Clinical Informatics at the Graduate Medical Education Level
Domains of clinical informatics (CI)—such as telemedicine,[1] large language models,[2] and artificial intelligence (AI)[3]—have touched the lives of medical trainees in recent years. Now more than ever, it is crucial to unlock the potential of CI-related education in undergraduate medical education (UME)[4]
[5]
[6]
[7]
[8]
[9]
[10] and graduate medical education (GME). Prior literature regarding medical students suggests that there is interest in CI but a lack of clarity around opportunities for CI training, mentorship, and careers.[11] Recent literature has highlighted guidelines for standardizing CI education at the UME level[7] and fundamentals for CI curricula for medical schools including AI and data management.[10] CI departments have created combined UME and GME[12] initiatives as well as specific hospital-wide programs for residents and fellows across all specialties.[13] Individual programs in internal medicine,[14] pediatrics,[15] emergency medicine,[16]
[17] and psychiatry[18] have been described.
At least three decades ago, educators were incorporating CI content into residency education (Norwalk Hospital created CI curricula for residents in 1992).[19] The Association of American Medical Colleges (AAMC) first issued a report on informatics and population health in medical school curricula with suggested learning objectives in 1998.[20] The American Academy of Family Physicians first published informatics curricula guidelines in 1996, most recently updated in 2016,[21] although these are distinct from the Accreditation Council for Graduate Medical Education (ACGME) requirements, which do not explicitly include CI content for family medicine residents.[22]
Radiology and pathology educators have addressed the CI gap in GME in their respective specialties. Notably, in 2016, multiple pathology associations including the College of American Pathologists, Association of Pathology Chairs, and Association for Pathology Informatics came together to publish pathology informatics curricula, called Pathology Informatics Essentials for Residents (PIER), tied to ACGME program requirements.[23] Radiologists have called for expanded education in AI and curricula in key areas such as imaging informatics.[24]
[25]
Four major clinical specialties—internal medicine, pediatrics, family medicine, and emergency medicine—represent almost three quarters of subspecialists boarded in CI[26] and 60% of CI fellowship graduates.[27] These specialties are critical in training future board-certified CI physicians and physicians with CI skills. All of these specialties cite “using information technology (IT) to optimize learning” as an ACGME competency and include quality improvement, population health, and social determinants of health as aspects of the ACGME competencies.[22]
[28]
[29]
[30] ACGME emergency medicine milestones include “using technology to accomplish and document safe health care delivery” and “using IT to improve patient care”;[28] ACGME internal medicine program requirements state that residents should be able to “[apply] technology appropriate for the clinical context, including evolving techniques,” use telemedicine, use population-based data;[29] and ACGME family medicine milestones include patient care with “telephone visits” and “evisits.”[22] ACGME and AAMC have published telehealth competencies and milestones, which are being adopted nationwide.[31] These competencies address components of CI education but stop short of a comprehensive approach to CI integration into residency curricula.
Educational efforts in CI have implications for the CI workforce pipeline. Early exposure to CI can spark interest in CI careers and enhance trainees' knowledge around CI. Early exposure during medical school has correlated with career choice in primary care,[32] radiology,[33] and surgery.[34] Work in biomedical informatics has emphasized the importance of exposure to informatics opportunities as early as high school in engaging underrepresented minorities and women in future careers in biomedical informatics.[35] Specialized residency tracks in areas such as hospitalist medicine,[36] leadership,[37] and clinical education[38] have helped to build skills and influence career decisions including pursuit of leadership positions. Compared with earlier stages of medical training, residents possess practical clinical experience to inform use and understanding of informatics tools and often serve as “frontline” users for many clinical workflows. Resident engagement in hospital IT systems has been shown to have institutional impact beyond direct impact on residents and increasing resident interest in CI careers.[6] It is especially crucial to quantify CI education at the residency level, as it has implications for the diversity of the CI workforce. CI fellowship applicant data suggest significant gaps between genders and races[39]
[40]
[41] with similar gaps in CI fellowship graduates.[27] Surveying residents who have completed CI curricula may provide perspectives on creating a more diverse, learner-friendly environment.
Current State of Clinical Informatics Curricula in Residency Programs
To assess the extent of CI curricula at the residency level, a comprehensive landscape survey is challenging due to the numerous residency specialties with potential CI curricula. Few CI education curricula are documented in formal journal articles, and web presence may be limited as electives and pathways are not necessarily publicly advertised on a residency or hospital website. Searching AAMC's MedEd Portal, a popular repository for medical education curricular innovations in July 2023 did not return any relevant results, using keywords “informatics,” “informatics residency,” “clinical informatics,” “informatics track,” “informatics elective,” and “informatics curriculum.” In the Journal of Graduate Medical Education, the search term “informatics” returned one relevant article about the impact of the electronic health record in GME (although not about informatics curricula broadly)[42] and one article about pathology informatics milestones; “informatics track,” “informatics elective,” “informatics pathway,” “informatics curriculum,” and “clinical informatics” did not return any relevant results.
We performed a web search of U.S.-based CI curricula in residency such as electives and pathways and subsequent survey of CI residency educators through a national email mailing list of internal medicine residency program directors and advertisement at CI-related conferences. We focused on U.S.-based residency programs given heterogeneity in training across countries and differences in availability of CI board certification outside of the United States,[43] although physician training in CI and biomedical informatics exists in Europe,[44]
[45] Australia,[46] and Latin America.[47] We observed a variety of CI curricula ranging from generalized CI curricula to electives and pathways with resident participants going on to careers in CI or incorporating CI into their clinical careers. Educators noted challenges including time commitment or interest from clinical residency and informatics leadership, CI curricula competing with other program requirements, and resident interest in CI, mirroring early challenges in sustaining CI fellowship programs.[48]
Need for Clinical Informatics Guidelines and Measurement of Impact
A more centralized approach to data collection on CI residency education may heighten awareness of CI education for residents and educators and ultimately galvanize CI educational innovation in multiple specialties. Centralized efforts may include the ACGME guidelines around CI education or specialty-specific measurement of CI education impact.
Educational policy changes or guidance can be invaluable and highly influential in shaping the direction of CI residency training. However, such changes often are a long-term, multidisciplinary effort that require multiple stakeholders, such as clinical informaticists, medical education specialists, and residency program leadership regardless of clinical specialty. Expanding on existing ACGME guidelines may allow residency educators and program directors to rally resources in support of CI residency training pathways; for example, the current guidelines for internal medicine residency programs provide open-ended recommendations for “emerging technologies,”[29] which may include informatics applications and competencies. More generally, systems-based practice, as one of the six ACGME core competencies, may offer some room for incorporating CI into routine health care delivery and practice for residents. The limit of CI educational resources is similar to challenges faced in fields with a limited supply of specialists but immense demand, such as geriatrics and palliative medicine; specialists in these fields have proposed a dual model in which generalists are trained in the basic skills of the specialty, and specialists are trained to provide care to more complex patients.[49] CI curricula could similarly include general CI curricula (with opportunities for in-depth CI experience with electives or pathways) and specialization through ACGME CI fellowships. Guidelines for general CI curricula or more detailed instructional resources similar to the pathology informatics curriculum PIER[23] could help advance standardization of this dual generalist specialization approach.
In conclusion, CI and GME stand at a crucial juncture for empowering the physician workforce at a time of rapidly evolving technology. Equipping physicians with CI skills will enrich their careers and lead to more clinically driven input into emerging technologies. One of the first steps to advancing CI curricula at the residency level is to establish standardized means of data collection through the ACGME or other specialty societies, which will then enable measurement of trends in CI curricula and highlight areas for growth. Metrics and guidelines will pave the way for stronger curricula and physicians who are able to take on the challenges of these dynamic times.
Clinical Relevance Statement
This commentary discusses informatics education of resident physicians in the context of preparing trainees to apply CI to patient care and clinical practice.
