Medical Training in the US & UK (11.07.2022)

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Hello and welcome to our next episode of Clinical Conversations. We're delighted today to have special guests, the Curbsiders Team. So we've got with us today Dr. Matthew Watto 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 Dr Bardgett as well, who you'll know from our Clinical Conversations. And I'll let everyone introduce themselves.

{( speakerName('C') )} {( convertTime(80932) )}

So hi, I'm Johnny Bardgett and I'm a T&MC member. And again, guys, welcome to the podcast. Would you like to introduce yourselves?

{( speakerName('D') )} {( convertTime(88686) )}

I would like Paul to introduce himself first.

{( speakerName('E') )} {( convertTime(91750) )}

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 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. I don't count myself as a new member, but there early on.

{( speakerName('D') )} {( convertTime(112816) )}

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 picking up this podcast thing. 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'm also a clinician educator. I live and work in the Philadelphia area. I work for a residency programme where I work with medical students and medical residents. And I see some of my own patients and outpatient clinic and spend way too much time on Curbsiders, which is something I'm working on. But we will keep putting out episodes because overall, on balance, Paul, I think it's been pretty fun.

{( speakerName('E') )} {( convertTime(145492) )}

Yeah, absolutely.

{( speakerName('C') )} {( convertTime(147850) )}

So it's great to have you guys. 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?

{( speakerName('D') )} {( convertTime(162250) )}

I'm always going to defer to Paul.

{( speakerName('E') )} {( convertTime(163734) )}

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 Stewart Brigham, another physician, were actually responsible for running an ambulatory curriculum where they were working together, and after some, because of the conversation that would arise, 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 as one of the first guests, they actually asked me about the Sprint trial, 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?

{( speakerName('D') )} {( convertTime(220278) )}

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 podcasts that exist 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 would 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. It just all sort of went from there. And some of our first episodes, we called 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 people respond because it turns out they weren't getting hundreds of emails a day offering them to come on podcasts 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 realised 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.

{( speakerName('B') )} {( convertTime(298690) )}

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

{( speakerName('D') )} {( convertTime(319450) )}

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

{( speakerName('E') )} {( convertTime(336136) )}

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 something I have a handle on, but not as strong a 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 the 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.

{( speakerName('C') )} {( convertTime(379458) )}

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 curriculum, and we have training programmes to accredit to, and so we have different presentations that we have to learn about and show evidence for. And we thought podcast is probably one of the most accessible ways of obtaining that knowledge. But we're quite lucky that we get feedback directly from the Royal College of Physicians 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? Can you tell us a bit more about that?

{( speakerName('D') )} {( convertTime(417750) )}

Well, we get a lot of unsolicited feedback from the audience. No, 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 little minute thing, or criticising us for the first ten 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.

{( speakerName('C') )} {( convertTime(453222) )}

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 episode on reflection, cognitive bias, and how we make decisions. Anda, do you want to talk a little bit about that?

{( speakerName('B') )} {( convertTime(467030) )}

Yes. So our main remit is to record podcasts on clinical topics, as we discussed, but we do some nonclinical topics as well. So Jonny was 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 concentrated on working and learning about cognitive bias and clinical decision making. I think it was fascinating as well, because whilst learning about clinical topics, you bring together all those nonclinical 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 undergraduate medical students, but also those in postgraduate training, from the beginning of training 'til 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 podcasts, 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 medical training process and you're all happy with that? Tell us a bit about undergraduate training in the US, and Jonny and I can compare that to what happens in the UK.

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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 the sort of ongoing conversations. But essentially, Matt, you'll correct me if I'm wrong if I see something that is unclear. Medical school or 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, premed. 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, if 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 into medical school, the requirements are evolving and changing as well. It used to be just good scores and you had to get good letters, then you're 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 their, at least the institutions where I'm working in, they're actually interested in 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, 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 travelling is financially burdensome to a lot of applicants. And medical schools are also evolving in terms of the way that they train. I should probably pause here, actually, before I get into actual medical school proper, if there's any questions up to this point.

{( speakerName('C') )} {( convertTime(639400) )}

So I think we have a similar sort of admission test you have to go through and I think was it the UK CAT, Anda, although it might have changed. So it's the UK Clinical Aptitudes Test, sort of like a situational judgement test that is 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 centre of your choices you are alluding to?

{( speakerName('E') )} {( convertTime(677056) )}

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 at some point during your final year of clinical rotations, then you're applying into your residency programme of choice, whether that will 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 licencing 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 practise 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 standardised patients and you would write down your progress note and say what's your best plan and what your thoughts were. And that's actually recently been kiboshed. It's been eliminated and it's not part of the licencing requirements. So that is something that has been a recent change. 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.

{( speakerName('C') )} {( convertTime(754750) )}

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 the Objective Structured Clinical Examination, or OSCE, and usually it is done one or two years into your internal medicine training programme, although it can be done in theory, prior to even entering that programme. Some people choose to do these sort of after you're in the UK, you have your foundation year programme. So after you leave medical school, you go into foundation year, which is you're training to achieve your GMC, so your General Medical Council licence, and then you're registered from a provisional licence to practise to your full registration, which is essentially your ability to practise 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. Anda, do you want to talk a bit about that?

{( speakerName('B') )} {( convertTime(818812) )}

Yes. So PACES examination starts, kind of, with clinical examination. So it's going through some restructuring at the moment, 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. 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're in the examination and you will be asked to examine a real life patient, the patient most commonly will have pathology. You'll have to pick up the signs and discuss the findings with the examiner. It's very quick, trying to mimic clinical practise, 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 patientt during a consultation with the patient. And usually that would 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 Jonny was saying, foundation is kind of the programme 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, which stage you do, but you have also final exams, which will also usually include OSCE clinical examination as well, and then also the situational judgement 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.

{( speakerName('D') )} {( convertTime(913300) )}

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

{( speakerName('E') )} {( convertTime(917778) )}

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, like all of that just gives me-

{( speakerName('B') )} {( convertTime(927484) )}

That's exactly what I had in my exam, yeah! I don't, I'm not sure I should say that, but I'm not sure-

{( speakerName('D') )} {( convertTime(933610) )}

Someone with papilloedema, Paul, you're just like, what the hell?

{( speakerName('B') )} {( convertTime(939310) )}

We do kind of say, Jonny, correct me if I'm 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.

{( speakerName('E') )} {( convertTime(951604) )}

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 there's some that may complain about that. In terms of the examinations that you all take, do you feel like they reflect the practise you will ultimately be doing? And are they fair assessments of where you need to be?

{( speakerName('C') )} {( convertTime(982120) )}

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, don't know what they call it, the grade before attending in America.

{( speakerName('E') )} {( convertTime(994926) )}

The resident.

{( speakerName('C') )} {( convertTime(995550) )}

Yes, the resident. And so to be able to run the hospital at night, to run the acute medical take, you need to reach 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 more of a capability-based curriculum. So it's not focusing on whether you know how to manage them with chest pain, but more managing the patient presenting in 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. Anda, you have a bit more experience of that than I do.

{( speakerName('B') )} {( convertTime(1037920) )}

Yes, certainly. So just to ask also that question about the exam. So I think I'd agree with all Jonny says. It is a very, well, it's an exam, it's a difficult exam, can be a very stressful, challenging time. But I think that preparation for that exam, because the way we prepare for it, 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 are going through the same process and you go around the wards in the hospital and examine patients. 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 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 what happens after foundation when you start internal medicine training. So, up to three years ago, wasn't it, Jonny, we were doing a programme called Core Medical Training, which involves two years of rotation. If you decided to go and train towards a physician specialty, two years of rotation around an internal medicine, and then after that, you would choose your specialist registrar training or residence programme. That has now changed and we move to an internal medicine training programme. 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. 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 and general medicine at the same time. So when you become a consultant, at the moment, you would dual accredit in those specialties. So that's more towards a shift of recognising that we all deal with comorbid patients, we all should be able to manage those patients and manage their complex illness.

{( speakerName('E') )} {( convertTime(1150770) )}

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, 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 this strange configuration. I'm wondering if that is similar how you all practise or what that mix looks like for you.

{( speakerName('C') )} {( convertTime(1172956) )}

Yeah, so every year we go through appraisals. I'm sure you do the same in US training. We have an e-portfolio, 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 a five year or four year training programme 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 1000 patients in the acute undifferentiated medical take, so front door, and I have to have attended 184 outpatient clinics. You can have equivalent number of clinics, so for instance doing a wardround on your own or 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 acute medical take as equivalent of a clinic, if that makes sense. Is there anything like that in the US?

{( speakerName('D') )} {( convertTime(1243810) )}

I guess- so, this is not during medical school, this is after your medical school?

{( speakerName('C') )} {( convertTime(1247860) )}

Yeah, residency, yeah.

{( speakerName('D') )} {( convertTime(1248784) )}

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 programmes 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 in 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 with their outpatient duties in a specific ratio. And, apologies, doesn't that number seem similar? Right? It's 100 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 in most residency programmes. I think that's like, it's 60 or 70% 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 they going to spend most of their time in outpatients, even if they go into a sub specialty?

{( speakerName('C') )} {( convertTime(1314534) )}

That's interesting.

{( speakerName('B') )} {( convertTime(1316110) )}

How do you keep record of that? So what do you use for your training in the US? So Jonny was saying we have a training curriculum here and we use an online e-portfolio where we add in the experience cases we've seen and link that to the curriculum. Also say we've been to conferences or talks or we've got training days. We all link that to the e-portfolio, and that's used at our yearly ARCP to allow us to kind of progress and review. What system do you use?

{( speakerName('D') )} {( convertTime(1349548) )}

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 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 programme level that's logging those things, but as residents, they mainly just log duty hours and procedures, to my knowledge.

{( speakerName('E') )} {( convertTime(1381326) )}

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

{( speakerName('C') )} {( convertTime(1407964) )}

So the ARCP Anda 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?

{( speakerName('D') )} {( convertTime(1420492) )}

Yeah. Paul, do you sit on the Clinical Competency Committee for your programme?

{( speakerName('E') )} {( convertTime(1424296) )}

I sure do.

{( speakerName('D') )} {( convertTime(1424812) )}

Do you want to tell them about that?

{( speakerName('E') )} {( convertTime(1426576) )}

Sure. 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 programme directors, key and core faculty that sort of sits and review each resident's performance individually and see are they meeting the metrics that are needed to advance to the next year. And this isn't a one time end of the year meeting, this is actually part of an ongoing process. 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. 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 a 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 the milestones and metrics to actually advance to the next year of training.

{( speakerName('D') )} {( convertTime(1480624) )}

Yeah, for instance, in the programmes I've worked in, several programmes 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 summarise 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 free handwrite 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.

{( speakerName('C') )} {( convertTime(1544120) )}

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

{( speakerName('D') )} {( convertTime(1551426) )}

Yeah, for my job in the US, they usually call you a core faculty member, some cohort of people that work closely with the programme directors of the residency programme 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.

{( speakerName('B') )} {( convertTime(1582230) )}

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 make kind of at the beginning of the block, set up a personal development plan, and then midway through the blocks, after two months, of course we work with them daily, 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, a very similar process.

{( speakerName('E') )} {( convertTime(1612630) )}

And is there someone who's tracking and sort of having those conversations with you throughout the training? So it sounds like this is sort of block specific, but I know, for instance, Matt and 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?

{( speakerName('B') )} {( convertTime(1628656) )}

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

{( speakerName('C') )} {( convertTime(1655610) )}

One of the main roles of the TPD or the training programme director, is to do that additional level of support, obviously, but to help you navigate your rotations. There's a degree of flexibility within my training programme. So my training programme, you do two years of general internal medicine, you do four months of geriatric medicine or medicine for the elderly, and then four months of cardiology, four months of respiratory, six months of intensive care, and then six months of any specialty or specialty of your choice. And then you have your certificate of completion of training. So, like, for the six months that I did during the pandemic, I chose to do ID - infectious diseases - and renal 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 programme director.

{( speakerName('D') )} {( convertTime(1697044) )}

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 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.

{( speakerName('C') )} {( convertTime(1759816) )}

Yeah, the ADR week sounds particularly arduous. Our European working time directive may change. Obviously, with Brexit has usually a cap around 40 hours a week. That can vary from week to week. I'm lucky; I've gone into a less than full time training programme 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?

{( speakerName('D') )} {( convertTime(1785370) )}

No, not in trading. There's no option. It's six days a week for years. I remember, 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 doing things with all this free time I suddenly had. But you go from through medical school and residency, it's 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'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.

{( speakerName('E') )} {( convertTime(1832164) )}

I think the culture is evolving, though. I think back in the Stone Ages, when Matt and I did training, you can't work more than 80 hours a week (wink!) and we'd all be working 100-120 hours a week. That was not unusual. I think we're being more thoughtful about duty or 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 programmes that are just doing away with 24 hours shifts, which 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. 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 ten years, in terms of expectations of duty hours. But they still trainees work a tonne. There's no getting around it.

{( speakerName('C') )} {( convertTime(1880890) )}

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

{( speakerName('E') )} {( convertTime(1896370) )}

It depends on the level of training. So, I think it's not unusual; there are find MDPhD programmes from the medical school standpoint where students will do their preclinical years, then they go off and they'll do some research and they'll come back into their clinical years. It's a longer period, but then they graduate with both the medical doctor and the PhD training. There are also combined programmes in medical schools that allow for you to get like MD, Masters of Business or probably some even give you Masters 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 Masters training during the residency training, but it's not unusual for attendings, once you've actually got some of your time back. It's not unusual for attendings to go back and maybe get their Masters degree or get their Masters of Education after they're done with the residency training. So once they're no longer doing 3 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?

{( speakerName('D') )} {( convertTime(1946214) )}

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 services 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.

{( speakerName('B') )} {( convertTime(1981228) )}

And then what about opportunities for training and 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 part in training and out of programme work to do a fellowship in medical education, which you work alongside university programme for undergraduates and postgraduates and develop certain skills in that area and knowledge in that area and then work on projects alongside.

{( speakerName('E') )} {( convertTime(2008938) )}

Great question. There's a couple of ways that you can pursue an interest in medical education. I think a lot of residency programmes are now incorporating various career tracks into their training programmes. So once you're in your internal medicine residency programme, 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 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 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 and 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 path you're interested in.

{( speakerName('C') )} {( convertTime(2056288) )}

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?

{( speakerName('D') )} {( convertTime(2064916) )}

When I left my residency programme, 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 are 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 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 Curbsiders. 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.

{( speakerName('E') )} {( convertTime(2118316) )}

Yeah, and the same process for me, it's something you kind of find - or at least, won't say "you" - I find myself kind of drifting into. After doing residency, it turned out that I really liked working with the medical students. I did a chief residency year where I 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 early on in your career, you just say yes to lots of stuff and you get a chance to sort of be part of committees and be part of educational initiatives. And if you find out that you like it and you do an OK job, you get asked to do more and more of that and eventually you get paid for your time, it's I think the typical pathway to it. There are people who are smarter than I am who knew that they wanted 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 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 establish yourself that way.

{( speakerName('C') )} {( convertTime(2165836) )}

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.

{( speakerName('E') )} {( convertTime(2179626) )}

Right.

{( speakerName('C') )} {( convertTime(2180200) )}

Have you had any advice from mentors in days gone by? What would your key sort of tips for trainees be, each of you?

{( speakerName('D') )} {( convertTime(2187136) )}

Well, you just said the feedback things. 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 Gurpreet Dhaliwal 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. 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. Doesn't mean they hate you, they don't like you. They're just trying to help you.

{( speakerName('E') )} {( convertTime(2232652) )}

Yeah. In terms of specific advice about feedback, which I think is the question, something that probably talked about before, it's 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. I think sometimes it's easy to miss something if you don't be explicit about labelling the feedback. So some of the best advice I actually got was from our most important mentor, Dylan, who is like, just say I'm giving you feedback now, and then actually give the feedback. Like, really that explicit about it. Because a lot of the time people will be like, well, I never got any feedback about that. It turns out you were giving it all the time. You didn't label it. And as a result, I think 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 they know they're getting feedback from you, is also just a really helpful, fundamental thing that I think often gets missed.

{( speakerName('D') )} {( convertTime(2276272) )}

Paul the buzzword there is sign posting, right?

{( speakerName('E') )} {( convertTime(2276272) )}

Sign posting, sure.

{( speakerName('C') )} {( convertTime(2280490) )}

Yeah. I don't know what it's like in America. One of the things that our GMC - General Medical Council - asks the last of the year is to survey our training programmes, 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 programmes?

{( speakerName('D') )} {( convertTime(2312142) )}

Yes, there's the ACGME. Again, this is the body that oversees the residency programmes anyway, and once a year, you have to evaluate your own programme, and both the residents do it and all the core faculty members for the programmes 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.

{( speakerName('E') )} {( convertTime(2333200) )}

Yes, that's right. And then the other thing is, most programmes, probably all programmes, have internal quality improvement, too. So it's 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, we had to do sort of daily feedback for every single person in the small group that we were working with. And eventually you just panic and you'll be like, I like the colour of magic marker you used on the whiteboard. Like it becomes, you're giving feedback for the sake of giving feedback, which is not terribly helpful. The point is that most programmes will sort of elicit feedback on specific curricula and specific things that they do internally, above and beyond just the ACGME sort of summative feedback that they ask for as well. So there's usually an ongoing process, too.

{( speakerName('B') )} {( convertTime(2366776) )}

On the topic of that, of education, because we're all here interested in medical education, where do you see it going in the next few years? Also considering that we 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 medical education going?

{( speakerName('E') )} {( convertTime(2391010) )}

Yeah, I think even pre-COVID, a push to so-called asynchronous learning, which is, I think, where podcast fits into, the idea is that sitting people down, we know that the average adult attention spans 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 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 the small group and team-based learning. I think that's largely happened, at least in most medical schools. I think residency programmes 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 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. 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.

{( speakerName('D') )} {( convertTime(2448450) )}

Not really, but I'm just curious how simulation, 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, it's just going to be interesting. And how we're training our physicians or whatever medical trainees you're working with. The guy that was in charge of Jefferson, who is now moving somewhere else, is Dr. Classco, 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 memorise and kill a test, it's the person who is good at talking to patients, solving problems, using the information you have. So I think the skill set is going to change a little bit from what it used to be.

{( speakerName('C') )} {( convertTime(2502388) )}

Certainly with online programmes and online education resources, there are learning analytics so you can assess how much someone is engaging. And one of the things that we're looking at with the podcast is how many listens we get and 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.

{( speakerName('D') )} {( convertTime(2527570) )}

I'm not sure if I understand how that would work. 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.

{( speakerName('C') )} {( convertTime(2536504) )}

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. 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. But at least whenever you're on award or you're in a lecture you're physically there and part of the community of learning.

{( speakerName('D') )} {( convertTime(2557324) )}

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, where there's some sort of observed interaction with the patient or with other team members. I mean, I think you have to watch these people interact because you could have someone that's brilliant at answering medical questions but they're a total sociopath that 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 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, use what they're learning.

{( speakerName('E') )} {( convertTime(2606590) )}

There have been stops thrown towards this. I don't think we're there yet. For so long, since as far back as I remember, the currency of medical education has been just the sheer volume of stuff that you know. It's our currency, it's things like eponyms, and this is how we impress each other, these obscure disease states and that kind of stuff. And it turns out 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. When you were talking about how capable is the assessment of when someone knows how to ask for help and not whether they know stuff, but sort of how they manage situation in general, I think that's great. That's the key. I think if there's a way we can figure out how to assess that, that'd be fantastic. 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 open book examinations, because there's no context in that we're practising, 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, we should know where to look and how to look and when to look and how to talk to each other, so 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 for the examination and I don't know if that makes sense or answers your question, but 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.

{( speakerName('C') )} {( convertTime(2679774) )}

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

{( speakerName('B') )} {( convertTime(2682748) )}

I just wanted to say, because I think we started with that as well, and ultimately is also about, as we discussed before, how we bring all this and take all this interest in medical education to the patient, because that's what we want, to find better patient care and be better doctors. And that's what we're trying to do for those who teach as well.

{( speakerName('C') )} {( convertTime(2700844) )}

Yeah, completely echo that. 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 added programme 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?

{( speakerName('D') )} {( convertTime(2727616) )}

The programme that I work for right now is quite filled with international medical graduates. I'm not sure the exact percentage, but 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 system in the United States. Sometimes the medical schools have a connection with a US training programme. 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'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 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, how did you perform in your medical school? Those are the main things.

{( speakerName('C') )} {( convertTime(2789950) )}

When people come across, 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?

{( speakerName('D') )} {( convertTime(2801716) )}

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 think it's mostly medical students. A lot of people have done, 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 sub-intern.

{( speakerName('C') )} {( convertTime(2823490) )}

That would be similar to our elective programme, Anda, wouldn't it?

{( speakerName('B') )} {( convertTime(2825480) )}

Yeah, exactly. So we have a similar programme during the latter year of medical school, where students will take some time out. So it will be six weeks, two months, to go somewhere abroad, do a clinical elective and have experience of the medical system and work there.

{( speakerName('D') )} {( convertTime(2843710) )}

Yeah, I can speak from the last few programmes I've worked in, when we have some interns. 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.

{( speakerName('B') )} {( convertTime(2869576) )}

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

{( speakerName('C') )} {( convertTime(2887210) )}

So the thing that we've talked about is 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 take-home messages being from today's chat, guys?

{( speakerName('D') )} {( convertTime(2906668) )}

Paul, you want to take this one first?

{( speakerName('E') )} {( convertTime(2909710) )}

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 cliched. Despite the differences, it sounds like we have relatively the same aims and the same goals, and our programmes 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. Despite the fact that the terminology seemed a little bit strange, I'm sure usually processes are not that fundamentally different.

{( speakerName('D') )} {( convertTime(2935210) )}

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 programmes, 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 or in UK, that's the same kind of thing. There are 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.

{( speakerName('B') )} {( convertTime(2974990) )}

Thank you very much. Really, it's been an excellent discussion and we've learned a lot about the medical degree, taking forward that 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 listen to the next the Curbsiders episodes as well. So thank you. And thank you very much to the audience as well.

{( speakerName('D') )} {( convertTime(2998732) )}

You're welcome.

{( speakerName('C') )} {( convertTime(2999280) )}

Thank you guys.