Monday, August 2, 2010

Medical Education Is Changing in a Bad Way and It Will Affect You!

As a former surgical residency program director for more than 23 years, I must comment on the proposed changes in the way physicians, particularly surgeons, are trained. Some history. In 1984, an unfortunate young woman died at a prestigious hospital in New York. The case was followed closely by the media. Several important issues relevant to her death were under-reported. She had taken illicit drugs on the night of her death and she withheld this fact from her doctors. Because of this, she had a reaction to sedation that was administer which led to her death.

There was a suggestion that the residents may not have been properly supervised. The residents who treated her had been on duty for UNDER 24 HOURS. Her father, a reporter for the New York Times, started a crusade against what was perceived to be the main cause of her death, doctors-in-training working long hours.

This case resulted in the creation of the Bell Commission which formulated regulations limiting doctors-in-training in New York State to a maximum of 24 hours of work per shift and 80 hours per week. [Note to any non-physicians reading this: being on-call for 24 hours straight does not mean that one is necessarily always awake for all 24 hours.]

Several years later, the national organization that governs medical resident training, the Accreditation Council for Graduate Medical Education (ACGME), adopted similar rules. The ACGME has now decided to ratchet down the hours for first year trainees to a maximum of 16 hours per day with a mandatory 10 hour rest period thereafter.

It is amazing to realize that in the so-called era of evidence-based medicine, none of the current or proposed work hours rules are based on any solid evidence that tired doctors are harming patients or that limiting hours worked will lead to better patient outcomes. In fact, Bertrand Bell, head of the commission that first limited resident work hours, admitted that the limit of 80 hours was based on no data, but rather just seemed like a good number.

Here is what Dr. Bell said in a letter to the Journal of the American Medical Association in 2007, “The specific “80-hour week” was actually determined by a colleague ON MY PORCH [my emphasis added] and was based on the following informal reasoning: (1) there are 168 hours in a week; (2) it is reasonable for residents to work a 10-hour day for 5 days a week; (3) it is humane for people to work every fourth night; (4) subtracting the 50-hour week (10 hours per day × 5 days) from 168 hours leaves 118 hours; (5) divide 118 by 4 (every fourth night) and add to the 50 hours and, eureka, that equals an 80-hour week.” How’s that for evidence? I particularly like “… eureka, that equals an 80-hour week.”

There is good evidence that limiting work hours can be detrimental to surgical resident education and possibly to patient care due to a lack of continuity and frequent “handoffs” of patient care. Certainly, there are no studies proving that patient outcomes are better since the initial work hours changes went into effect and there are several that show it has made no difference. Don Nakayama, a surgical program director in Georgia, pointed out an unintended consequence of the rules that has occurred as supervision was increased as well.

He said, “The unanticipated problem is one of excessive supervision of residents at all levels where residents never have the experience with practicing independently.” This has led to a feeling among graduating residents that they must take further fellowship training because as Nakayama put it, they “…feel unsure and avoid going into independent surgical practice right out of training. The effects (of excessive supervision) aren't going to be seen until the pre-duty hour, pre-malpractice crisis, pre-health care crisis generation retires.”

A program director who wanted to remain anonymous said, “Where is the response from organized medicine on this (the work hours rules)?” Another program director asked, “How can a first year resident advance to the second year and supervise next year’s first year residents if he/she has never even worked a 24 hour shift?”

What about the projected shortage of general surgeons within the next few years? A decline in the number of general surgeons per capita already exists. If restricting work hours leads to a lengthening of surgical residency training, how will the future need for surgeons be met? How can surgery training be lengthened from what is now 5 years in the face of massive debt for college and medical school tuition incurred by most residents? Absent the first year residents in the wee hours, who is going to pay for physician extenders to help care for patients? Well, I can only think of these questions, not answer them. Maybe someone else has an idea.


Anonymous said...

Yep, you guys in Med So-Called Education always singin the same ol tune...

Face it: Residency, especially in your discipline surgery, is indentured servitude. Things have changed since the old days, when staff guys listened to histories mostly for billable procedures, but not much.

If you can train an average person to be a combat soldier in 18mos, the brightest should be able to learn General Surgery in 4 years...but it never was about education, it was about service and staff guys billings.

I like your blog but you are wrong on this.

Skeptical Scalpel said...

Thanks for commenting. I'm not sure what you mean by "Things have changed since the old days, when staff guys listened to histories mostly for billable procedures, but not much."

I'd say there's a big difference between a combat soldier who does nothing but what he is told and a surgeon.

Perhaps some could learn general surgery in 4 years, but if you look at some of my recent posts on this, you will note that many can't do it in 5. And this is the era of the 16-hour day.

Teresa Chan said...

Are all hours in a 16 hour day actually learning hours? How much of it is useless clerical work? How much of it is pure clinical decision making? I think there are ways we can short cut learning and be more efficient with the process?

That said, I work in Emergency Medicine where our learners have always worked less that the staff physicians (on average), and they are an added bonus rather than mandatory-help. My ED does not stand still without a learner (I see roughly the same number of pts with or without learners, I've kept my own metrics). And I am not dependent on my learners to run the department. This is in contrast, of course, to many in patient services where the resident to staff ratio is not 1:2 or 1:3. One of my friends asked rhetorical question one time: If you need 6 residents for your team, and can't handle the volume if they're away at academic day, are you really able to handle that volume??

All in all, I still think, though, that often ward medicine and in-patient medicine is highly inefficient for learning. And a LOT of the time spent in the previous 16 hour days was unnecesary and unhelpful for learning. Yes, occasionally, there would be a great case that MIGHT happen... But I have learned during my EM training that you can't 'will' great cases to happen! You certainly can't sleep in the ED waiting for a great case either. (I would have lived for 4 straight years in the ED before another thoracotomy... Luckily, I happened to be working the day we did a double-one).

So I would posit that if time was the ONLY metric for learning, then yes, you might be right regarding work hours and their impact on surgical learners.

Deliberate practice theory suggests that you can get better by practicing... deliberately! And if we can find the right technologies or spheres where your learners can 'practice' (whether that be simulation lab or serious games, etc..), maybe there is a light at the end of the tunnel.

You will note that North of the Border, a hard number did not wind up in our national consensus statement ( Even our provincial housestaff organization in Ontario (PARO) has taken the stance against sleep deprivation, but has acknowledge the tension between quality learning and work hours.

That said, as educators we need to rise to the occasion. A recent TED talk highlighted the importance of scarcity in spurring creativity.

Yes, they were talking about scarcity of money... but ANY resource can be scarce. And in medicine, for better or for worse... Time is going to be the resource that is scarce.

We need to find our creativity and think about how we flourish under the conditions. Most MDs are survivors and fighters, and I think that we will find our creative selves to overcome the perceived obstacles. I feel we have to believe we can innovate before we actually can get out there!!

We have to be more efficient about the time spent learning and working... And as educators we need to actually be thoughtful and mindful of all the competing interests that residents may have at work (in the OR, on the wards, in the ED, prepping for exams, doing research).

Can we rise to the occasion? It seems like such a tall order, I fear too many people are giving up before they even try!


Skeptical Scalpel said...

Teresa, thanks for the interesting and thoughtful comments. We already know from at least 3 different papers that ward residents spend about 12% of their time taking care of patients. It would be interesting to see what that % is for ED residents.

In June, I heard Richard Reznick of Kingston, Ontario speak. He is revamping medical education in Canada. They will be going to competence-based training in a few years. I blogged about that concept back in June ( It will be interesting to see if it works.

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