Wednesday, February 8, 2012

Finally, an internist discovers some pitfalls of the ACGME work hours restrictions

In a blog post, noted patient safety expert and hospitalist movement founder Bob Wachter discussed some new realities in resident education as a result of the recent [July, 2011] ratcheting down of resident work hours by the Accreditation Council for Graduate Medical Education [ACGME]. While applauding the more humane conditions under which residents now labor, he noticed disturbing changes in the way residents are being trained. The issues he raised have been well-known to surgical educators since the institution of the 80-hour work week in 2003.

He unknowingly agreed with something I wrote recently about today’s residents lacking opportunities to function independently, which leads them to worry about their competence after graduation. Wachter wrote: “Learning from one’s mistakes is fundamentally unethical when you have a human life in your hands. But an environment in which the housestaff are trained to read the attending’s body language before making a tough call can’t be right either, particularly when our third-year residents morph from resident to attending on June 30th each year.”

Continuity of care is another issue. Wachter: “A second worry is the relative dearth of patients being followed by a single resident from admission to denouement. Our teams inherited nearly half their patients as handoffs from night admitters.”

He stated the problem very well. “So many emergency admissions traverse a trajectory in which an early assessment is followed by a period of data gathering (tests, consults), followed by an initial patient response, which is evaluated in context. In a system in which half the patients are cared for by two sets of doctors during these crucial stages, neither group fully sees this arc play out, and their education suffers.”

And regarding hand-offs. “While some trainees forced themselves to rethink their patients’ problems and actively ward off anchoring bias, others didn’t, accepting what they were told as gospel and never coming to know the handed-off patients as well as those they admitted themselves.” This happens a lot more often than most people think.

He wondered how this fragmentation of care could be ameliorated but did not offer any solutions. Fragmentation of care during resident training will at least prepare internal medicine residents to become hospitalists, since lack of continuity permeates most hospitalist services that I am aware of.

Wachter has also just noticed that formal educational conferences are another casualty of the time limitations. He said: “The other thing that worries me about the new schedules is the palpably limited time available for education. In the 16 days I spent as attending in January, I recall only two in which the entire team was available for our traditional hour-long teaching rounds.” Bob, this has been a significant problem since 2003. It didn’t start last July. There is no such thing as an afternoon educational conference any more.

It’s nice to know that someone else is at least concerned about this. Neither Wachter nor I have any answers. I will just echo what many doctors of my generation are saying. We hope we still can figure out who the good MDs are by the time we need care for ourselves.

Thanks to Susan Carr for tweeting a link to Dr. Wachter’s blog.

4 comments:

RobertL39 said...

You and Dr. Wachter aren't really trying to tell us that something besides data matters, are you? The Health Informatics people seem to think that working with the computer is far more important than working with the patient. We get LOTS of education in that, I guess to take the place of those silly afternoon teaching conferences. And it ain't getting better soon.

Chris Porter MD said...

Let's move to competency-based advancement and let the residents teach us how they learn best. I'm totally unconvinced the system we learned in was any good - varying from it doesn't worry me at all.

Skeptical Scalpel said...

RobertL39:

Thanks. As long as it's documented, it's Ok.

Chris:

ACGME agrees with you. My concern is that the numbers of residents in programs will be hard to manage when people are held back. I foresee chaos.

Chris Porter MD said...

Indeed the resident numbers will be weird. Imagine a cluster who all finish early!

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