Summergrad Addresses Training Directors on Development of Physician Identity

“Not everything that counts can be counted, and not everything that can be counted counts.”

In a lecture at last month’s meeting of the American Association of Directors of Psychiatric Residency Training (AADPRT) in Tucson, Ariz., APA President-elect Paul Summergrad, M.D., alluded to the above statement—often attributed erroneously to Albert Einstein—to highlight the tension experienced throughout medicine today between the emphasis on accountability and measurement and the harder-to-quantify developmental challenge of being and becoming a physician.

Referring to the remark attributed to Einstein, Summergrad said, “Something in that non-quote speaks to a sense that we may have overemphasized accuracy, proof, and measurement.” He added that that “there are also other ways of knowing and judging the completion of key tasks in the development of young physicians.”

Rick Brandt/AADPRT

These tasks include professional values, the ability to form a trusting relationship with patients, and—most relevant for educators—the formation of a professional identity as a physician that has traditionally been forged in what Summergrad called the “crucible” of medical school and residency training. He delivered the annual Harvey Shein Memorial Lecture, which he titled “Going to Sea: Psychiatric Education in an Era of Accountability.”

As important as measurement, reliability, and evidence of effective training are to the field and the general public, they need to be balanced with other important considerations in the training of young physicians, Summergrad said.

“The title of my talk is really about a far broader trend than the Accountable Care Act,” he told educators at the meeting. “It’s about the balance and tension between measurement—what we measure, how we measure—and what we don’t or can’t do because of where our limited attention is focused.”

It was a timely message for educators who are wrestling with the demands of the so-called “next accreditation system”—one that aims to move the training of physicians toward an outcome-based measurement system, as exemplified by the Milestone Project, for assessing the progress of trainees from the beginning of residency through entry into professional practice (Psychiatric News, August 28, 2013).

They are also wrestling with resident duty-hour restrictions that can, in some cases, cause disruptions in continuity of patient care.

Summergrad assured educators that the movement toward measurement and outcome-based performance is a generally healthy one—and one that was not likely to recede in any case. “Measurement and evidence are very important in making sure we graduate psychiatry residents and fellows who are as capable as they can be,” he said. “It is more a question of really thinking together about the tasks of training and how we not only assess their presence or absence in our trainees, but also what methodologies and approaches will achieve which of those ends.”

He reviewed the broad historical trends that have led to the era of accountability, including a dramatic expansion of knowledge about the genetic and neurobiological bases of psychiatric disorders that have helped to make psychiatry increasingly a part of the house of medicine—bringing with it the demand for outcome-based measurement of all medical care, including psychiatric practice.

“We are in an extraordinary period in the history of neuroscience, genetics, cognitive neuroscience, and therapeutics, with a flood of findings,” he said. “While we have not yet clearly elucidated the fundamental causes of psychiatric illness, we someday will. Our immersion in the world of medicine has revealed other links. . . . Our disorders are highly comorbid with many other common medical illnesses, and the costs of these illnesses together are potentially staggering. . . . While it is unclear whether our interventions can reduce costs in all settings, there is no question that psychiatric illness is rife in the health care system, and ignoring these conditions will not reduce suffering and will certainly not reduce costs.”

Meanwhile, he said, health care reform has focused on population health, which demands measurement and evidence-based care. “The movement from fee-for-service to global or so-called value-based reimbursement depends in large degree on outcome and quality measures,” he said. “The expectation of accurate measurement is unlikely to diminish.”

But with specific reference to the challenge of duty-hour restrictions, Summergrad pointed out that some aspects of medical professionalism—such as the willingness to be present for patients in an hour of need—may not be measurable.

“That you can’t improve what you don’t measure has become axiomatic in our culture,” he said. “However, when issues of patient safety . . . become a summum bonum [‘the highest good’] regardless of other considerations, such as the importance of continuity of patient care, we have shifted the ground of our expectations and values. It may be important at least at some point in life to stretch yourself beyond what you may think you can do, if for no other reason but to reshape one’s character or identity. If we don’t, then we risk developing other longer-term problems, including physicians who may not feel it is their responsibility to answer a call at 3 a.m. when someone is standing at the precipice of life and death.”

Similarly, he said that psychiatrists in particular must learn through encounters with difficult and extremely ill patients to tolerate and manage painful or frightening feelings. “Our capacity as physicians to manage very difficult experiences both in and with our patients requires a capacity to absorb fearful emotions and mental states,” he said. “While our observational capacities and measurement activities may be able to assess this in part, our trainees—and we as their mentors—are also embarking on a journey. If our time and attention are diverted to only filling out rating sheets, it will work as well for residency training as filling out an electronic medical record during a patient visit works for patient care.”

Summergrad said that the professional values that compel physicians to be at the bedside for their patients, including the most difficult and severely ill, are forged in residency. He gave a passionate defense of what he called the “crucible” of medical training; it is in that crucible of long hours, rigorous training, and encounters with difficult patients that a new identity—as a physician—is formed.

That crucible is not different from the rites of initiation that young people undergo in the pursuit of professional identity in other fields—the military, priesthood, law, and architecture; as in those professions, aspiring physicians in training are separated from their customary surroundings and expected to venture into unknown territory so that a new identity can be forged.

“Uncertain, sleep deprived, facing internal and external risk . . . we expect [our trainees] to change, . . . to place the needs of their patients ahead of their own, even at 2 a.m., and to otherwise achieve not only competence and expertise but a new identity,” Summergrad said. “Not all succeed in this process, and at the moment, with our overweighted valuation of measurements rather than relationships, of duty-hour limitations rather than the crucible, of education rather than service or intense clinical experience, we risk overcorrecting for the sins of prior training regimes.”

He concluded, “I hope we don’t forget what Osler called the higher walks of medicine, nor forget under the weight of current fashion Charcot’s wise guidance about ideological fashions—theory is good, but it doesn’t prevent the existence of reality. If we are to change and grow during residency training, we must learn to let go and leave our comforting shores; if we don’t, how will we ever get to the other side?” ■