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Millennials are quickly becoming the most prevalent generation of medical learners. These individuals have a unique outlook on education and have different preferences and expectations than their predecessors. As evidenced by its implementation by the Accreditation Council for Graduate Medical Education in the United States and the Royal College of Physicians and Surgeons in Canada, competency based medical education is rapidly gaining international acceptance. Characteristics of competency based medical education can be perfectly paired with Millennial educational needs in several dimensions including educational expectations, the educational process, attention to emotional quotient and professionalism, assessment, feedback, and intended outcomes. We propose that with its attention to transparency, personalized learning, and frequent formative assessment, competency based medical education is an ideal fit for the Millennial generation as it realigns education and assessment with the needs of these 21st century learners.

Competency-based medical education holds the promise of producing a better-trained workforce — and for many physicians, this training could be accomplished within a shorter time frame.

Medical residents in hospitals are often required to be on duty for long hours. In 2003 the organization overseeing graduate medical education adopted common program requirements to restrict resident workweeks, including limits to an average of 80 hours over 4 weeks and the longest consecutive period of work to 30 hours in order to protect patients and residents from unsafe conditions resulting from excessive fatigue. Resident Duty Hours provides a timely examination of how those requirements were implemented and their impact on safety, education, and the training institutions. An in-depth review of the evidence on sleep and human performance indicated a need to increase opportunities for sleep during residency training to prevent acute and chronic sleep deprivation and minimize the risk of fatigue-related errors. In addition to recommending opportunities for on-duty sleep during long duty periods and breaks for sleep of appropriate lengths between work periods, the committee also recommends enhancements of supervision, appropriate workload, and changes in the work environment to improve conditions for safety and learning. All residents, medical educators, those involved with academic training institutions, specialty societies, professional groups, and consumer/patient safety organizations will find this book useful to advocate for an improved culture of safety.

The American Council of Graduate Medical Education is moving from accrediting residency programs every 5 years to a new system for the annual evaluation of trends in measures of performance. In 1999, the Accreditation Council for Graduate Medical Education (ACGME) introduced the six domains of clinical competency to the profession, 1 and in 2009, it began a multiyear process of restructuring its accreditation system to be based on educational outcomes in these competencies. The result of this effort is the Next Accreditation System (NAS), scheduled for phased implementation beginning in July 2013. The aims of the NAS are threefold: to enhance the ability of the peer-review system to prepare physicians for practice in the 21st century, to accelerate the ACGME's movement toward accreditation on the basis of educational outcomes, and to . . .

The Covid-19 pandemic presents an urgent imperative to rethink residency graduation requirements and an opportunity to implement the competency-based approach for which many educators have been calling.

Graduate medical education (GME) funding comes from predominantly two public sources: Medicare and Medicaid. In recent years, concerns have been voiced as to whether these GME payments to teaching hospitals and other entities are sufficiently transparent and publicly accountable. Most of these concerns have been directed at the financing and governance of Medicare GME payments. In the past 10 years, two major reports examined this issue.The main premise of the first report, a 2014 study by the Institute of Medicine (nowthe National Academy ofMedicine), is that Medicare GME payments, and federal funding for GME more broadly, lack a clear purpose. Medicare does not produce enough physicians prepared to practice in the most needed specialties or geographic areas and has insufficient oversight and infrastructure to measure GME program outcomes and reward performance. In terms of accountability, the study found that the stewardship of the public's investment in GME was critically absent. In particular, any data that teaching hospitals are required to report to the federal government has limited use for program oversight, workforce analysis, or policy development; consequently, the report concluded that most questions about the effectiveness of the Medicare GME program are unanswerable.

The Accreditation Council for Graduate Medical Education (ACGME) emphasizes the importance of medical trainees meeting specific performance benchmarks and demonstrating readiness for unsupervised practice. The aim of this study was to examine the readiness of Gastroenterology (GI) fellowship programs for competency-based evaluation in endoscopic procedural training. ACGME-accredited GI program directors (PDs) and GI trainees nationwide completed an online survey of domains relevant to endoscopy training and competency assessment. Participants were queried about current methods and perceived quality of endoscopy training and assessment of competence. Participants were also queried about factors deemed important in endoscopy competence assessment. Five-point Likert items were analyzed as continuous variables by an independent t-test and χ(2)-test was used for comparison of proportions. Survey response rate was 64% (94/148) for PDs and 47% (546/1,167) for trainees. Twenty-three percent of surveyed PDs reported that they do not have a formal endoscopy curriculum. PDs placed less importance (1—very important to 5—very unimportant) on endoscopy volume (1.57 vs. 1.18, P<0.001), adenoma detection rate (2.00 vs. 1.53, P<0.001), and withdrawal times (1.96 vs. 1.68, P=0.009) in determining endoscopy competence compared with trainees. A majority of PDs report that competence is assessed by procedure volume (85%) and teaching attending evaluations (96%). Only a minority of programs use skills assessment tools (30%) or specific quality metrics (28%). Specific competencies are mostly assessed by individual teaching attending feedback as opposed to official documentation or feedback from a PD. PDs rate the overall quality of their endoscopy training and assessment of competence as better than overall ratings by trainees. Although the majority of PDs and trainees nationwide believe that measuring specific metrics is important in determining endoscopy competence, most programs still rely on procedure volume and subjective attending evaluations to determine overall competence. As medical training transitions from an apprenticeship model to competency-based education, there is a need for improved endoscopy curricula which are better suited to demonstrate readiness for unsupervised practice.

Background Effective humanitarian surgeons require skills in general surgery, OB/GYN, orthopedics, and urology. With increasing specialization, it is unclear whether US general surgery residents are receiving exposure to these disparate fields. We sought to assess the preparedness of graduating American surgical residents for humanitarian deployment. Methods We retrospectively analyzed cases performed by American College of Graduate Medical Education general surgery graduates from 2009 to 2015 and cases performed at select Médecins Sans Frontières (MSF) facilities from 2008 to 2012. Cases were categorized by specialty (general surgery, orthopedics, OB/GYN, urology) and compared with Chi-squared testing. Non-operative care including basic wound and drain care was excluded from both data sets. Results US general surgery residents performed 41.3% MSF relevant general surgery cases, 1.9% orthopedic cases, 0.1% OB/GYN cases, and 0.3% urology cases; the remaining 56.4% of cases exceeded the standard MSF scope of care. In comparison, MSF cases were 30.1% general surgery, 21.2% orthopedics, 46.8% OB/GYN, and 1.9% urology. US residents performed fewer OB/GYN cases ( p  < 0.01) and fewer orthopedic cases ( p  < 0.01). Differences in general surgery and urology caseloads were not statistically significant. Key procedures in which residents lacked experience included cesarean sections, hysterectomies, and external bony fixation. Conclusion Current US surgical training is poorly aligned with typical MSF surgical caseloads, particularly in OB/GYN and orthopedics. New mechanisms for obtaining relevant surgical skills should be developed to better prepare American surgical trainees interested in humanitarian work.

Background E-learning—the use of Internet technologies to enhance knowledge and performance—has become a widely accepted instructional approach. Little is known about the current use of e-learning in postgraduate medical education. To determine utilization of e-learning by United States internal medicine residency programs, program director (PD) perceptions of e-learning, and associations between e-learning use and residency program characteristics. Methods We conducted a national survey in collaboration with the Association of Program Directors in Internal Medicine of all United States internal medicine residency programs. Results Of the 368 PDs, 214 (58.2%) completed the e-learning survey. Use of synchronous e-learning at least sometimes, somewhat often, or very often was reported by 85 (39.7%); 153 programs (71.5%) use asynchronous e-learning at least sometimes, somewhat often, or very often. Most programs (168; 79%) do not have a budget to integrate e-learning. Mean (SD) scores for the PD perceptions of e-learning ranged from 3.01 (0.94) to 3.86 (0.72) on a 5-point scale. The odds of synchronous e-learning use were higher in programs with a budget for its implementation (odds ratio, 3.0 [95% CI, 1.04–8.7]; P  = .04). Conclusions Residency programs could be better resourced to integrate e-learning technologies. Asynchronous e-learning was used more than synchronous, which may be to accommodate busy resident schedules and duty-hour restrictions. PD perceptions of e-learning are relatively moderate and future research should determine whether PD reluctance to adopt e-learning is based on unawareness of the evidence, perceptions that e-learning is expensive, or judgments about value versus effectiveness.

In this randomized trial comparing ACGME duty-hour policies with more flexible policies for surgical residents, the flexible policies resulted in noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality. In response to concerns about patient safety and resident well-being, the Accreditation Council for Graduate Medical Education (ACGME) introduced national regulations in 2003 that limited resident duty periods to 80 hours per week, capped overnight shift lengths, and mandated minimum time off between shifts. 1 , 2 Concerns persisted, 3 and in 2011, the ACGME implemented further restrictions to shorten maximum shift lengths for interns and increase time off after overnight on-call duty for residents. 1 , 4 , 5 Although most observers agree that some duty-hour regulation was necessary, critics cite a weak evidence base for the 2003 and 2011 reforms. 3 , 6 , 7 Several retrospective . . .