Role of the attending physician in medical education

Recently JAMA published a short viewpoint on the role of the attending physician on ward rounds. This was brought to my attention from a great blog/website that highlights what’s new in the world of medical education.

In medical education there’s been quite a bit about different teaching methods and how to incorporate new approaches like simulation and case-based learning. But this viewpoint brings up an interesting perspective that we rarely consider…the role of our teachers and how it should change. While I didn’t agree with everything that authors mentioned, the concept is important to address.

In the article, the change from “older” to “younger” attendings was discussed and how it will impact trainees. The authors argue the hierarchy has disappeared and younger attendings are more comfortable helping trainees out with the workload. This works well given the increased emphasis on duty hour restrictions. Furthermore, the authors describe older physicians as more likely to teach at the bedside and less comfortable with technology.

I was surprised, however, to read how little attention was paid to the impact of technology on trainee education. To discuss the changing role of the attending must also include the changing methods that trainees learn. Attending physicians are no longer the fountain of knowledge they once were. Wikipedia has quickly taken over this role!  Trainees can easily access the opinions of 100 attendings with a quick glance on their smartphone. The experience of attendings in stating “I had a similar case and this is how I dealt with it” is arguably less important now as evidence-based medicine has become pervasive in medicine. Technology has augmented the trainees ability to find 10 articles about how to manage a particular condition, often drawing on the results of several studies – this is significantly more than an “experienced clinician” can provide. I write this understanding this may be provocative and subject to disagreement but sometimes controversy is good! What’s more is that some have used this article to prove the utility of apprenticeship. It’s difficult to imagine that in an era where competency-based education has been repeatedly shown to be superior to the “see one, do one, teach one” method, we still have to continue talking about it. More studies than I care to cite have demonstrated that its no longer good enough to have “done a procedure” as a surrogate for competence. There should be a uniform approach where trainees meet a minimum standard. They’ll have knowledge of complications and ideally even demonstrate this in a simulation (without having harm come to a patient). Finally, they’ll be assessed as they perform the skill in the clinical setting – all stakeholders benefiting including the patient, trainee and teacher.

A reply to the article mentioned above was posted by another group of authors who have addressed teaching by staff attending physicians. These authors conducted a survey that identified  “Sharing of attending’s thought processes” as among the most important attributes an attending physician could share during rounds. This highlights nicely how trainees are changing and as a result how staff physicians should re-focus their teaching.

Trainees can be effectively taught by flipping the classroom and learning on the web. 30 years ago this wasn’t possible but now with exponential growth of technology, learning can occur before actually seeing patients. However, what must be learned from experienced clinicians is their cognitive reasoning. Learning such a skill from the web or a textbook is much more difficult. Rounds or bedside teaching sessions should focus on how clinicians avoid biases in their decision making. Trainees should be taught early on how to think like an expert.

Attending clinicians must focus their efforts on training new doctors to think like they do – employing a sound approach to each clinical decision . And teaching faculty should be taught how to teach these skills.  In an era when trainee clinical time has become a scare commodity, efficiency becomes paramount. Teaching core content has become increasingly inefficient especially during precious clinical rounds when both the trainee & attending have access to patients!  Trainees have no shortage of information to diagnose and treat patients but they must be taught to use it. This is the new role of the attending physician in medical education.