Approximately 100 years after Flexner's landmark report on medical education, consensus has emerged that the delivery of health care requires transformational change in physician learning.1 This affects the almost 170 000 medical students and resident/fellow trainees and the more than 900 000 practicing physicians in the United States. “Change” in medical education abounds, often benchmarked against the adoption of the 6 competencies.2 Yet, the graduate medical education (GME) community has been slow to reconfigure learning to align with health care redesign3 and with the evolving context for health care.
Aurora Health Care is an integrated health care system that serves as the sponsoring organization for 145 residents and fellows, and a clinical training site for an additional 4500 trainees each year in a range of health professions. With so many learners in the clinical workplace, we do feel the mismatch between trainees' “competency” requirements and the actual roles they will occupy as clinicians if hired at our sites. Our health care system is not alone in playing an important role in GME. Nationally, more than 50% of residency/fellowship programs are based at nonuniversity sponsoring institutions, and the majority of graduates take jobs in community settings or in integrated health care systems.4
To begin, we focused on the jobs our graduates will take after completing training, as true competency-based education begins with an analysis of job expectations.5 We looked for job expectations for physicians for the year 2020. Despite the calls for reforms, competencies, milestones, entrustable professional activities, and other innovations, a job description that defines the performance expected of physicians in practice in 2020 did not exist.
We decided to develop a physician job description for 2020. We identified 52 national health care leaders using a key informant approach including health system CEOs; senior leaders/deans of professional societies, medical education organizations, and medical schools; and public policy and community health experts.6 Fifty leaders agreed to be interviewed. We began by setting the context: “It is 2020, and you are hiring a physician. First, you must write a ‘job description.'” The interviews centered on one fundamental question: “What are the critical job roles and responsibilities that candidates must demonstrate?”
The Aurora Health System Research Subject Protection Program determined the activity did not constitute human subject research.
The leaders interviewed identified a surprisingly consistent list of physician job expectations for 2020, which were distilled into 6 categories (box). These expectations provide a template that can drive the design, delivery, and evaluation of medical education, with performance expectations aligned with “job demands.” For example, many practicing physicians are not yet digitally, data, or technologically fluent or skilled at leading data-driven improvement (Responsibility No. 4) as agile, adaptive innovators (Responsibility No. 5). In contrast, most students and residents are formally trained in these role dimensions, and may be able to coach practicing physicians. This suggests an approach for meeting these job expectations across the continuum by formally implementing a co-learning approach,7 consistent with the expectation that physicians must be committed to lifelong learning (Responsibility No. 6).
Physician Job Description for 2020: Major Responsibilitiesa
1. A proactive, clinically competent health care physician for patients and populations to fulfill the social contract between physician and patient with the highest ethical standards for patients' health care.
Curious and committed to do better, resulting in the highest quality and safety for patients.
Balance putting patients first and a steward for high-value population health care.
2. Skilled at leading and serving as a member on interprofessional teams.
Accept team accountability and interdependence for care with all members working at the top of their license.
3. Able to communicate superbly with professionalism, engaging patients in trusting team-oriented relationships as the approach to continuous contact with the patient (eg, the patient recognizes that the team, not the individual physician, has shared responsibility for care).
4. Digitally, data, and technologically fluent; skilled at utilizing the electronic health record, person/disease registries, and data displays/dashboards to identify gaps and engage in rapid cycle improvements as individual and team.
5. Agile, adaptable, and innovation-driven as health care delivery and physicians' roles will continue to evolve.
6. Committed to lifelong learning and self-care:
Use data to identify gaps;
Engage in continuous learning as individual and team to address gaps/improve care; and
Self-care balancing personal and professional: “be resilient.”
A detailed description of each responsibility and methods is available under “Featured Works” at https://works.bepress.com/deb_simpson.
Physicians' professional identity must center on being compassionate, competent clinicians (Responsibility No. 1) and agile, improvement agents and leaders (Responsibility No. 5). Be it a case-based learning exercise, a core curriculum session, or a journal club on chronic disease, it is important to ask: “Did the education emphasize an interprofessional team approach?” (Responsibility No. 2); “Did it emphasize how to communicate the ‘team' approach to patients?” (Responsibility No. 3); “Did it reference electronic health record smart phrases and disease registries?” (Responsibility No. 4); and “Did it minimize the job-related stressors and enhance the physician's well-being?” (Responsibility No. 6). Unfortunately, the current answer to these questions is often “No.”
The good news is that at Aurora Health Care, we are using the six 2020 job expectations to drive the design, delivery, and evaluation of our residency, fellowship, and overall medical education efforts. This is not in a siloed fashion, but as a true education continuum, with performance expectations matched to education level and aligned with job demands. For example, we identified an opportunity to improve care for patients with asthma, a chronic disease. We designed a Maintenance of Certification Part IV activity for physicians and residents (aligned with milestones), and delineated roles and targeted education for medical students that are aligned with their curriculum requirements. The result was high satisfaction across the learner continuum and significantly improved care for patients.8
Learning across the continuum has always been embedded in the clinical learning environment. We do not need, nor can we afford, to wait for others to design physicians' graduate education or the next “accreditation” requirements, as we prepare residents/fellows for their first job. We acknowledge that while some may disagree with the job roles we have created, and/or emphasize one role over another, the health care leaders we interviewed emphasized the interdependent nature of these job roles.
We believe that it is time for each health care system, from its leaders down to individual practicing physicians, to proactively use the intersection of health care and medical education as an opportunity to maximize value (outcomes/costs). Kaiser Permanente, Mayo Clinic, and a few other health care systems have already designed their GME programs to enable physicians to be ready as hires within their system. The Cleveland Clinic, North Shore-LIJ (now Northwell Health), Geisinger Health System, and others have either created or purchased medical schools.9 Kaiser Permanente's medical school will further align training across the job expectation continuum with its planned opening in 2019.10
Using these 2020 physician job responsibilities as a national benchmark allows us to act within our local environments to identify sustainable solutions that support the learning and development of our trainees (and physicians in practice) to perform the needed job roles. We should begin by aligning our GME efforts with our health care system, community, population needs, and then guide changes up (continuing medical education) and down (medical student) the continuum of medical education.
This local transformation of the learning environment can and must be done now. Our clinical environments (like our physicians) must be agile, and adapt and innovate to become models of team-based interprofessional care. These teams should have ready access to technology and big data to inform care in a culture of continuous learning within our clinical environments to mirror our 2020 job roles. Leaders in health care are enthusiastic to join and accomplish shared learning outcomes that will benefit the health and well-being of patients and communities, and of our physicians.