Slouching Towards Bethlehem: Journal of Graduate Medical Education as Midwife

In March, when I met with our interns to talk about potential subspecialty training, I flashed back to a meeting during March of my intern year. At this meeting, the chief resident escorted me to his office and, once inside, asked me how I was doing. “Good,” I replied shortly. He clapped me on my back, said “Great, good job!” and ended our meeting.

That brief encounter was the sole feedback session, formative or summative, of my residency years. As described by Dr. Jack Ende,1 I believed my performance to be acceptable because my fellow residents told me so. The teaching credo of the day, not always hyperbole, was “see one, do one, teach one.” The curriculum was determined according to what services usually had “interesting” patients as well as the greatest need for overnight physician care—the hospital. Evaluations were brief or nonexistent. Noon conferences consisted of faculty or trainee case presentations coordinated by the chief resident. Senior faculty or review articles from the library guided decision-making.

At the same time attendings worked days, side-by-side with residents, and were usually pleased to return to the emergency room or ward overnight for consultations or admissions. While on service, faculty physicians were freed from most other obligations. Attendings enjoyed making weekend rounds, which felt relaxed and included appealing food donations. All trainees visited the “fascinoma” of the day. Residents and attendings talked about clinical reasoning and practice philosophy until late; opportunities for reflective learning2 flourished. Patients remained in the hospital until they were nearly well and then returned to the clinic for ongoing care. An essential team member, the head nurse rounded with the medical team every day. For residents, paperwork was limited to the communication of essential clinical information gathered personally.

Driven by the moving targets of health economics and medical practice, today's residency training experience, while equally as intimidating and stressful to interns as in the past, is a different animal. Program directors struggle with requirements regarding residency content, format, and evaluation that have multiplied exponentially, often without a concomitant increase in education research. At times, the focus seems to have shifted to documentation and total hours worked rather than the amount of time spent with patients and preceptors.3 Some teachers have decried the rapid pace of change. This calls to mind W.B. Yeats' poem The Second Coming, which depicts the unstable new world order4:

According to some writers, medical education is in a similar free fall.

Studies of medical education are hard: difficulty randomizing trainees and experiences; regular turnover of subjects; cohort effects; selecting appropriate outcome measures (convenient proxies vs downstream benefits); and negligible to absent funding sources. Yet despite these barriers, important research into all facets of medical learning is exploding, in the US and around the world.

As of June 2010, I assumed the helm of the Journal of Graduate Medical Education, a quarterly journal with its first publication in September 2009. While funded by ACGME, the Journal is an entirely independent publication: articles published do not reflect ACGME policies or program requirements. The Journal will be guided by an independent editorial board of skilled medical educators, education researchers, and teachers of various disciplines and clinical settings. The editorial board, recruited during summer 2010, will determine the policies, processes, and articles chosen for Journal publication. With the Journal's focus on residency education, scholarship, and accessibility for both teachers and researchers, it fills a unique niche amongst existing education journals.

Providing a venue for publication as well as stimulating and nurturing valuable research, the Journal of Graduate Medical Education will function as a midwife to the plethora of new work underway. The editors will work to improve the overall quality of education publications5,6 as judged by standard criteria.7,8 The Journal will publish articles that may be discipline-specific, yet with methods or outcomes transportable to other specialties. My talented editorial colleagues and I will strive to enhance the clarity and reach of new studies, as well as place them in the context of prior work. We want articles to be concise and clearly written for a broad audience: busy teachers, experienced program directors, novice as well as seasoned investigators, and designated institutional officials with policy and cost concerns. For upcoming issues, we will create several categories of articles in order to share new advances with these various audiences.

Feedback from potential readers will be needed in an ongoing fashion to produce a journal that is read: tell us what you need, like, and don't like. In short, we seek to be reader—as well as author—friendly as we foster the dissemination of new work.

We need valid and generalizable evidence to guide our programs and our teaching. Out of past “anarchy,” with few training requirements, we may have birthed a “rough beast”4 of regulation, which we can tame through thoughtful, creative studies about complex issues. Research has provided answers to many questions, including demonstrating the advantages of early, specific feedback, from which I would have benefited during my own training.

Did I tell the intern group about this exciting new journal? Of course not. I talked about elective opportunities, timelines, family-life balance, and how to derive the most out of their next few years. At the same time, I worried tremendously whether the program in which they were fully engaged was designed optimally to produce physicians to whom I could entrust loved ones. To move closer to this goal, we commit to bringing forth the best in the art and science of graduate medical education.