A Call to Support Informatics Curricula in U.S.-Based Residency Education

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.

Conflict of Interest

None declared.

Acknowledgments

None.

Protection of Human and Animal Subjects

Participation was voluntary and does not pose undue risk. This was a remote unmoderated study and was fully implemented in Qualtrics. The study protocol was reviewed and approved by the Boston University Medical Campus/Boston Medical Center Institutional Review Board (H-42611: “Evaluation of Clinical Informatics Residency-Level Training”).

• References

• 1 Jumreornvong O, Yang E, Race J, Appel J. Telemedicine and medical education in the age of COVID-19. Acad Med 2020; 95 (12) 1838-1843
• 2 Singhal K, Azizi S, Tu T. et al. Large language models encode clinical knowledge. Nature 2023; 620 (7972): 172-180
• 3 Haug CJ, Drazen JM. Artificial intelligence and machine learning in clinical medicine, 2023. N Engl J Med 2023; 388 (13) 1201-1208
• 4 Hersh WR, Gorman PN, Biagioli FE, Mohan V, Gold JA, Mejicano GC. Beyond information retrieval and electronic health record use: competencies in clinical informatics for medical education. Adv Med Educ Pract 2014; 5 (null): 205-212
• 5 Hersh W, Biagioli F, Scholl G. et al. Chapter 13 - From competencies to competence: model, approach, and lessons learned from implementing a clinical informatics curriculum for medical students. In: Shachak A, Borycki EM, Reis SP. eds. Health Professionals' Education in the Age of Clinical Information Systems, Mobile Computing and Social Networks. Academic Press; 2017: 269-287
• 6 Quach WT, Le CH, Clark MG. et al. Engaging the next generation of physician-informaticians through early exposure to the field: successes and challenges associated with starting a novel clinical informatics interest group. J Am Med Inform Assoc 2022; 30 (01) 202-205
• 7 Chartash D, Rosenman M, Wang K, Chen E. Informatics in undergraduate medical education: analysis of competency frameworks and practices across North America. JMIR Med Educ 2022; 8 (03) e39794
• 8 Wang JJ, Singh RK, Miselis HH, Stapleton SN. Technology literacy in undergraduate medical education: review and survey of the US medical school innovation and technology programs. JMIR Med Educ 2022; 8 (01) e32183
• 9 Hare AJ, Soegaard Ballester JM, Gabriel PE, Adusumalli S, Hanson III CW. Training digital natives to transform healthcare: a 5-tiered approach for integrating clinical informatics into undergraduate medical education. J Am Med Inform Assoc 2022; 30 (01) 139-143
• 10 Zainal H, Tan JK, Xiaohui X, Thumboo J, Yong FK. Clinical informatics training in medical school education curricula: a scoping review. J Am Med Inform Assoc 2023; 30 (03) 604-616
• 11 Banerjee R, George P, Priebe C, Alper E. Medical student awareness of and interest in clinical informatics. J Am Med Inform Assoc 2015; 22 (e1): e42-e47
• 12 Mize DE, Osterman TJ. A unified approach to clinical informatics education for undergraduate and graduate medical education. AMIA Annu Symp Proc 2023; 2022: 766-774
• 13 Singer JS, Cheng EM, Baldwin K, Pfeffer MA. UCLA Health Physician Informaticist Committee. The UCLA health resident informaticist program - a novel clinical informatics training program. J Am Med Inform Assoc 2017; 24 (04) 832-840
• 14 Kohn MS, Topaloglu U, Kirkendall ES, Dharod A, Wells BJ, Gurcan M. Creating learning health systems and the emerging role of biomedical informatics. Learn Health Syst 2021; 6 (01) e10259
• 15 Mai MV, Luo BT, Orenstein EW, Luberti AA. A model for clinical informatics education for residents: addressing an unmet need. Appl Clin Inform 2018; 9 (02) 261-267
• 16 Turer RW, Arribas M, Balgord SM. et al. Clinical informatics training during emergency medicine residency: the University of Michigan experience. AEM Educ Train 2020; 5 (03) e10518
• 17 Baker CK, Maniam N, Schnapp BH. et al. A model curriculum for an emergency medicine residency rotation in clinical informatics. J Educ Teach Emerg Med 2022; 7 (04) C1-C50
• 18 Vitiello E, Kane M, Hutto A, Hall A. Building for the future: the creation of a residency training track to foster innovation through clinical informatics in psychiatry. J Am Med Inform Assoc 2020; 27 (11) 1747-1751
• 19 Moidu K, Leehy MA, Steinberg I. et al. Informatics integration in a medical residency program: early experiences. Proc Conf Am Med Inform Assoc AMIA Fall Symp 1996; 55-59
• 20 Contemporary issues in medicine–medical informatics and population health: report II of the Medical School Objectives Project. Acad Med 1999; 74 (02) 130-141
• 21 American Academy of Family Physicians. AAFP Reprint No. 288: Recommended curriculum guidelines for family medicine residents - Medical Informatics; 2019. Accessed July 24, 2023 at: https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint288_Informatics.pdf
• 22 Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Family Medicine.; 2023. Accessed July 24, 2023 at: https://www.acgme.org/globalassets/pfassets/programrequirements/120_familymedicine_2023.pdf
• 23 Henricks WH, Karcher DS, Harrison Jr JHJ. et al. Pathology informatics essentials for residents: a flexible informatics curriculum linked to Accreditation Council for Graduate Medical Education milestones. Arch Pathol Lab Med 2017; 141 (01) 113-124
• 24 Forney MC, McBride AF. Artificial intelligence in radiology residency training. Semin Musculoskelet Radiol 2020; 24 (01) 74-80
• 25 Balthazar P, Harri P, Prater A, Heilbrun ME, Mullins ME, Safdar N. Development and implementation of an integrated imaging informatics track for radiology residents: our 3-year experience. Acad Radiol 2022; 29 (Suppl. 05) S58-S64
• 26 Desai S, Mostaghimi A, Nambudiri VE. Clinical informatics subspecialists: characterizing a novel evolving workforce. J Am Med Inform Assoc 2020; 27 (11) 1711-1715
• 27 Kim E, Van Cain M, Hron J. Survey of clinical informatics fellows graduating 2016-2024: experiences before and during fellowship. J Am Med Inform Assoc 2023; 30 (10) 1608-1613
• 28 Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Emergency Medicine. 2023. Accessed July 24, 2023 at: https://www.acgme.org/globalassets/pfassets/programrequirements/110_emergencymedicine_2023.pdf
• 29 Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Internal Medicine. 2023. Accessed July 24, 2023 at: https://www.acgme.org/globalassets/pfassets/programrequirements/140_internalmedicine_2023.pdf
• 30 Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Pediatrics. 2022. https://www.acgme.org/globalassets/pfassets/programrequirements/320_pediatrics_2023.pdf
• 31 Noronha C, Lo MC, Nikiforova T. et al; Society of General Internal Medicine (SGIM) Education Committee. Telehealth competencies in medical education: new frontiers in faculty development and learner assessments. J Gen Intern Med 2022; 37 (12) 3168-3173
• 32 Bland CJ, Meurer LN, Maldonado G. Determinants of primary care specialty choice: a non-statistical meta-analysis of the literature. Acad Med 1995; 70 (07) 620-641
• 33 Donnelly LF, Racadio JM, Strife JL. Exposure of first-year medical students to a pediatric radiology research program: is there an influence on career choice?. Pediatr Radiol 2007; 37 (09) 876-878
• 34 Haggerty KA, Beaty CA, George TJ, Arnaoutakis GJ, Baumgartner WA. Increased exposure improves recruitment: early results of a program designed to attract medical students into surgical careers. Ann Thorac Surg 2014; 97 (06) 2111-2114 , discussion 2114
• 35 Bright TJ, Williams KS, Rajamani S. et al. Making the case for workforce diversity in biomedical informatics to help achieve equity-centered care: a look at the AMIA First Look Program. J Am Med Inform Assoc 2021; 29 (01) 171-175
• 36 Sweigart JR, Tad-Y D, Kneeland P, Williams MV, Glasheen JJ. Hospital medicine resident training tracks: developing the hospital medicine pipeline. J Hosp Med 2017; 12 (03) 173-176
• 37 Kuo AK, Thyne SM, Chen HC, West DC, Kamei RK. An innovative residency program designed to develop leaders to improve the health of children. Acad Med 2010; 85 (10) 1603-1608
• 38 Daaboul Y, Lin A, Vitale K, Snydman LK. Current status of clinician-educator tracks in internal medicine residency programmes. Postgrad Med J 2021; 97 (1143): 29-33
• 39 Bell DS, Baldwin K, Bell III EJ. et al. Characteristics of the national applicant pool for clinical informatics fellowships (2016-2017). AMIA Annu Symp Proc 2018; 2018: 225-231
• 40 Wiley K, Dixon BE, Grannis SJ, Menachemi N. Underrepresented racial minorities in biomedical informatics doctoral programs: graduation trends and academic placement (2002-2017). J Am Med Inform Assoc 2020; 27 (11) 1641-1647
• 41 Griffin AC, Leung TI, Tenenbaum JD, Chung AE. Gender representation in U.S. biomedical informatics leadership and recognition. J Am Med Inform Assoc 2021; 28 (06) 1270-1274
• 42 Atwater AR, Rudd M, Brown A. et al. Developing teaching strategies in the EHR era: a survey of GME experts. J Grad Med Educ 2016; 8 (04) 581-586
• 43 Gundlapalli AV, Gundlapalli AV, Greaves WW. et al. Clinical informatics board specialty certification for physicians: a global view. Stud Health Technol Inform 2015; 216: 501-505
• 44 Kolokathi A, Hasman A, Chronaki C. et al. Education in biomedical and health informatics: a European perspective. Stud Health Technol Inform 2019; 264: 1951-1952
• 45 Costa PD, Almeida J, Araujo SM. et al. Biomedical and health informatics teaching in Portugal: current status. Heliyon 2023; 9 (03) e14163
• 46 Gray K, Sim J. Factors in the development of clinical informatics competence in early career health sciences professionals in Australia: a qualitative study. Adv Health Sci Educ Theory Pract 2011; 16 (01) 31-46
• 47 de Quirós FGB, Analía B, Lira A. Active participation and engagement of residents in clinical informatics. Appl Clin Inform 2019; 10 (01) 038-039
• 48 Longhurst CA, Pageler NM, Palma JP. et al. Early experiences of accredited clinical informatics fellowships. J Am Med Inform Assoc 2016; 23 (04) 829-834
• 49 Quill TE, Abernethy AP. Generalist plus specialist palliative care–creating a more sustainable model. N Engl J Med 2013; 368 (13) 1173-1175

Publication History

Received: 17 May 2023

Accepted: 23 October 2023

Accepted Manuscript online:
25 October 2023

Article published online:
20 December 2023