Generations of physicians did and still do fine just learning the right stuff from the right people in the right way at the right time in the right environment, and they learned how to keep learning and changing. Could not those responsible for training programs (who must be deemed experts) make valid assessments and judgments without a proliferation of definitions and details? I understand that Dr. Stead’s notions are fanciful today, but I believe some of his thinking remains valid.
Our imperative today is to make the NAS work. As a division chief and department chair for 35 years, I confronted the problems of struggling to reconcile our education and training to contemporary practice. I appreciate that we live and work in an environment of omnipresent regulation. While I, and others, might have wished otherwise, it is now our reality and we must deal with it.
Assuring quality and appropriate education and training, and patient care, are indeed important. I accept that we are expected to do better, as interpreted and promulgated for society by the ACGME. How should rheumatology respond to this imperative? I think we can yet do this reasonably well. Calvin Brown, Jr., our liaison to the ACGME, American Board of Internal Medicine, and internal medicine subspecialties dialogue about the NAS, reminded me that Mozart’s reply to the emperor was, “Which [notes] did you have in mind, majesty?” We must make music. The challenge is to select which notes are important, pick the tune, make it pleasing, keep it harmonious, find one that is satisfying for both the orchestra and audience, and recognize that we won’t all share the same tastes. We should, I think, be careful about too many details, or definitions, however appealing or seductive. Less is sometimes more. We should, I think, be skeptical about prescriptions and processes insensitive to change. We should, I think, espouse enduring principles. We must assure that medical education can be fun, and an attractive and rewarding career path.
I’ve expressed my admiration for the hopes of the NAS, despite concerns about its implementation. There exists now at least some opportunity for self-determination. I want us to successfully retain the best of our traditions and values and adapt them for the future. Dr. Stead’s perspective is relevant. We should, I think, resist the impulse to necessarily add more “stuff,” such as we can, adopt as principle-based and elemental an approach as possible, keep this uncomplicated, empower program directors’ judgments insofar as practicable, and develop curricula, measures, definitions, competencies, milestones, entrustable professional activities, outcomes, and the corresponding tools that are simple and enduring, coming together melodiously—without cacophony—as good (maybe even great) music. If anyone can do this, we rheumatologists will.
