How might a pure competency-based curriculum change residency interview season?

OHSU is one of several schools that recently received an AMA-funded grant to push medical educational innovation.  Our new curriculum, YourMD (yeah it has a cool marketable name), is in many ways a test lab for this grant (to be clear, most of what I'm going to discuss here is beyond the scope of the current version being developed for the YourMD curriculum, and I'm outlining my personal view of what the model may look like in the future).  One of the primary themes in OHSU's work for this grant is to create a workable competency-based (not time-based) model of medical education.

Multnomah County Hospital residents and interns, circa 1925

 

 

As you can imagine, there have been many questions about the logistical problems with such a system.  One of the issues raised at our institution as this concept has been discussed at various faculty meetings is the perceived trouble students in such a system will have in finding a residency program.  After all, the student will have this transcript which looks remarkably different from most of the current school transcripts.  It will have a bunch of competencies and EPA's.  It may not have any mention of honors.  How is a residency director to be able to choose who is the best candidate for their program?

I've thought about this a bit, and have a few ideas.  First, if the school is truly competency-based, just the fact that the student has been able to graduate should indicate that:

a) The student understands and applies the knowledge necessary to start as an intern,
b) The student clearly demonstrates the skills necessary to start as an intern
c)  The student clearly demonstrates the professionalism necessary to start as an intern
 
To my mind (assuming the system will work as advertised), this is revolutionary.   This means you don't have to guess as a residency director what you are getting.  You don't have to read between the lines for the secret codes hidden in the letters of recommendation.  This person is ready for residency
.  End of line.

So, then what do you look for now?  Now, as a program director, you can begin to look more at what other experiences and skills does this particular individual have that would help them thrive at any particular institution. Instead of trying to assure that the person had 'honors' in internal medicine, the medicine program director can sort applicants in all manner of ways. They could determine their program wants people who have above-average skill in quality-improvement, or they could decide they want residents who are particularly interested in medical education. They can rank based on how well they operate in a team-environment. They can look for students who have had particular experiences that would benefit them in their environment - say a lot of rural practice experience or many rotations in an under-served inner-city.  Each program director can choose what they'd like to highlight, and I don't see a problem with letting students know what they are looking for in applicants. This makes the interview sessions even less about figuring out if this person can operate on the ward successfully, and more about does this person fit well with our system and our culture.

If competency-based education works, this may be something residency program directors will need to think about. We're all well on the way to competency-based education. So, program directors, prepare yourselves. I think it'll make interview season more fun actually.

Does a practicing physician need to be in the primary literature?

This post is more of a thought experiment than a suggestion for a new policy statement for medical education.  So, please understand part of why I'm putting this question up is to get you all to think a bit about this concept.

The underlying theme I've heard over and over ever since I was a resident was that getting data from a primary source was better than an aggregate source.  The idea was that everybody is much better off seeing the primary data for themselves, and then coming to their own conclusion on whether it applies to their individual patient or not.  Thus, when a student or a resident brings in some medical literature for the team to review, there are more  'points' awarded if the literature is a randomized-controlled trial or a case report, than a printout of 'UpToDate'.  I've heard one of my colleagues in a meeting essentially say that he wished 'UpToDate' didn't exist as it was making residents 'lazy'.

My argument against this idea is that we are teaching students how to behave as they get into practice.  I've talked with many friends in private practice, who have good intentions, and do read some from the main journal from their physician group.  However, not many of them have the time nor the energy to look up primary literature on every patient issue they run across.  Also, the primary literature is messy.  If you have time to look up 2-3 articles on a topic like correct choice of an antihypertensive, which primary articles should I choose to look at?  How deep of a search into the primary literature is necessary?  Should a practicing physician need to know about current animal models on hypertension research?  Where do you draw the line?  Honestly, I don't have time to go the primary literature for every patient issue I'm confronted with.

I see this as another area where it used to be OK to be able to keep up on the primary literature for a give topic.  However, as the medical literature has exploded exponentially, it is literally going to be impossible for anyone person to keep up.  That's where we need to start trusting one another more.  Services that aggregate data from primary literature are very valuable.  I honestly won't look down on a student looking things up before rounds on 'UpToDate' as that is a practice that will likely be sustainable.  Is having them look deeper into the literature sustainable or not?  What do you think?