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The education and training of future physicians: why coaches can't be judges.

A PHYSICIAN MUST BE ABLE TO DIAGNOSE AND TREAT patients. The clinical skills required to be successful include gathering data, differentiating important from unimportant facts, making decisions about further investigations and treatments, implementing therapy, and providing follow-up, education, and counseling. These skills cannot be learned through reading or in classrooms alone; practical experience is required. The present method of exposing physicians-intraining to practical experience involves a hierarchical team approach with graded levels of responsibility whereby the decisions of the most junior members of the team are reviewed by physicians with more experience and seniority. These practical experiences impart content knowledge and also allow trainees to become comfortable with decision making and to learn the consequences of these decisions. Although there may be better ways to train future physicians, this apprenticeship method seems to work, as evidenced by the relatively low failure rate in medical schools and training programs. Part of the apprenticeship experience also includes having members at higher levels of the hierarchy evaluate those at lower levels. As such, the supervising individuals are both coaches (instructing and assisting trainees in improving their clinical skills) and judges (responsible for performance assessment of the same trainees). In this Commentary we discuss some of the problems created by this dual role and offer potential solutions.