WORKSHOP--QUALITY ASSURANCE IN ADVANCED TRAINING PROGRAMS
Leader: Leon Potgieter, DVM, PhD
Rapporteur: John Galland, PhD
This workshop focused its attention on problems related to assuring the quality of the educational experience within three types of programs: non-degree (residency), degree, and combined residency/degree programs. While there are some issues unique to each of the three programs, other issues were considered to be involved in all three areas. Problems common to all program types included mentoring, establishment of clear programmatic goals, and monitoring outcomes.
Nondegree (Residency) Programs
There is a lack of clearly stated measurable objectives and outcomes that are communicated to students and faculty before training begins. Students experience time management difficulties when their attention must be divided between clinical service and research as a result of ill-defined training requirements.
Establishment of program objectives will help students and faculty understand what is expected of them, focus instruction, and provide a measuring stick for evaluating student and faculty performance. Examples of objectives for a nondegree program might be to pass the board examination or to gain clinical experience by managing hospital cases.
Two bodies have responsibilities for addressing this concern. The appropriate specialty board has the major responsibility for setting requirements and criteria for a successful program while the unit in which the training occurs has to assume responsibility for communicating and enforcing these requirements and criteria.
- The following minimum requirements should be defined:
- a) Ratio of diplomate mentors to residents,
- b) Amount of 1-to-1 contact between mentor and student,
- c) Class hours, topics and other relevant experiences should be specified,
- d) Facilities and equipment required,
- e) Patient numbers and required species distribution.
- Locations where these requirements have been met should be listed.
- Requirements should be communicated to participating institutions so that appropriate internal controls can be set in place.
Outcome assessment--may include certification by a specialty board within a reasonable time after completion of training and/or gainful employment in an appropriate environment. The participating institution, the specialty board, and the American Board of Veterinary Specialties could have a role in outcome assessment of training programs.
Inconsistency in mentoring and availability of relevant clinical cases makes it difficult to meet program objectives. Trainees are either too busy or not busy enough. Faculty are often unavailable to fulfill their mentor roles.
Inconsistency of student mentoring is due to being uninformed about the elements of mentoring, its assignment to a low priority or poor interpersonal skills.
Mentors' responsibilities should be defined. Mentoring guidelines should be established and shared with students and faculty.
If new faculty have not had adequate experience with a mentor role model, an opportunity for training should be provided, perhaps by the specialty board. Faculty should acquire experience in their specialty before being required to serve as mentors.
Mentoring of interns and residents should be a departmental priority, and incentives to reward excellent mentoring should be in place.
Minimal contact time and the nature of "supervised" activity should be defined.
- Department heads must be informed of mentoring guidelines.
Inadequate evaluation of program and trainees occurs and there is a lack of consistent and regular evaluation of training programs, including both internal and external review. Such evaluations should supplement information from the diplomate examinations or job success of the trainees.
- An external review should be done by the appropriate specialty board.
- a) The board should provide guidelines and minimal requirements for outcomes assessment criteria.
- b) The board should evaluate experiential training and case logs.
- c) The board should interview candidates at certifying examinations on their experiences at training institutions.
- d) The board should monitor success rates of applicants in certifying examinations and numbers of individuals entering programs.
- An internal review should be done by a faculty committee on house-officer programs (separate from research and graduate student committees).
- a) Obtain standards from all specialty boards for comparison to program standards at the institution.
- b) Standardize policies across programs whenever feasible
- c) Guidelines for internship should be established.
- d) Coordinate cross-residency experiences for boards requiring such experiences to be coordinated.
- A mechanism for periodic review of individual trainees should be developed.
- a) All specialists in the program should be included.
- b) Review resident experiences, logs, progress, and requirements.
There are no national board examinations for persons completing MS or PhD degrees to help assure quality education and outcome. Quality assurance for the MS and PhD degrees is entirely the responsibility of the University and/or graduate programs within University departments or programs. Recommendations by members of this symposium may be useful in stimulating universities to review their quality assurance efforts.
Administrators, faculty in disciplines outside veterinary medicine, and even members of the veterinary profession, have the perception that acquiring a PhD in veterinary medicine is less rigorous than acquiring a PhD in other disciplines. The following table illustrates the dilemma of a veterinarian aspiring to a research career.
Trainee 21-22 years old 26-27 years old 30 years old Research Track BS PhD 2 Post Docs Veterinary BS DVM PhD Track
The research track individual can focus on his/her research specialty at 21-22 years of age, whereas with the veterinary track individual this focus is difficult to achieve and, at the earliest, occurs 5 to 6 years later than for the former. Furthermore, few veterinarians with a PhD enter into postdoctoral training programs. There is a need for more consistent monitoring of program content and mentoring to ensure students are receiving appropriate quality programs.
The goals of degree programs should be defined. Consensus exists that degree programs should emphasize research. Acquiring a degree has become a stepping stone for achieving any faculty status in all preclinical disciplines and may be becoming a factor for candidates in clinical disciplines aspiring to academic careers. However, many veterinary faculty, although scholarship is an essential component of their assignment, are not in a position to compete for major extramural funding.
Often, training is inappropriate for a research degree and too much formal coursework is required. Flexibility should be sought to allow for training appropriate to the individual's goals.
Clinical departments should promote high-quality, controlled, clinical research. A need exists to develop and validate the knowledge base in clinical medicine. Vigorous quality control on experimental design must be in place.
Inconsistent mentoring, inadequate monitoring of comprehensive examinations, and inadequate rigor of thesis defense may exist in some degree programs. The following recommendations should be considered:
- Advisors for the PhD degree should have a track record of sustained research and grantsmanship.
- Advisors and doctoral committees should be approved by a committee with significant membership outside the department or program. Mentoring track record of advisors should be considered in these decisions.
- An independent monitor or independent examination committee should be appointed for the comprehensive preliminary examination.
- Research defense should include a seminar open to all members of the university community.
- Good communication skills among mentors are essential, especially in combined residency/degree programs.
Combined Residency and Degree Programs
The conflicting objectives, divided responsibilities, time constraints, and conflicting demands of combined programs may adversely affect the quality of these programs. In general, parallel programs should be discouraged because of conflicting objectives, divided responsibility, and time constraints. Sequential or separate programs can allow adequate time and focus and thereby promote improved quality training. However, Masters' degree (especially, the nonthesis masters degree option) can be done in parallel with a residency. This can be facilitated if some residency activities (seminars, training experiences, etc.) are given graduate credit.
Combined programs may devalue or diminish DVM, MS, PhD and board certification programs or give the perception thereof. Maintaining the historical value of the earlier degree (DVM) is difficult as credential requirements continue to increase.
- Ambivalence exists within the veterinary profession concerning the equivalence of board certification versus degree programs. What equivalency does board certification have for clinical faculty? What is the value of board certification plus MS or PhD enhancing an academic career or a career in a referral practice?
- Often clinical or applied research is deemphasized or regarded as an inferior experience.
- Combined programs require a critical mass of board-certified faculty and most should also have advanced degrees or significant experience in conducting research.
- Instead of combining a degree program with nondegree clinical training, a "Physician Scientist" approach may be used for promoting research training of students in nondegree programs. It envisages graduates of clinical training programs establishing sponsorships with established researchers in academic institutions, clinical departments or industry. This training may be an efficient mechanism of ensuring high standards in clinical research.
- If a combined program is to be established, minimum recommended combined program requirements could be as follows:
- a) Didactic courses should be reduced to a minimum.
- b) All (or most) clinicians within a program or department should support the program.
- c) The didactic and clinician requirements should be highly structured and carefully mapped out.
- d) An emphasis should be placed on seminars and rounds for which residents may obtain graduate credit.
- e) If two mentors (residency and graduate) are involved, a mechanism must be in place for them to meet regularly to coordinate residents programs.
- f) Residency and degree components of these programs should be evaluated with no less rigor than for separate programs.
The combined programs require a long-term financial commitment (often more than 5 years).
- Combined programs should be securely funded for the appropriate time (at least 5 years for residency/PhD).
- Investigators should be encouraged to pick up stipends for students in such programs sometime during the student's tenure.
- Students, faculty, and departments should be encouraged to apply for fellowships (USDA, NIH, Private).
- Students should be aware of all funding constraints at the beginning of their programs.
There were some topics which were considered by the workshop group that pertained to two or more of the type programs discussed. These topics are presented below with some commentary for each.
Evaluation of background and credentials of incoming students sometimes is difficult, especially for international students when veterinary degrees from different institutions may not be equivalent. Although most residency programs require an internship or practice experience before residency, some students entering the programs are inadequately prepared. Social (animal rights) and financial issues may adversely affect the experience veterinary graduates have before entering residency programs. Only high-quality students should be admitted into a program. Minimal GPA and GRE scores and other appropriate criteria should be established for the admissions process.
Oversupply and Credentials Inflation.
Too many specialists in certain disciplines may be graduating from residency training programs. Do programs have a responsibility to students not to create an oversupply of graduates who cannot be supported by the job marketplace? The job marketplace (supply and demand) cannot be ignored by instructors and programs. A program must add value for the student and make the student more marketable for employment and to enhance his/her professional competence. An oversupply of qualified individuals means more credentials may be needed to become employable, especially at academic institutions.
Inadequate Funding and Support.
Universities and other sponsoring institutions must have the necessary budget, instrumentation, facilities, patients, type of patients, and technology to support the training program either in basic or clinical sciences. The budget should support enough residents or graduate students for the necessary critical mass to optimize instruction.
Difficulty in Defining Competency
Board certification appears to be the only means to define competency legally.