Introductory Chapter: Navigating Challenges and Opportunities in Modern Graduate Medical Education

1. Introduction

Modern graduate medical education (GME) continues to evolve and transform, with increasing emphasis on evidence-based approaches, general competencies, objective assessment, and focus on value-and-quality considerations [1, 2, 3]. GME represents the gradual transition between what is traditionally understood as “undergraduate education” (including medical school) and one’s full professional engagement within a medical or surgical specialty [4, 5]. The concept of “readiness for practice” has emerged as an important driver of how graduate medical training is adapting to each trainee’s individual needs and accomplishments, with milestone-based re-calibrations throughout the learning continuum [6, 7]. This results in the creation of a highly competent medical workforce ready to meet the expectations and sophistication of a busy, modern-day clinical practice [5, 8]. As part of this transition, contemporary GME’s character has evolved beyond a well-established repertoire of didactic techniques, increasingly embracing immersive simulation, multimedia platforms, and various emerging real-time feedback technologies [9, 10, 11].

Consistent with the current book series title, Contemporary Topics in Graduate Medical Education, our editorial team and chapter authors are focused on sharing their thoughts and wisdom regarding the optimal approaches to preparing future generations of physicians (Figure 1). Parallel to the current GME paradigm shift, we clearly observe that the nature of physicians’ work continues to change and evolve [12, 13]. The themes underlying this transformation will create unique opportunities and challenges for tomorrow’s physicians, requiring an in-depth re-engineering of the established construct of “readiness for (independent) practice” [14, 15]. Within this overarching context, modern GME experts must navigate the careful balance between “the art and science” of medicine.

Figure 1.

A word cloud depicting an amalgam of key concepts discussed in this chapter and throughout this book.

2. Focus on outcomes: safety and quality as cornerstones of modern graduate medical education

The above-mentioned challenges are clearly evident when examining contemporary healthcare practices and outcomes, especially when compared to quality, reliability, and safety across other major industries, such as air transportation and finance [16, 17]. Progress is being made, with ongoing focus on quality and value creation beginning to result in measurable improvements. For example, the overall mortality has declined in high-income countries over the past ten years due to better prevention, early detection, and improved treatments [18, 19, 20]. This was accompanied by increases in life expectancy and a shift in chronic comorbidity patterns [21, 22], creating unique socioeconomic challenges [23]. Note that although the average annual per-capita growth in health expenditures has declined during the past decade, the US health-care system still holds the highest per-capita cost among high-income countries (approximately $11,000) [24, 25]. The coronavirus disease 2019 (COVID-19) pandemic exposed several critical vulnerabilities among global healthcare systems. Among the most urgent systemic shortcomings,, behavioral health needs, which were among the top five conditions driving overall healthcare costs, have become a major challenge [26, 27].

3. Navigating complexity: interdisciplinary and team-based character of modern graduate medical education systems

As one explores this second volume of Contemporary Topics in Graduate Medical Education, it becomes apparent how complex and interdependent various components are within the matrix of modern healthcare and graduate medical training [25]. The same can be said about the different domains of one’s life, as a physician-in-training is an individual with a personal life, family, goals and ambitions, and hobbies as well as unique gifts and abilities. Residents and fellows experience a tremendous amount of personal and professional stress, and because it is virtually impossible to separate the “clinical life” from the “home life,” concepts such as burnout, resilience, and work–life integration (as opposed to the increasingly outdated paradigm of work–life balance) begin to emerge [28, 29]. The latter paradigm is especially important in the context of training “practice-ready” physicians in the era where our daily routines are increasingly defined by technological implementations, such as electronic medical records [30]. Novel developments in work–life integration include a rapidly growing area of “coping intelligence” – one of many innovative topics in this book [31, 32].

4. Embracing technology: telepresence and virtual platforms in graduate medical education

Graduate medical education is not a random process; individuals who graduate from medical schools and begin the residency training process dedicated themselves to attaining the goal of becoming a physician from much earlier in their lives [33]. As their journey through the decade-long quest to join the medical community continues, new challenges emerge and many important life lessons are learned. For the most recent generation of medical trainees, the COVID-19 pandemic has become a defining, once-in-a-generation (if not once-in-a-century) event. In this book, we discuss some of the adaptations by the GME community in response to the global pandemic. One of such adaptations – “virtual interviews” – helped leverage the existing technologies to transform our well-established candidate selection/match process [34].

Due to the COVID-19 pandemic, the use of telemedicine has increased markedly in the medical world, including resident education. Residents are now expected to navigate through the new world of telemedicine with little guidance or instruction, and minimal to no experience. Almost overnight, telemedicine became the main means of communicating with patients, especially for outpatient visits, and was used extensively during the pandemic. The Accreditation Council for Graduate Medical Education (ACGME) responded to this immediate need by setting up a framework for permitting residents/fellows to use telemedicine for patient care [35]. However, some residents reported a degree of unease in managing chronic diseases via telemedicine visits [35]. Careful consideration of how telepresence affects resident education and patient care, including further development of guidelines for its use, will be necessary as telemedicine services continue to grow.

5. Addressing critical shortages: investing in the next generation of primary care physicians

Primary care remains the cornerstone of modern, highly progressive, patient-centered, integrated healthcare systems, and the need for primary care providers (PCP) remains a global priority [36, 37, 38]. Regions with the best-performing healthcare systems tend to have the highest percentage of PCPs [39]. Consequently, numerous initiatives are underway to address the looming shortages, including the development of more targeted high-school/college career “pipeline” programs, medical training innovations, office practice transformation, and compensation/payment reforms [40].

6. Training future leaders: the growing importance of physician leadership and leadership education

Leadership in healthcare is extremely important, and there needs to be more emphasis on fostering the development of physician-leaders within our GME programs [25]. The physician’s primary purpose is patient care, accompanied by the education of patients, students, residents, colleagues, and various decision-makers within the society. In doing so, physicians bear the social responsibility of not only individual healthcare, but also the public’s general health and well-being. Beyond this, it is critical that physicians understand what leadership is, are skilled in applying it, and know how to effectively interact within the “leadership sphere.” As such, they will be well suited to advocate for patient safety, efficacious delivery of care, and financial stewardship of resources – factors required for sustainable healthcare.

Contemporary Topics represents a tremendous effort by many GME leaders, and this second Volume will hopefully serve as a foundation for further texts as educators continue to explore the general question of “what are the best approaches to train tomorrow’s doctors?” The challenges are great as both the goals and the overall GME landscape continue to evolve rapidly. Above all, a physician is an individual who is responsible for the health and well-being of his or her patients. However, being a physician is not limited to providing healthcare services or medical/administrative leadership but extends beyond these functional domains. Consequently, physician education must ensure a certain degree of proficiency across all relevant spheres of professional functioning. In addition, unique challenges may arise regarding the most optimal ways of instilling the sense of “ownership” regarding patient outcomes and creating accountability within a framework where constructive feedback is not perceived as unfair or punishing. These concepts, especially as they relate to the ethical basis of “what physicians do” at the fundamental level, permeate throughout this text, along with the key question related to GME – “how do we best educate physicians-in-training”?

Interprofessional education is becoming increasingly important as an integral part of modern GME methodology [41]. Within interprofessional collaboration, the most fundamental operating principle is the maintenance of multilateral communication, respect, and open-minded attitude [42, 43]. As more areas of medicine evolve toward team-based and multidisciplinary models of care, we must actively pursue effective ways to train physicians to embrace the leadership of interprofessional, collaborative, and team-based models [44, 45, 46, 47].

Effective multidisciplinary teams require strong, yet flexible, leaders who possess a good understanding of clinical research and key scientific principles, the ability to comfortably approach complex disease states and pathophysiology, familiarity with medical economics, ethics, diversity and inclusion, as well as skills required to build and maintain collaborative relationships across disciplines [25]. Physicians are uniquely suited to provide such leadership, and it is critical for our GME systems to adequately prepare such leaders of tomorrow by teaching flexibility, nimbleness, and adaptability. Our medical education system must effectively adapt and evolve with the times because change is a continuous state of this noble profession.

Unfortunately, as we argue for physicians to emerge as leaders and wear several “hats” all at once, the time crunch of everyday clinical practice stands in stark contrast to this call. Physicians find themselves unable to “do it all” as “patient-consumer” demands, new technologies, and increased administrative burdens [48] become more prominent. Because the evolution of medicine is inevitable and ultimately a necessity, the physician of the future may be prone to misperceive himself or herself to be overwhelmed or potentially even redundant. If physicians are expected to teach, listen, innovate, and lead, in addition to the traditional procedural and diagnostic aspects of the job, then the time dedicated to such pursuits must be re-allocated from some other aspect of their professional life. This would seem particularly true for primary care physicians who appear to be disproportionately affected by the often competing time pressures [49].

Although controversial, physicians may have to “give up” some of their traditional role to take on new challenges. Some solutions could include outsourcing diagnostics to artificial intelligence and advanced electronic medical record (EMR) and software [50, 51]. Additionally, particularly in the case of outpatient primary care and hospitalist practice, physicians and physicians-in-training may face the risk of being increasingly replaced by advanced practitioners [52, 53] with little or no perceptible compromise to patient safety or satisfaction. Similarly, one study points out that physical therapists could replace physicians during encounters for assessment of knee osteoarthritis and other similar conditions [54].

This outsourcing of work may ultimately improve the primary care shortage, without increasing the cost to the healthcare system at large. Additionally, it may lessen the time constraints on physicians while enabling them to take on more leadership and teaching roles. However, as physicians render themselves increasingly redundant or replaceable in more fields, there is also the danger of devaluation of the profession itself. Any solutions to the above will require a fine balance involving the creation of appropriate synergies between advanced practitioners and physicians, and the associated process will necessitate significant amounts of time and investment by all stakeholders. This delicate equilibrium is one area that will need to be addressed in GME training - the creation of a carefully crafted framework that fosters the interplay of team care models and inclusivity. It is a unique opportunity to include all types of clinicians in shaping the future of patient care in the post-COVID era.

7. Focus on diversity, equity, and inclusion

It is of utmost importance for the medical community (and the society, in general) to address the challenge of, and opportunity for, inclusion and advancement for underrepresented minorities and women in medical leadership positions. There is an established bias in academic medicine leadership, which, if not addressed, will continue to propagate. Only 21% of women are full professors and only 15% of department chairs are female [55, 56]; moreover, a disproportionately small 8% of academic faculty are underrepresented minorities [56]. This gap is very likely to widen post-COVID. We will not fully understand the toll of the COVID-19 pandemic, but the tremendous burdens placed by our society on women physicians have resulted in formidable challenges for maintaining clinical practice. Addressing this fundamental issue, especially within GME, is of highest priority. If properly structured and implemented, solutions based on diversity, equity, and inclusion will lead to improved health care and outcomes for patients, which is our ultimate goal.

A simple yet profound concept in medical learning is that of interdependent opposites: presentation of opposing ideas to explore the alternatives and stake out the trainee’s own position on a given matter. Through this repeated exercise, the trainee develops a medical attitude that informs future decision-making and philosophy. Ultimately, this allows expression of the developing practitioner’s unique medical personality, a blend of personal thought and collective information grounded in the latest scientific and ethical frameworks.

8. Synthesis and conclusion

Graduate medical education continually evolves to meet the challenges facing physicians-in-training. Contemporary Topics in Graduate Medical Education discusses concepts of physician leadership in team-based healthcare models, the lasting impact of the COVID-19 pandemic on medical training and resources, and the importance of inclusivity and advancement of underrepresented minorities and women in academic medicine. The recognition and ongoing discussion of these topics will be important at the level of graduate medical education. These fundamental sets of knowledge and skills will help positively shape a physician’s career to support the development of competent future leaders who have the foundational skills to adapt to the inevitable transformation of medicine and healthcare delivery over time.