I do not think that more standardized tests in residency will be helpful -- multiple choice questions can only test medical knowledge, not the actual delivery of patient care
However, I think that some commitment between program and learner is necessary. It would be nice to see programs held to a standard of helping their residents who leave to get a new spot -- not by "covering things up" but by helping them find a fresh start. My experience is that very few residents are truly incompetent -- some just need a different program, or a different field, to bloom.
There are newer computer based examinations that do test clinical decision making, like Step 3, . . . what I would suggest is weekly such sessions AND the program directors/attendings could "make up" scenarios based on what a resident did wrong 3 months ago and see if they remembered. I know one PD who sort of does this.
I was very averse to standardized patient encounters and training with "dummies" until I saw how advanced these can be AND some residency programs are using these to supplement resident education, there being less hours during residency which I think is a very real issue.
Although I passed Step 2 CS on the first try, and so don't have a bone to pick about it being "unfair", I did study very hard for this examination sort of thinking I would fail and learned so much stuff that I didn't know that it was scary! (And I did get 99 on Step 2 CK and having been reading medical journals the past three years +), . . .
So, I think if there was an advanced Step 2 CS offered by residency programs, maybe monthly, that was then reviewed with preceptors i.e. attendings, then this would be a better learning situation as no real lives were in danger and this takes out some of the ego and fear of the real clinical situation and makes feedback easier to give.
Most of the feedback I have been given in a clinical setting has been very unspecific, and is therefore unhelpful. Say I get an evaluation form back that has "average" history taking skills. What does this mean? We all know how to do a full an complete history, which would take at least 45 minutes, but if we are admitting patients more quickly then what are the right questions to ask? Did I miss an important question? As a student if I forgot to say ask a specific question, like "You didn't ask about past antibiotic use in the past month, which the patient may have discontinued", then a light goes on in my head, and I sure haven't forgotten any of those "pearls", and likewise when I teach students then I would politley remind them and even tell them how I made the same mistake.
I think is how evaluations should be, timely, specific and helpful. We have all been on a rotation and been yelled at and realizes that an attending "doesn't like us", and we may get a mediocre evaluation, but never get any specific comments. Even such vague comments and just being "satisfactory" in history taking don't help as we can't remember exactly what went wrong.
If evaluations were more timely and more specific then residents would be able to learn better, but currently evaluations are sporadic, maybe just at the end of a rotation block so nobody knows what is going on. I think this is the big problem as attendings sit back and watch med students and residents make mistake or at least approach things inefficiently or incorrectly and then give a bad or mediocre written eval months late, sure we may be "judged" correctly, but that is all the attending is, a judge and not a teacher . . .
While the Indian/British system has its drawbacks, it would sure motivate "lazy" attendings who don't teach and just judge or evaluate without feedback and without taking any responsibility that if they see an underperforming resident then they need to make specific comments and to impart their knowledge. This would force attendings to teach med students/residents they don't like. I have taught medical students in a nice and thorough way whom I personally didn't care for, i.e. inappropriate jokes or something, and I thought it was my duty as they would be physicians one day, and surprisingly they become more "nice" or at least more like me so I actually liked them. Most attendings have students they don't like and refuse in a way to teach them and then give them bad evals.
I have been in the position of teaching medical students, and taught students in other situations as well. There is a difference between a value judgment and a specific appropriate criticism, one wears you down and the other is an exciting piece of useful information. When I slip and make a value judgment, which rarely happens, then the student doctor will lose interest and understanding, and perhaps rightly so.
For example: Value Judgment: "You aren't following up enough on your patients." Nonspecific, just a sort of "you suck" comment.
Specific Criticism: "Make sure to review the lab values before you round each day as things can change quickly and we want to make sure we have up to date information about our patients." This lets the student in on the interesting aspects of patient care and makes learning medicine more patient focused than on complaints about a person's personality or even appearance.
Sometimes if someone tells you to "follow up better the patients" you figure out what to do differently, but other times you pour your resources into doing things that waste your time and don't improve your performance.
Many attendings apparently didn't go into medicine in part to educate patients or subordinates, as evidenced by lack of teaching, learning via osmosis, and no attention to giving real feedback in a nice manner, which is an important part of teaching patients and teaching residents. So, really, as I look as being a doctor as it being important to educate people, i.e. patients and students, then when I see an attending who really doesn't care about the teaching aspects and who is more of a judge versus a teacher then I think that a lot of residents/students becomes loss and disillusioned and resort to teaching themselves.
Worst, people who verbally abuse others, and there are a handful of attendings who do, often make students and residents feel like they are walking on eggshells and these attendings give inappropriate and constant "criticism", more to "let off steam" and as a way to be mean to students/residents than to teach, the problem is that medical education is an oxymoron as few attendings are properly trained to teach. I think more than attendings would like to admit, a lot of people look at their evaluations as being much less objective than real factors such as standardized testing.
If I have an internal medicine residents who does weekly standardized exams, testing real life clinical scenarios, and monthy preceptored evaluations ALL excellently, and if there is one or two even bad evals then I would reasonably conclude that the resident brushed the attending (s) the wrong way. I think weekly stadardized examinations, i.e. short 30-45 minute computer based scenarios would both teach and also help evaluate resident skills.
All sorts of written examinations DO test the knowledge as well as applied knowledge. In terms of lazy residents, I think this is a different issue, there aren't that many, and certainly unfairly attacking a resident or even denying them to practice medicine based on a personality conflict does significant harm to society due to the potential loss of a good doctor that some sort of standardized examination should be implemented. There are a lot of medical students/residents who DO care about getting proper feedback who don't get it and get harassment and evaluations that come to late or are unspecific. The residents I have seen that I was told were a concern for the PD in terms of being "incompetent" had failed shelf examinations and didn't have the body of medical knowledge (which I consider to include every facet of deliverying patient care outside of being lazy) and could not most likely do well on weekly computer based or written questions that have management details.
