What is the best curriculum design for patient care? Discrete rotations?  Longitudinal training?

If you had the choice to customize a training program for yourself – or for your residents – which rotational model would you pick: A longitudinal approach, or a more traditional model, consisting of a number of rotations?

During the International Conference on Residency Education’s special plenary debate Longitudinal or traditional rotations: Which is better for patient care? on Saturday, October 1 (08:00 – 09:00), Fiona Moss,  Dean of the UK’s Royal Society of Medicine and Salvatore M. Spadafora, Vice Dean of Post MD Education at the University of Toronto will go head to head to debate the pros and cons of a rotational model for residents. The context is a healthcare system-wide push towards quality improvement in medical education and training.

This Q&A is a sneak peek into their much-anticipated debate:

ICRE: Without giving everything away, let’s hear your overarching views: In the context of a health system-wide push towards quality improvement and enhanced patient care, which rotational model is best for the training of residents? Can there be such thing as a one-size-fits-all approach to training models?

Fiona Moss (FM): Residents need to acquire the skills that enable them to both care for individual patients and to “look after the system of care”. These latter skills include team working, leadership, and organizational skills, along with the science crucial for quality improvement science. Acquiring these skills cannot be done quickly – and because they are so important for the care of individuals, I favour a model of training that limits the rotational changes experienced by residents.

Sal Spadafora (SS): In a pro/ con debate I must say that I would suggest that traditional rotations are the best way to cover the often varied breadth of specialty training requirements. Traditional rotations provide us with the opportunity to ensure that our learners are exposed to the multiple contexts of clinical care that provides a comprehensive suite of learning opportunities. The reality however, is that one size likely does not fit all and that most of our future approaches to medical education must include a component of individualized or customized learning plans. 

ICRE: Can you give an example from your own professional life that might help explain why it is that you view the particular model above as being the best approach to take in terms of planning resident rotations?

FM: As a senior resident (registrar) in the UK, my program had me essentially spend two years in each of two places. I learned an enormous amount about the ins and outs of working in a single organization, and it was not possible to “rotate” away from difficult situations.  I was able to see the long term impact of quality improvement; develop long term working relationships with a whole range of staff and patients; and to get to know the local primary care practitioners as well as the local population. Because I became part of each institution for a long time, I was given organizational responsibilities, which allowed me to develop organizational skills in a way that would not have been possible in shorter rotations.  In addition, my trainers were able to supervise and appraise my development much more in-depth.

SS: Ironically, my training for my specialty was not that of what we would describe as traditional rotation.  It was site-based longitudinal, and you moved every four to 12 months.  It was felt that if we stayed at a site for long enough, we would “see it all”. We went to a site daily “tarred”; the teachers threw enough “feathers” at us, and hoped that some of them stuck. Not all of us ended up looking like birds. They called them rotations, but there was no structure to them other than showing up at a site for what felt like a very long time, and being assigned to an operating room. I was pretty diligent and assertive, but felt that I really had to advocate and be quite loud to get what I was missing. 

Learning is a partnership, and as much as I want learners to be active, assertive and speak up (and they do), I believe it is our collective obligation to provide some structure and partner with the learners to provide the rotations that are carefully planned, exquisitely supervised, and take into account the integration of patient care/ service and trainee learning. This is what I spent the first portion of my career doing, as a teacher, and then as a Program Director; transforming a longitudinal, site-based approach to true rotations.   

ICRE: Why do you think an analysis/evaluation of training models is important now, in the context of 21st century medical education and the quality improvement movement?

FM: Medical technology and the delivery of patient care have changed hugely over the past 20 years.  To quote a Sir Cyril Chantler writing from the ‘Lancet’ (UK medical journal) in the 1990s, “medicine used to be simple, ineffective, and relatively safe; it is now complex, effective and potentially dangerous”.  This has many implications for training. For example, supervision is now much more crucial, and as new modalities of treatment alter the delivery of care, there are consequential implications for the delivery of resident training.  In addition, we now know so much more about quality and safety improvement; so if training does not include a significant focus on the science,  skills and behaviours necessary for quality improvement,  it  should be considered  incomplete. The need to deliver training in QI should drive links between organizations that train, their training programs and their residents.  Finally, hospitals that deliver good quality care are likely to be “learning organizations”; and these should be the best places for residents training. 

SS: As I said earlier – one size will not likely fit all the learners all the time.  We need to focus less on the label for the model of training.  We should place our focus, instead, on those we train and the patients we care for, as well as the specific key elements of the learning experience.  Current and future program evaluation should focus on the outcomes of learning (which theoretically should lead to better patient outcomes), and components of the learning activities that are essential to the training of a competent physician.  You can likely have the best of both paradigms and the worst of each as well.  It’s not what you do – it’s the way that you do it!  Partnering with learners, exquisite supervision, and a focus on integration of superb patient care and patient safety with individualized learning are the key components of both modern longitudinal and rotation based learning.

ICRE: What can ICRE attendees expect from this debate? How might it be of value to participants who may not directly be involved in the planning of, or participation in, rotational training models?

FM: I hope that those in the audience will see that there perhaps needs to be a greater alignment between residents, their training programs, and the organizations in which they work and train.  Residents are among the most able, ambitious and energetic of our health care professionals, and if they were a greater part of – and more “aligned with” – their educational organizations, this could benefit the clinics/hospitals and their patients, as well as the residents themselves. In addition, this would perhaps drive more hospitals to aim to truly be “learning organizations”.

SS: Well for starters I like a good debate (as my family would say – “he likes to argue and he always thinks he is right!”).  So attendees can expect me to be less “on the fence”, and be a bit more dogmatic about the traditional model of rotational learning as the quintessential way to produce the model physician for the 21st century. 

I think the session will be valuable to the reflective educator who can expect to find the good, the bad and the ugly of each model exposed for what it is, and decide for themselves if they want a polarized, off the rack item to fit onto each learner and each learning environment.  I suspect participants will take in the good of each model, avoid the bad of each model and shun the ugly of each model.  The result may be a future that is awash with thoughtful, customized, individualized, “bespoke” rotations that focus on the learner and the patients!   

Fiona Moss is a most capable opponent to debate – expect sparks to fly!  

If you can’t join us live for the debate, check back here the week of September 25th, for details on how to stream the debate live.

To view the full lineup of plenaries, workshops and sessions taking place during ICRE 2016, click here.