Insights from the Medical Education Year in Review
WASHINTON, D.C.—In the session Medical Education Year in Review at ACR Convergence, David Leverenz, MD, MEd, associate professor of medicine at Duke University School of Medicine, Durham, N.C., and founder of RheumMadness, a free educational tournament funding by a Clinician Scholar Educator Award from the Rheumatology Research Foundation, gave a wide view of rheumatology professional education. He highlighted selected major studies published between January 2023 and September 2024, and focused on three main areas: Who are we? What are we doing? Where are we going?
A high-level takeaway from the session was that rheumatology as a profession is growing, but also facing expected workforce shortages and is under-represented geographically. Rheumatology is also becoming more diverse, but is still far short of where it needs to be. Also members of the profession have overcome incredible challenges, such as COVID, but burnout looms large.
Who We Are?
Opening his talk, Dr. Leverenz referenced the unease within the specialty around a projected workforce shortage, but cited a study he says offers encouragement. It showed that between 2009 and 2020, there was a 23% increase in adult rheumatologists, a 141% increase in nurse practitioners (NPs) and physician assistants (PAs), and an increase in the proportion female rheumatologists. However, unchanged in the data is the geographic maldistribution in the workforce and low percentage of practitioners in rural practice—only 5%.1
Despite these numbers, the study makes clear that a workforce shortage is still in the offing if the observed increase of 100 rheumatologists per year continues. “We are training more rheumatologists,” Dr. Leverenz said, “but still not enough.’
Race & Ethnicity
To understand the diversity among rheumatology trainees, Dr. Leverenz showed that the number of underrepresented fellows in rheumatology increased by 13% from 2006 to 2023, which is slightly lower than all subspecialty fellows (14% increase) and lower still when looking only at internal medicine residents (17% increase).
When it comes to diversity in rheumatology educational materials (i.e., Image Library, Kelley’s Textbook, New England Journal of Medicine articles on rheumatology or UpToDate), the proportion of images depicting people of color remains smaller than the overall population, as well as for what you would expect in disease prevalence in those populations.
“Diversity and equity are improving,” Dr. Leverenz said, “but we’re still not where we need to be.”
Mental Health
Looking at burnout and depression among rheumatology trainees—based on pre-COVID survey responses, about 40% of first-year fellows had at least one symptom of burnout and 13% screening positive for depression.
“We have overcome some incredible challenges,” Dr. Leverenz said, “but burnout looms large.”
What Are We Doing?
A through line of Dr. Leverenz’s presentation was the focus on competency-based medical training (CBME) and the different ways of measuring competency. In the U.S., he pointed to the updated Accreditation Council for Graduate Medical Education (ACGME) Milestones 2.0 in pediatric rheumatology, which is similar to Milestones 2.0 in adult rheumatology in terms of process and outcomes.2
Europe also has come out with new competency-based standards. The EULAR-Union Européenne des Médecins Spécialistes (UEMS) standards for training rheumatologists define key areas of competency, including quality safety, ethics and professional behavior, communication, health policy and advocacy, teaching and learning, research, leadership, management and teamwork.3
Dr. Leverenz showed a comparison of EULAR-UEMS standards with adult rheumatology ACGME Milestones 2.0, noting the similarities between the two for competency-based training. He also highlighted some slight, mostly verbiage, differences. Examples: What U.S. rheumatology calls a core competency, the Europeans call a domain. What the U.S. call a sub-competency, the Europeans call a core theme. The main difference, he noted, is that the European standards do not grade milestones from 1–5, but simply state what is expected in terms of competency.
“It’s just interesting to see the process by which we may go about finding what competence is in different contexts,” Dr. Leverenz said.
One study that raises questions about competency looked at two different measures of competency and patient outcomes. The study looked at whether an association exists between competence defined by milestones and patient outcomes vs. competence assessed by board examination scores and patient outcomes. The study used data from more than 400,000 hospitalizations from 7,000 physicians and recent graduates working as hospitalists.4 Although no association was found between milestone ratings and seven-day mortality and seven-day readmission (i.e., the patient outcomes), significantly better patient outcomes were seen in physicians who scored high on board exams.
Where Are We Going?
Going forward, Dr. Leverenz pointed to two main areas of focus in rheumatology training gleaned from looking at medical education in general: working in a safe learning environment and optimizing assessments. Artificial intelligence was a third area also mentioned, but only briefly.
Dr. Leverenz highlighted a study on bystander intervention training that helps physicians manage micro- and macro-aggressive discriminatory behavior in the workplace.5 Of 159 physicians who undertook the training and responded to a follow-up survey a year later, 18% said they had had an opportunity to be an active bystander and, of those, 83% intervened. Dr. Leverenz noted that implementing such programs as provide physicians with simple tools (i.e., phrases to use) to intervene in unsafe situations with institutional backing.
Another key area of focus is optimizing assessments, raising such questions as whether CBME is enough to train competent physicians to meet the needs of the public? While lauding CBME, Dr. Leverenz highlighted a study that raises questions about the sufficiency of CBME given that its curricula focus on what learners do. It may unintentionally overlook who learners are and who they are becoming, which is the focus of Professional Identity Formation.6
The study from researchers in The Netherlands raises questions about how to reconcile the different foci of these two competency schemes. CBME focuses on behavioral outcomes, standardization and observed competency. Meanwhile, Professional Identity Formation is focused on a more holistic assessment of physician trainees and who they are becoming—not just the end process of competency. This approach includes consideration of how trainees are learning (i.e., developmental processes) and the unique way in which individuals are gaining competency (i.e., individualization).6 Example: What is happening to a trainee as they move from one competency level to another? A greater understanding of this, said Dr. Leverenz, allows trainees to develop in their own individual way as opposed to a standardized way.
“This paper raises very interesting questions about what CBME may not be doing as we’re thinking about what is happening to our trainees and when we reflect on Professional Identity Formation in our training,” he said.
Mary Beth Nierengarten is a freelance medical journalist based in Minneapolis.
References
- Mannion ML, Xie F, FitzGerald JD, et al. Changes in the workforce characteristics of providers who care for adult patients with rheumatologic and musculoskeletal disease in the United States. Arthritis Rheumatol. 2024 Jul;76(7):1153–1161.
- Nowicki KD, Balboni IM, Cidon MJ, et al. Assessing pediatric rheumatology fellow competence in the milestone era: Past, present and future. Arthritis Care Res (Hoboken). 2024 May;76(5):600–607.
- Alunno A, Avcin T, Haines C, et al. Points to consider: EULAR-UEMS standards for the training of European rheumatologists. Ann Rheum Dis. 2023 Aug;82(8): 1107–1113.
- Gray BM, Vandergrift JL, Stevens JP, et al. Associations of internal medicine residency milestone ratings and certification examination scores with patient outcomes. JAMA. 2024 Jul 23;332(4):300–309.
- Tyson L, Skinner J, Hariharan B, et al. Tackling discrimination in medicine head on: The impact of bystander intervention training. Med Teach. 2024 Feb 24;1–10.
- Sternszus R, Slattery NK, Cruess RL, et al. Contradictions and opportunities: Reconciling professional identity formation and competency-based education. Perspect Med Educ. 2023 Nov 6;12(1):507–516.
