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Residents as Teachers in CBME and the Timing of Treatment: Important Aspects of the Future of Medical Education and Patient Outcomes

Madison MacKinnon, MSc Candidate, Translational Medicine

At the December 4th Medical Grand Rounds, the Department of Medicine hosted two Chief Medical Residents, Dr. Kirsten Nesset and Dr. Rob Clayden.
 

Dr. Nesset’s talk focused on Competency-based Medical Education (CBME) and the role residents have as clinical educators. Medical education commonly followed a time-based model, which assumed residents were competent to practice independently after training for a certain number of years or participating in a certain number of cases. Recently, however, it’s been identified that doctors need some sort of proof that trainees meet a certain standard of care for patients and they are ready for independent practice.
 

This is where CBME shines. CBME is an outcomes-based educational framework that focuses on patient outcomes and individualized learning plans. CBME routinely assesses the competence of residents through multiple, lower-stake evaluations of milestones called Entrustable Professional Activities (EPA’s) completed throughout their education. Once the EPA’s are achieved, this will be proof that trainees are competent.
 

Attending physicians often complete resident assessments, yet they rarely directly observe their trainees, thus feedback might not be entirely accurate. However, residents themselves might be an underutilized resource in these assessments. Thirty-nine percent of resident assessments this year came from other residents and currently, residents spend about 30% of their time teaching anyways. Therefore, residents are in an optimal position to accurately assess trainees and give feedback.
 

Ultimately, residents as teachers improve the quality and diversity of the assessment of junior trainees, and would be able to directly observe if they are meeting the competencies set out by the CBME framework. Residents benefit from teaching too: they recognize the importance of patient care and safety, exhibit role modeling for the junior residents and deliver excellent education-based teaching, all of which improves the treatment of patients.
 

In our post-rounds discussion, we identified the challenges residents can face in dealing with constructive criticism and consistent feedback, particularly learning to not take it personally. Dr. Nesset reasoned that the earlier feedback is given in one’s medical education, trainees will become used to hearing it and that doctors might benefit from training in resilience to help combat this.  
 

Dr. Clayden’s talk focused on chronotherapy and the timing of medication and education in the healthcare field. Chronotherapy is an emerging field that focuses on giving medical interventions at a specific time, usually revolving around the body’s natural rhythms, to improve patient outcomes. For example, it was found that taking blood pressure medication at night reduced the number of cardiovascular events seen in patients than in usual practice. In terms of chemotherapy, patients tolerated drugs better and lived longer when the drugs were given at certain times. While this is interesting and exciting, Dr. Clayden was clear in identifying that this is a new field, therefore research is still underway.
 

Dr. Clayden also mentioned that timing could be important in resident education, as it can influence specialty choice and satisfaction. For example, those who like to stay up late at night often have more job satisfaction in specialties with more shift work.  But, timing should also be considered in patient care. The time physicians have with patients is precious and often limited and for patients, quality of time with physicians often matters more the quantity of time.
 

In our post rounds discussion, Dr. Clayton spoke on the topic of how to ensure patient compliance in chronomedicine and ways to overcome it. We discussed the need for more trials in this area and the potential difficulty of translating this research to practice due to the individual variations seen in patient’s natural rhythms. Dr. Clayton reiterated that this research is still in its infancy therefore more trials should be done before it is represented in the lay press and will take probably many years to be incorporated into clinical practice.
 

Both Dr. Nesset and Dr. Clayden are nearing the end of their residency training and looking forward to fellowships in respirology and hematology, respectively. They both cite the mentors and teachers they interacted with during their training greatly impacted their career path and inspired their next steps in the medical training.
 

On behalf of the TMED students, we wish both Dr. Nesset and Dr. Clayden luck at their upcoming fellowships and thank them for taking the time to discuss these fascinating topics with us. 

Comments

Name
Daniel Rivera

Mon, 12/09/2019 - 10:07

Great summary, Madison!

I enjoyed this past week's MGR very much. I think Dr. Nesset made a good case for increased incorporation of residences in the CBME framework as assessors. Particularly, she was able to explain the benefits of having peer-evaluations that are often unique and can be particularly useful. Given that residents learn together, their feedback may be more accurate and perhaps more useful as they are likely to be more in-tune with the learning process, as they are also experiencing it, and be able to provide better comments regarding it in the context of other residents. I wonder whether, in practice, receiving peer feedback that is less positive will create team-issues or be taken poorly amongst residents and how effective will teaching and assessment trainings for residences will be at ensuring quality of teaching and assessment.

Dr. Clayden, too, had a very interesting talk about time. He was able to discuss chronobiology, which is a fascinating field, and how this is being further studied with randomized control trials. It does seem as though the research he spoke of is on the cusp of changing clinical practice and challenge the standard timing of medication for patients. This brought up, however, a thought regarding patient heterogeneity - will this affect how useful our understanding of time-based medication is in the clinic? I imagine there is considerable heterogeneity in the response to medications among patients and wonder how well-equipped physicians will be in using the consideration of time in the clinic. It would be interesting to see if this is incorporated to medical education and in what contexts (which drugs, conditions, etc). It was a though provoking and interesting talk!

Name
Daniel Rivera

Great points, Daniel! I agree that it is important to understand how less positive feedback given affects team dynamics. Dr. Nesset did stress that the team environment and delivery of the feedback greatly impacts how one takes it. Therefore, if a positive, encouraging learning environment could be created, and feedback is given with tact, this could ensure that there are no team issues.
I agree with your point on Dr. Clayden's talk as well- patient heterogeneity is a major factor in translating chronomedicine research into practice. I do not think we have an answer yet, but hopefully upcoming research in the field will provide insight to this!

Name
Madison MacKinnon

Name
Quentin Tsang

Mon, 12/09/2019 - 15:01

Great summary of Grand Rounds and the post-rounds discussion Madison!
The point that stuck out to me most during our post-round discussion with the two Chief Residents is the fact that their careers were shaped and guided quite early on by their mentors. I find it fascinating how impactful a mentorship can be for the careers of future physicians and I can see a parallel with ourselves, as TMED students and junior trainees. We have access to some of the best basic science and medicine mentors in the world, which may very well guide the future of our careers. For myself, working closely with Drs. Vanner and Reed, I can envision myself pursuing a career in gastroenterology and basic science research regarding gastrointestinal diseases! I was wondering if anyone else has received a profound impact from a mentor that may guide their careers? Or perhaps a previous observorship/mentorship/job that may deter you from pursuing that as a career?

Name
Quentin Tsang

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