By: Michael S. Ryan, MD, MEHP
Story #1
I leapt out of my twin call room bed to the terrifying but increasingly familiar sound of my bulky plastic pager with its dim, green, backlit screen. It was hour 22 of my first night on call as an intern. The sound woke me from a 30-minute nap, the first of my 30-hour day. The clock read 4:51am. The pager read:
“Bed #47, 7.32/52/75/32.”a
It was a capillary blood gas result. The result was obtained from one of 60+ babies I was responsible for in the neonatal ICU (NICU). Though not stated, the question was, “do you want to do anything with this baby’s ventilator settings?” Before I had a chance to respond, another came through. And then another…
I learned to dread the 4:30-5:30am hour in the NICU. Turns out, all the ventilated babies get their blood gases drawn at that time. And my job, as an intern, was to determine what to do with those results. In my cumulative 22 hours of experience, I learned I had 4 options – mess with the pressure (or volume), the rate, the oxygen, or do nothing. I could ask for help, sure. There was a senior resident sleeping in another call room and a fellow down the hall from her. But, the first call came to me. A 20-something one month removed from a gruelingb fourth year of medical school.
I became competent(ish) in some basics the night before and felt comfortable letting my bosses sleep while I communicated plans to the nurses. When the “night” ended at 1pm, I went home, ate 5 bowls of Fruit Loops, and went to bed. I felt better about managing vents and interpreting blood gases, but something about the situation bothered me in a way I couldn’t yet express.
Story #2
Fast forward one year. Same time of day,different hospital. Just a third-year resident and I overnight, responsible for 45 hospitalized children with chronic needs. It was an easy call because “nothing happens there overnight.”
So, of course, at 4am, I was promptly paged to the bedside of an ex-preemie.
“Bed #40, can you please come, patient is tachycardic and febrile”
I didn’t understand the urgency until I got there. We have lots of tachycardic and febrile children, that’s like 90% of Pediatrics. Turns out, the child was in (barely) compensated hypovolemic shock. I tried to get an IV but couldn’t. And then we started losing our pulse ox readings.
Uh oh…
The child was rapidly decompensating. Before I knew it, the senior resident was in the room. The senior recognized the urgency, and together, we placed an intraosseous needle into the child’s tibia, started CPR, and transferred the child to the main Children’s Hospital for ICU-level care.
Unfortunately, the result for this child was not a good one.
I learned about the outcome in the middle of rounds later that morning. After I finished signing out my patients, I couldn’t sleep. So, I drove back to the main hospital, second-guessing myself and searching for answers.
****
I like to think I graduated from a good medical school.
I passed my boards on the first try and finished right smack in the middle of my class. I learned how to take histories and perform physicals. I learned how to interpret blood gases and chest x-rays. I wrote notes, and, sometimes, my attendings even read them. I also completed a pediatric ICU rotation in my fourth year. They let me carry a pager and everything.c
But the transition to residency was rough. And the stories above bothered me in ways I couldn’t articulate for several years.
Fast forward to 2013. I had just become the clinical curriculum dean at Virginia Commonwealth University School of Medicine. I inherited our fourth year “Capstone,” the final course to prepare medical students for internship. Truthfully, the students didn’t want to be there. The 3-week course got in the way of everything else. I understood it. But, at the same time, I knew this transition was critical. I was trying to think of how to share the importance of these sessions on order entry, prescription writing, teamwork, and communication in some way that would resonate.
Finally, I decided to just confront the issue directly. I started the course with one slide. The slide read, “why are you here?” I left that up for 5-10 minutes. Once everyone was there and moderately curious, I told them the second story I just shared with you. Then, I explained what I learned, what I wished I knew, and how I was hoping they would be in a better position when they became interns. I am not sure if it worked, but no one asked me why they were there.
I hadn’t yet heard the term “competency-based education (CBE),” but the idea of improving the preparation of our graduates just made sense. It apparently also made sense to people in bigger positions than I.
Later that year, I learned that Bob Englander and the American Association of Medical Colleges (AAMC) were interested in the same concept, acknowledging, through the Core Entrustable Professional Activities (EPAs), the need to “define the professional activities that every resident should be able to do without direct supervision on day one of residency,”1 I now had a word to describe the things interns needed to do… “EPA.” I also recognized that this was not a “me issue.”
EPAs provided the framing I had been looking for when trying to conduct a needs assessment to describe the medical school and residency gap.2 The idea of joining others who cared the same issues led to my participation in the AAMC’s Core EPA pilot3 and, more recently, my decision to pursue a PhD centered on competency decisions in medical school.
Over the past two years, I had the pleasure of interviewing CBME leaders across 7 US medical schools for one of my PhD studies. They all designed competency committees without any mandate from an accreditor. So, my research question was essentially, “why did you do it?” And, they all described, unequivocally, a desire to train a better doctor…So, that’s the title of our paper, “It’s about better doctors,” 4 because it describes their “why.”
And, it conveniently summarizes my “why,” too. We can get caught up in issues with CBE, and CBE has issues. If you don’t believe me, get in front of a group of medical students and tell them they need to complete x number of workplace-based assessments. It doesn’t go over well. But, those are “how” issues; they’re not “why” issues.
The bottom line is, the “why” matters. Our personal stories, the stories of our patients, and the stories of our trainees are reasons to pursue CBE with passion. It’s also our source of resilience when we are faced with adversity. CBE is accountability. CBE is better supervision, not more supervision. And, fundamentally, it’s about doing better for our patients and our trainees.
****
Footnotes
- a – These are made up numbers.
- b- To clarify, the second half of my 4th year largely involved attending White Sox games, hanging out with friends, playing poker and basketball.
- c – I said carry a pager. I don’t think anyone ever called it.
About the Author:
Michael S. Ryan, MD, MEHP is Professor of Pediatrics, Associate Dean for Assessment, Evaluation, and Scholarship, and Director of the Center for Excellence in Education at the University of Virginia. He works clinically as a pediatric hospitalist at UVA and spends his non-clinical time focusing on developing better systems of assessment and conducting research related to competency decisions in medical school.
References
- Englander R, Flynn T, Call S, Carraccio C, Cleary L, Fulton TB, et al. Toward Defining the Foundation of the MD Degree: Core Entrustable Professional Activities for Entering Residency. Acad Med. 2016 Oct;91(10):1352-1358.
- Ryan MS, Lockeman K, Feldman M, Dow A. The gap between current and ideal approaches to the Core EPAs: A mixed methods study of recent medical school graduates. Med Sci Educ. 2016; 26: 463-473.
- Lomis K, Amiel JM, Ryan, MS, Esposito K, Green M, Stagnaro-Green A, et al. Implementing an entrustable professional activities framework in undergraduate medical education: early lessons from the AAMC core entrustable professional activities for entering residency pilot. Acad Med. 2017; 92: 765-770.
- Ryan MS, Teunissen P, Santen SA, Emke A, Jones RL, Kelleher M, Parsons A, Jolani S, Vinson A. “It’s about better doctors:” A multi-institutional ethnography exploring the purpose, structure, and function of competency committees in medical school. Oral presentation at International Competency-Based Education Summit (Basel Switzerland, 2024). Manuscript currently under review for publication. 2025
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