpatient versus outpatient training, like what percentage of what, if you can sort of estimate? Because I can say, you know, by and large, in the American system, it's largely intensive inpatient training. And then the vast majority of patient care, of a course, is mostly outpatient care. So it's just sort of this strange configuration. I'm wondering if that is similar to how you all practice or what that mix looks like for you.

SPEAKER_02 19:11

Yeah. So every year we go through appraisals. I'm sure you do the same in US training. We have an ePortfolio. It's our method of recording our competency or our learning events. And we have to basically show that we've attended a set number of clinics and a set number of patients that we've seen on acute medical take over the five-year or four-year training program as a registrar. So for me, I'm an acute internal medicine and a general internal medicine registrar, and I'm coming to the end of my training. And by the end of next year, I'll have had to have seen over a thousand patients in the acute undifferentiated medical take. So the front door, and I have to have attended one hundred and eighty-four outpatient clinics. You can have an equivalent number of clinics. So, for instance, doing a ward round on your own of five new patients on an acute medical take can be an equivalent of one outpatient clinic. So if you're not able to hit a regular number of outpatient clinics, then you can count an ambulatory care or an acute medical take as an equivocal of a clinic, if that makes sense. Is there anything like that in the US?

SPEAKER_00 20:22

I guess this so this is not during medical school, this is after your medical school. Yeah, I believe there's a certain number of clinics that they have to do. I don't know the number offhand. What a lot of programs do is they do at least one day a week of an outpatient clinic, or they have this X plus Y system where they maybe spend X number of weeks, let's say four weeks, doing some sort of medical rotation. Maybe they're an ICU, maybe they're on the general medical wards, and then they spend a week or two weeks seeing an ambulatory clinic. So they would get a bunch of clinics during that week or two. So they're sort of splitting their inpatient duties up with their outpatient duties in a specific ratio. And I apologize, doesn't that number seem similar, right? It's a hundred some clinics you have to see and over the course of a three-year internal medicine residency. So it's similar there. And it's definitely weighted more towards inpatient in the United States and most residency programs. That I think that's like it's 60 or 70 percent of your time is spent on the inpatient side. And it's always kind of joked about that despite most people that are graduating are then going to spend most of their time in outpatients, even if they go into a subspecialty. That's interesting.

SPEAKER_05 21:35

How um do you keep a record of that? So, what do you use throughout your training in the US? Uh so Junior saying we have a training curriculum here and we use an online ePortfolio where we add in, you know, the experience cases we've seen and link that, map that to the curriculum. Also, say if we've been to conferences or talks or we've got training days. We all link that to that ePortfolio. And that's used at our yearly RP to allow us to kind of progress and review. What system do you use?

SPEAKER_00 22:08

The residents log their duty hours, and that's mainly because there's a cap on the hours. So they're not supposed to work more than an average of 80 hours a week, and they have to have at least four days off each calendar month. And so that's what they're doing. They log any kind of medical procedures. Maybe they have to do a certain number of lumbar punctures or central lines before they can sign off as doing them themselves. I don't think the residents specifically log. There may be somebody at the program level that's logging those things, but as residents, they mainly just log duty hours and procedures, to my knowledge.

SPEAKER_01 22:40

Yeah, I think that's fairly consistent. That's usually the case. So there are usually program directors and administrative staff who are actually tracking the actual clinic sessions, but it's usually there's going to vary between residency programs or training programs. But there's usually some proprietary software that they're using to actually track their procedures. Sometimes, you know, what research and stuff they presented, it kind of depends on what they use and what systems, but it's going to vary from program to program. But in terms of keeping track and making sure they see enough outpatient visits, that's almost always at the administrative level, unless at the individual resident level.

SPEAKER_02 23:06

So the ARC that was talking about is the annual review of competency for progression and it's part of the annual appraisal. Can you tell us a little bit about what the equivalent method is in the US?

SPEAKER_00 23:19

Yeah, Paul, do you sit on the clinical competency committee for your program?

SPEAKER_01 23:23

I sure do.

SPEAKER_00 23:24

You want to tell them about that?

SPEAKER_01 23:25

Sure. I mean, there's probably also going to be a little bit of variation, but some of these things, there are specific guidelines outlined by governing bodies. But there is what's called a clinical competency committee, which basically has a lot of program directors and key and core faculty that sort of sit and review each resident's performance individually and see are they meeting the metrics that are needed to advance the next year? And this isn't a one-time end of the year meeting. This is actually part of an ongoing process. So rather than letting people flounder over the course of the year, it's a chance to kind of do individual performance improvements sort of over the course of the year. So they usually meet at least quarterly. They will identify residents that may need additional help. And then hopefully they're also identifying residents that are doing really well too. Like that's always a part that tends to be neglected. It's always sort of just like this punitive committee where they sit in dark cloaks and are mean about residents, but they actually like we compliment and think about how well they're doing as well, which is also the nice part of the job. So this happens at least quarterly usually. And then there's usually a summative meeting at the end of each year going through resident by resident and making sure they meet all of the milestones and metrics to actually advance to the next year of training.

SPEAKER_00 24:19

Yeah. For instance, in the programs, I've worked in several programs at this point, and most of them have twice a year they meet with the residents. So once in the beginning of the year and then once towards the end of the year, and you would review all the evaluations they've received through that time from everybody that you work with. So your students evaluate you, your co-residents, and your attending physicians evaluate you. You sort of read all those, maybe they have 15 or 20 evaluations, and you just sort of summarize any patterns you're seeing, good or bad. And you mentioned competencies. The ACGME is the American Graduate Medical Oversight Committee. And they have some core competencies, things like communication and professionalism and medical knowledge that they want us to comment on. So there's a lot of questions and check boxes that you check off. And then people can also just freehand write comments about the specific residents, what they're doing well, what they need to improve on. So you got to give people the chance to improve. If it was just once a year, they're not getting feedback timely, then they could be off the rails and they don't find out till the end of the year that they weren't meeting milestones.

SPEAKER_02 25:23

Are you guys educational or clinical supervisors in that role? Do you have trainees or residents that you mentor?

SPEAKER_00 25:30

Yeah. For my job, I mean, most in the US, they usually call you a core faculty member. It's some cohort of people that work closely with the program directors of the residency program to evaluate the residents and give them this feedback. And there's supposed to be a certain ratio of how many core faculty members you have versus how many residents you have. And you review the evaluations and then you go over them with the residents. So in my current job, I do quite a bit of that. We actually meet monthly to talk about not every resident, but some subset of the residents.

SPEAKER_05 26:01

Yes. We have a similar process here. So we've got clinical educational supervisors and they would be assigned per block or rotation. And we'd meet kind of at the beginning of the block to set up a personal development plan and then midway through the blocks after two months. Of course, you know, we work with them day-to-weekly basis and then review what we've achieved and things that we want to develop further and then meet at the end of the block as well, because they will provide reports. So similar, very similar process.

SPEAKER_01 26:31

And is there someone who's tracking and it's sort of having those conversations with you throughout the training? So it sounds like this is sort of block specific, but I know, you know, for instance, Matt and I, I think we probably have a cohort of residents that we're seeing from their first day of training all the way through their graduation. So there's some longitudinality to it. Do you have something comparable as well?

SPEAKER_05 26:47

Yeah, so we have that continuity. So we've got training program directors and they would be overviewing the group of trainees who've joined the internal medicine program at regional level. So they would be kind of overviewing our training, but ultimately they would communicate closely with our educational supervisor, clinical supervisor, just to cover if, say, you know, our training program director, we've not worked with them clinically in the same hospital. They know of us.

SPEAKER_02 27:15

I think that one of the main roles a bit of the TPD or the training program director is to do that additional level of support, obviously, but to help you navigate your rotations. So there's a degree of flexibility within my training program. So my training program, you do two years of general internal medicine, you do four months of geriatric or medicine for the elderly medicine, and then four months of cardiology, four months of respiratory, six months of intensive care, and then six months of any specialty or specialties of your choice. And then you have your certificate of completion of training. So for like for the six months that I did during the pandemic, I chose to do ID infectious diseases and real medicine. So that's the kind of flexibility that the TPD has allowed me to choose. And that's one of the gifts of having a flexible training program director.

SPEAKER_00 27:55

I wanted to bring up and just ask you all about this. I find that the medical residents, I went into general internal medicine, which is a much lower pressure situation because there's plenty of jobs in it in general internal medicine. But the vast majority of trainees in the United States want to go into some sort of subspecialty, and it's very competitive. And these people work so hard, in addition to just the regular stuff you have to do just to graduate and become a general internist. These people are trying to publish multiple papers on the side. They're trying to present at conferences, they're trying to network with other people in whatever specialty they're trying to get into. And it's just a really high pressure situation outside of just taking these step exams and there's a there's a board exam to become boarded in internal medicine. It's just, it's a pretty, you know, the pressure stays on for a long time. And these are young people working 80 hour weeks. A lot of them are far from their families and it's a tough situation. So I would just say that I'm very impressed always with all these medical students and residents that I work with because these pressures are just so high. I don't remember them being that way for me.

SPEAKER_02 28:58

Yeah, the 80 hour week sounds particularly arduous. Our European Working Time Directive, which may change obviously with Brexit, has usually a cap of around four to eight hours our week, but it can vary from week to week. I'm lucky I've gone into a less and full-time trading program in the last year. So when my son was born, I went to 80%. So I usually get one fixed day a week where I'm off. Do many people do that in the States?

SPEAKER_00 29:24

No, not in trading. There's no option. It's six days a week for years. I mean, I I remember when I'm not sure if you had this experience. I mean, this is part of why I created curbsiders because I felt like I was being lazy or something, not not doing things with all this free time I suddenly had. But you go from through medical school and residency, it's just at least seven years. If you're just going to general internal medicine, four years medical school, three years residency, you pretty much work six days a week and you know, you're just constantly studying. And then when you graduate residency, if you're working outpatient medicine, then you have weekends off. So you just suddenly just having a Saturday and a Sunday feels like, oh my gosh, what am I going to do with all this time? So it's unusual. I think the residents in the US, they just grind for three years straight, six days a week, usually 12, 14 hour days.

SPEAKER_01 30:10

I feel like the culture is evolving though. I, you know, I think back in the Stonian Jesus when Matt and I did training, it was, you know, you can't work more than 80 hours a week, wink. And like, you know, we'd all be working, you know, 100, 120 hours a week. That was not unusual. I think we're being more thoughtful about duty hour restrictions and really holding residents to that. I think there's been obviously even pre-COVID national conversations about burnout and psychological safety and that kind of stuff. So it's still imperfect, but there are some programs that are just doing away with 24-hour shifts, which, you know, for Matt and I, that was part of our training. We had ICU shifts where we were doing overnight call every three nights. Like that was just the expectation to work 21 days in a row was not unusual. It's just the way the schedule kind of shook out. I think you would not see that these days. So even though it doesn't sound like we're quite at the level of sophistication or civilization where you all are at, I will say things have gotten markedly better even over the past 10 years in terms of expectations of duty hours, but they still trainees work a ton. Like there's just there's no getting around it.

SPEAKER_02 30:59

One other thing that I'd like to really touch on is really about how people are managing their training programs. Do people go out of program sort of to do academic work? So do a PhD, do a master's? Is that something that you find a lot of your trainees do?

SPEAKER_01 31:15

It depends on the level of training. So I think it's not unusual. There are combined MD PhD programs from the medical school standpoint where students will do their preclinical years, then they'll go off and they'll do some research and then they'll come back into their clinical years. And it's a longer period, but then they graduate with both the medical doctor and the PhD training. There are also combined programs in medical schools that allow for you to get like MD and Masters of Business, or probably some even give you master's of education, I think, I want to say. So you can do it in your medical school training. Probably very few are actually doing PhD or master's training during their residency training, but it's not unusual for attendings. You know, once you've actually got some of your time back, it's not unusual for an attending to go back and maybe get their master's degree or get their master's of education after they're done with the residency training. So once they're no longer doing three million hours a week, then they might be able to find the time to go back and get those degrees, but rarely during the residency training itself. Does that sound right to you, Matt?

SPEAKER_00 32:05

Yeah, definitely. During residency, you're usually working on residency. The residents may go to another institution for a month to do sometimes they call it a tryout rotation, where let's say you're applying there for cardiology, you might go and hang out with their cardiologists and work on the consult service there. That is pretty common. And sometimes residents will perform some research between institutions with people at another institution. And I think that's mainly how people are working outside their day-to-day job in residency. It's mostly research or these away rotations, which typically last about a month at a time.

SPEAKER_05 32:40

And then what about opportunities for training in medical education or doing projects in medical education? Would there be a similar process? Are there opportunities there? For example, we have opportunities to take some amount of training and out-of-program work to do a fellowship in medical education, in which you work alongside a university program for undergraduates or postgraduates and develop certain skills in that area and knowledge in that area and then work on projects alongside.

SPEAKER_01 33:07

It's a great question. There's a couple of ways that you can pursue an interest in medical education. I think a lot of residency programs are now incorporating various career tracks into their training program. So once you're in your internal medicine residency program, you may have specific tracks such as hospital medicine or quality improvement or medical education or research, even. So there's a chance to do that even during your residency training where you may actually have a week off every so often to actually just do immersive training on how to actually teach appropriately. And then as you say, it's more here, there are fellowships specifically for medical education that happen after your internal medicine residency training. So you do your three years of residency and then you apply to a fellowship in medical education or even general internal medicine, as weird as that sounds, you you do residency training, then a general internal medicine fellowship after that, which usually incorporates a lot of educational stuff too. So there are different ways to tackle that depending on how intensive and sort of what career paths you're interested in.

SPEAKER_02 33:55

And you said that you're obviously both involved in clinical education, medical education. How did you get into those fields? And what does your average day look like?

SPEAKER_00 34:03

When I left my residency program, I was in the US military in the Air Force, and I went to work for the Air Force. And when they were asking me what sort of job I wanted, I wanted to work in a place where there were medical trainees. So I had a job where I was working some outpatient and some inpatient, and I would be working with trainees, both undergraduate, like medical students and medical residents. So I just expressed interest. And then there was a lot of mentorship from people who were already in that field at the site that I was at. And they would say, Hey, we should get you on the core faculty so you can learn what a competency committee does. And we should get you start to give lectures to the medical students. And that's how I got pushed into starting this ambulatory curriculum and eventually became curbsider. So it was just a lot of sort of expressing interest, finding out whether I actually liked it. And then some mentors sort of pushed me in the right direction.

SPEAKER_01 34:56

Yeah, and same process for me. It's something you kind of find, or at least I won't say you, I find myself kind of drifting into during residency. It turned out that I really liked working with the medical students. I did a chief residency year where I got to do a lot of educational stuff. And even though I am painfully introverted, like it turns out I actually like teaching and working with groups, at least in educational context. And so, you know, early on in your career, you just say yes to lots of stuff and you get a chance to sort of, you know, be part of committees and be part of educational initiatives. And if you find out that you like it and you do an okay job, you get asked to do more and more of that. And eventually you get paid for your time, is I think that the typical pathway to it. There are people who are smarter than I am who knew that they want to do this from day one of their training. And so they train specifically for medical education. Maybe when they are hired, they hire out Aindish for themselves. But I think by and large, most people just kind of chip your way into it. And eventually you sort of build yourself recognition as a medical educator and then you establish yourself that way.

SPEAKER_02 35:44

One of the great things about teaching is just seeing enthusiastic trainees achieve the things they want. And one of my mentors said that giving feedback to someone is like the currency of development. It was just perfect moments of wisdom. Have you had any advice from mentors in days gone by? What would your key sort of tips for trainees be, each of you?

SPEAKER_00 36:06

Well, you just said the feedback thing. So this is just one that comes to mind out of many, because we ask everybody on the show on Curbsiders, we've probably recorded close to 350 or more, Paul. And the Gurpreet Daliwal said to us, he's a clinical reasoning guru in the States. And he said that when he's giving feedback, even to his colleagues, he says, You have an emotional bank account with people. So he says, I like to give a lot of compliments to people so they know that I like them and I care about them. Because if I ever need to give more difficult feedback, they will accept it because they know I'm coming from a place of caring. And so I think that's great feedback for anybody who's either receiving either end of feedback. I think that could help you. So somebody gives you a lot of compliments and then one time they hit you with something that's a little harder to hear, it doesn't mean they hate you, they don't like you. They're just trying to help you.

SPEAKER_01 36:51

Yeah. In terms of specific advice about feedback, which I think is the question, something that probably talked about before, is just being explicit that you are giving feedback. I feel like that is sometimes a missed opportunity. You are giving feedback to someone and they may not take it, they may take it as a suggestion or conversation or an observation. And I think sometimes it's easy to miss something if you don't be explicit about labeling the feedback. So some of the best advice I actually got was from our most important mentors, Daryl Moyer, who's like, just say, I am giving you feedback now and then actually give the feedback, like really that explicit about it. Because a lot of the times people be like, Well, I never got any feedback about that. And it turns out you were giving it all the time, you didn't label it. And as a result, I think you know, if someone's not ready to hear it, they're not going to hear it. So I think preparing them, telling them, I'm going to give you directed feedback now, just to open up the conversation so that they know they're getting feedback from you is also just a really helpful fundamental thing that I think often gets messed.

SPEAKER_00 37:35

Oh, the buzzword there is signposting, right? Signposting. Yeah, sure. Sure.

SPEAKER_02 37:39

Yeah, I don't know what it's like in America. One of the things that our GMC General Medical Council asks of us every year is to survey our training programs, and that's through our educational bodies. And so one of the questions would be like a Likert scale, and you would have to say one to five, strongly disagree or strongly agree, you get feedback on a daily basis. And I guess, as you say, you may not get that feedback every day, but I guess sometimes if you don't get that feedback, you might be doing a great job, but you just don't know. Is there something similar to that in the US? Do you have to evaluate your training programs?

SPEAKER_00 38:11

Yes, there's the ACGME. Again, this is this body that oversees the residency programs anyway. And once a year you have to evaluate your own program. And both the residents do it and all the core faculty members for the programs evaluate it. And I believe it's anonymized, at least I'm led to believe that. Otherwise, I might be looking for a new job soon, Paul.

SPEAKER_01 38:32

Yeah, that's right. And then the other thing is most programs, probably all programs, have internal quality improvement too. So that it's I feel like you have to be a little bit careful. I remember I don't want to get myself in trouble, but when I was in school, like we had to do sort of daily feedback for every single person and the small group that we were working with, and eventually you just panic and be like, I like the color magic marker used to the whiteboard. Like it becomes you're just you're giving feedback for the sake of giving feedback, which is not terribly helpful. The point is that most programs will sort of elicit feedback on specific curricula and specific things that they do internally and above and beyond just this ACGME sort of summative feedback that that they ask for as well. So there's there's usually an ongoing process too.

SPEAKER_05 39:05

On the topic of that of education, because we're all here interested in magical education. Where do you see it going in the next few years? Also considering that we've had to adapt and change ways we do things for the last couple of years, but also build opportunities. I mean, podcasts is just I think an incredible opportunity to provide that flexible learning. But where do you see magical education going?

SPEAKER_01 39:30

Yeah, I think even pre-COVID, a push to so-called asynchronous learning, which is I think where podcasts fits into. The idea is that sitting people down, we know that the average adult's attention span is about 15 minutes, and yet every lecture you go to is about an hour long. So you've lost them after you've gone through your first five slides. And like we know that. So I think there's a recognition that the format of one person standing at a podium with a blue PowerPoint slide with yellow font talking for an hour and not doing any kind of interactivity is probably dying. And I think the evolution is now to sort of asynchronous learning, to sort of self-directed learning, and then also to small group and team-based learning. I think if that's largely happened, at least in most medical schools, I think residency programs are also moving towards that model as well. So I think we'll continue to look at ways where people can learn asynchronously and not sort of all at the same time because people prefer it. They're finding that they like the flexibility of it. And it turns out that interactivity and being part of an active part of the learning process is maybe a better way to learn than sort of passively absorbing from someone just talking at you. So those are the big broad trends that I'm seeing. And I'm not sure, Matt, if you agree or think of anything more granularly than that.

SPEAKER_00 40:28

Not really, but I'm just curious how simulation, like virtual reality, augmented reality, how those sort of things will come into play. And as we outsource more and more of our cognitive work to algorithms and our iPhone or whatever your preferred phone is, I think it's just going to be interesting. And how we're training our physicians or whatever medical trainees you're working with. The the guy that was in charge of Jefferson, who is now moving somewhere else, this Dr. Clasco, he famously speaks about this, how he's more looking for students who are creative and empathic because he thinks those are going to become more and more crucial skills because now it's not just going to be the person who can just like memorize and kill a test. It's the person who is good at like talking to patients, solving problems, using the information you have. And uh so I think the skill set's gonna change a little bit from what it used to be.

SPEAKER_02 41:21

Certainly with online programs and online education resources, there are learning analytics. So you obviously you can assess how much someone's engaging. And one of the things that we're looking at with the podcast is about how many listens we get and you know how many followers we have. I guess with face-to-face learning and blended learning, you can't really get learning analytics in the same way. And it'll be interesting to see how that goes in the future. I don't know what your thoughts on that are specifically.

SPEAKER_00 41:45

I I I'm not sure if I understand how that would work. I I don't know. How do you think it would work? Maybe then I'll be able to answer a little better. I'm just not sure what that would be like.

SPEAKER_02 41:55

Yeah, I think with how the education is changing or how it's delivered, I guess the concern would be if you have a student that's learning remotely, uh, you you may not be able to know whether they're logging in and doing the reading or in an asynchronous way, are they just reading it offline? Well, at least whenever you're on a ward or you're in a lecture, you're physically there. Yes and part of the community of of learning.

SPEAKER_00 42:16

I think for that sort of thing, there has to be some sort of interaction with somebody who can do evaluation at some point. And I think like we were talking about earlier in the conversation, the there where there's some sort of observed interaction with a patient or with other team members. I mean, I I think you have to watch these people interact because I mean, you could have someone that's a brilliant at answering medical questions, but they're a total sociopath if you don't want them passing into training and being out there. So I think you still have to evaluate the person and their personality, their inner communication skills, their professionalism, their ability to put the knowledge to work. So I think at some point, even if you're doing a lot of building the foundation of knowledge asynchronously and remotely, at some point you got to get together and have some way to assess this person, like use what they're learning.

SPEAKER_01 43:05

And there have been like SOPs thrown towards this. I'm not thinking we're there yet, but you know, it for so long, you know, since as far back as I remember, the currency of medical education has been just the sheer volume of stuff that you know. You know, is our currency is things like you know, eponyms and like this is how we impress each other, these obscure disease states and that kind of stuff. And it turns out, like I think it's far more important to know what you don't know and then know when to look for help and how to look for information. And I think that's the stuff that's going to be tricky to assess. Like, so when you were talking about how capable is you know, the assessment of when someone knows how to ask for help and not whether they know stuff, but sort of how they manage the situation in general, like I think that's great. Like that's the key. I think if there's a way we can figure out how to assess that, that'd be fantastic. You know, I think even to maintain our own certification, there's been a slight and not far enough push as far as I'm concerned, to like open book examinations, because there's no context in that we're practicing or we're not going to be able to look something up. And in fact, I think it's malpractice to not look something up. Like, I think you're like, we should know sort of where to look and how to. look and when to look and how to talk to each other. So I my hope is that we'll evolve to a state where we're assessing that and not just all the stuff we cram into our brains, you know, 24 hours before the examination. And I I don't know if that makes sense or answers your question, but I my hope is that we find some way to evaluate that because I think that's the meaningful way we're taking care of patients. It doesn't really matter the volume of stuff that you know anymore.

SPEAKER_02 44:18

Yeah, I mean this is why medical education is so interesting.

SPEAKER_05 44:21

I was just wanted to say because I think the starters of that as well, you know, ultimately is also about um as we discussed before how we bring all this and take all this interest in medical education to the patient, right? Because that's what we want to buy better patient care and be better doctors. And that's what we're trying to do for those who we teach as well.

SPEAKER_02 44:39

Yeah, completely echo that. Well what I'm keen to move on to on a sort of different path is just for the trainee that is working in the UK that has an interest in going to the US as an out of program experience or someone that has an enthusiasm for experiencing healthcare in the US, how might someone go about that? How could a UK graduate explore that avenue? Are there many people that you've come across in your time who have done that?

SPEAKER_00 45:06

The program that I work for right now is quite filled with international medical graduates. I'm not sure the exact percentage but it it's a good number and they're fantastic trainees from all over the world. And a lot of these folks have done some sort of rotation or observership in the United States. I think that always helps. So we know that you've been experienced to the the system in the United States. Sometimes the medical schools have a connection with a a US training program. So for instance when I was at a previous job the Royal College of Physicians actually sent their students there. So they would do a sub-internship with us. I think if you can get that, that that's great where you can actually show that you can embed yourself on a team in the United States and work within the US system and that's somebody they've been road tested in the US so I I think when you look at applications it's nice to see that on there. The other things they look at are just your letters of reference and your exams and things like that. Like how did you do in your school? Yeah, how did you perform in your medical school? Those are those are the main things.

SPEAKER_02 46:08

And when people come across at what grades in their training from do they come across that? Do you have a feel for whether they're like just finished their training and about to be a consultant or is it people who have maybe just finished medical school?

SPEAKER_00 46:20

The people that I see seem to be final year because they were people that were talking about going off on some trips with their classmates at the end of medical school. So I I think it's mostly medical students. A lot of people have done a I guess it's a third or fourth year of medical school where they've done some clinical stuff at their home institution and then they're coming to the US either as an observer or a subintern.

SPEAKER_05 46:42

That would be similar to our elective program during the latter year of medical school where students will take some time out. So usually six weeks two months to go somewhere abroad to do a clinical elective and have experience of the medical system and work there.

SPEAKER_00 47:02

Yeah I can speak from the last few programs I've worked in when we have subinterns I mean the RCP had some great students that rotated with us and many of them would end up if they wanted to come to the US we knew them. We knew that they performed very well they worked with us already and a lot of them would actually match at that institution because they could get letters from the faculty that were working there. Oh yeah I worked with this person they're great we'd love to have them as part of our residency class.

SPEAKER_05 47:28

I guess also the other thing is a kind of the end point of training to you do fellowships. So if for example cardiology if you do an interventional subspecialty then you have a year of a fellowship and you would go to the US or Canada or somewhere to practice that as well. So that would be the a double end.

SPEAKER_02 47:46

So the thing that we've talked about it's been fascinating and I guess I've learned a lot about the US medical education system and how you navigate your training and it's been really insightful just to learn a bit about how international medical graduates come across and get experience in the US what would you see the the take home messages being from today's chat guys?

SPEAKER_01 48:05

Paul you want to take this one first I feel like it's going to be tricky to talk about this without sounding cliched but that's okay. I'm used to sounding cliche. Like I think despite the differences it sounds like we have relatively the same aims and the same goals and our programs are not all that different from each other. So there's a lot of name differences and maybe sort of minor structural things but it sounds overall we have the same goals in terms of doing ongoing assessments and making sure that we're producing physicians capable of taking care of patients. So despite the fact that the terminology seem a little bit strange, I'm sure mutually processes are not that fundamentally different.

SPEAKER_00 48:34

And I will say it seems like as we were talking, I can say this is true in the US, certainly for internal medicine, that the people that work in these programs that we want the residents to succeed. And that's why we are very impressed we know how hard these people work. We want them to succeed we're there to help them and that's why we're giving feedback but they should ask for help from the great educators that are working with them. Sounds like in Ireland and UK that's the same kind of thing. There's people there that are meant to help get them through this because it's a stressful time. They're young they're working demanding jobs they're trying to get into these competitive fields. So use the resources that are there for you. I think sometimes people just feel like they're alone in it but that's definitely not true.

SPEAKER_05 49:14

Thank you very much. Really it's been an excellent discussion and we've learned a lot about it and I'll degree taking forward that kind of we need to seek all opportunities we have along our training pathway and later on. Thank you very much for your time we really enjoyed chatting to you and we are looking forward to listening to the next the Curbsiders episode as well. So thank you and thank you very much to the audience as well.

SPEAKER_04 49:37

You're welcome We wish to recommend our Demystifying PACE podcast series on career conversations. As some of you may know in late 2023 MRCP UK updated the PACE's exam format so we developed this new series to support PACE candidates. Episodes cover exam organization, calibration, every PACE station including key changes and candidate perspectives