Monday, September 16, 2013

Three more papers document the decline of resident education

A study of traditional every fourth night call compared to staggered shifts of every fifth night call or "night float" appeared in JAMA Internal Medicine.

Although interns working on the "night float" and every fifth night shifts got significantly more sleep than the control group of interns working longer shifts every fourth night, "both the every fifth night and night float  models increased hand-offs, decreased availability for teaching conferences, and reduced intern presence during daytime work hours. Residents and nurses in both experimental models perceived reduced quality of care, so much so with night float that it was terminated early."

A JAMA Surgery paper surveyed 213 surgical interns from 11 university hospitals in July of 2011 and May of 2012. This was the first academic year that the new 16-hour limit was in force.

Although 82% of the interns reported a neutral or good quality of life, more than a quarter of them had symptoms of emotional exhaustion and depersonalization and 32% said their work-life balance was poor. Two-thirds said they thought about their satisfaction with being a surgeon daily or weekly and 14% said they considered dropping out of surgery training at least weekly.

Over half of the residents said that the work hours changes had decreased their time spent in the operating room, and at the end of their intern year, 44% said they did not believe that the work hours limits led to reduced fatigue.

So in both medicine and surgery, the 16-hour work restriction has resulted in unintended consequences.

As if that is not bad enough, check out this blockbuster. The title of a paper in Annals of Surgery this month is "General Surgery Residency Inadequately Prepares Trainees for Fellowship: Results of a North American Survey of Program Directors."

General surgery subspecialty fellowship directors were surveyed and 91 (63%) responded.

From the abstract: "21% [of fellowship program directors] felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications." [Emphasis added]
Note that the residents in the Annals paper had not yet been subjected to the 16-hour work limits as that rule was not in effect when they were first-year trainees.

The good news is that by the end of their fellowship training, 82% could perform advanced cases independently. There was no word on the fate of the 18% who could not perform advanced cases independently.

Now that's reassuring, isn't it?


Anonymous said...

So, my question is whose fault is it? I've read reasons from work hour regulations being the culprit, to the residents themselves who are of a lazy generation etc. But, I think that maybe its also the residency programs and/or the faculty that suck. I'm probably alone in my thinking, but the way I see it, if a residency program graduates resident who can't operate, or treat patients then that is a reflection of the program and the quality of educators/faculty that make up that program.

Skeptical Scalpel said...

Anon, you ask a good question. I have written about all three of the issues you raise--work hours, resident attitudes and programs.

The best answer I can give you is that it is probably a combination of all three plus the decrease in the amount of resident independent decision-making that has occurred over the last 15-20 years.

artiger said...

I'm not sure I'd describe every fourth night call as "traditional".

OK, I know what you meant, I just had to throw that in.

Scalpel, those numbers from the Annals paper are downright scary. Aren't caseload numbers pretty much staying up? How can almost a third of senior residents not be able to perform a lap chole?

Weren't work hour limits designed with safety in mind?

Skeptical Scalpel said...

Yes, the number are scary. Yes, the work hours limits were supposed to make surgery safer. As I said above, it may not just be the work hours limits.

Anonymous said...

Do you think there is some degree of self- congratulation at work here? Fellowship director thinks he gets a bunch of incompetents and within a year he trains them to be real surgeons.

Anonymous said...

It's the quality of new doctors. Ambitious, concientious, intelligent young adults are not going into medicine anymore. You reap what you sow.

Anonymous said...

Just from a medical student's perspective, I agree that it is not just work hour limits. My general surgical rotation was probably the least helpful from actually a "learning on the clerkship" perspective. I'd actually place a lot of the blame on the rise in fellowships and them becoming almost the "norm" for surgical residents. Basically the junior residents did almost nothing in the OR, (meaning that I did absolutely nothing/learned very little) as either the seniors needed the numbers, or a fellow did almost the entire procedure. Teaching was also quite variable, with many opting to just rush through procedures and questions not being welcome until after the patient was stitched back up. Residents also had much better things to do than teaching, either each other or us medical students. There were many nights where I stuck around far later than necessary as I was promised a teaching session would occur, only to discover it cancelled at the last minute. Luckily I learned what I needed from books (got a 96 on the NBME "standardized" shelf) and I have no desire to enter surgery, but I could have done something much more useful with those 4 weeks of my life. Don't even get me started on the rise of departments hiring NP's to do most of the pre/post-op management.

Skeptical Scalpel said...

First anon, that's an interesting way of looking at it which I didn't consider. It's hard to believe that a significant number of the 91 program directors felt that way. Also, the paper did not specific who said what so there is no way that any single PD would be glorified.

Second anon, you may be right about that. It is hard to prove. If ambitious, concientious, intelligent young adults aren't going into medicine, what are they going into?

Third anon, thanks for your most enlightening comments. You have highlighted a number of issues that are real and worrisome. It really is a mess right now. They need to hire me as a consultant. I'll clean things up.

Anonymous said...

I think the comment of the use of NP's (and especially PA's) is interesting.

It has been a long-standing tradition that some surgical specialties (=orthopedics) do not handle any medical problems. Some years ago, they do manage to write basic orders and consult internists for everything else. In the past decade or so, they rely on PA's and NP's to handle all non-surgical management. Some of them are even incapable of entering orders in their hospital EMR systems.

General surgeons are quite good in managing acute medical problems, and I sure hope they don't start devolving care onto physician-extenders.

Ian M. said...

Is this a case of increased surveillance and reporting? Is there a comparable study or studies in the past that showed that newly graduated surgeons were more competent, had less post-operative complications, and were overall better surgeons? Also, not that I don't trust the judgement of the program directors, in fact I am not surprised at the numbers, but is a survey really a legitimate means to assess the situation? Is it internally valid, externally valid, and last but not least, objective? (Perhaps the numbers are even higher?) As always, thanks for the blog Dr. Scalpel.

Skeptical Scalpel said...

Anon, I agree that orthopedics has become a pseudomedical profession. Just focus on the bones and muscles and leave the doctoring to someone else. The PAs and NPs in general surgery are being hired to replace the hours that residents can no longer work. I don't think general surgery will go the way of ortho.

Ian, you raise a good question. I don't think there ever was a paper showing that graduates were more confident 20 or 30 years ago. PDs generally know who is competent and who isn't. Don't forget, 30% or so of residents themselves also do not feel that they can work independently.

artiger said...

Yes, orthopedics has pretty much gone the way of plastic surgery. A few other specialties aren't far behind. I shudder to think what will happen in 20 years if I break a bone.

Anonymous said...

A couple of years ago, I went to a talk at the ACS Clinical Congress called "Getting Out of Trouble in the Operating Room," or something similar. I arrived late from another talk and entered with the presenter discussing severe acute cholecystitis. His recommendation to the room of several hundred surgeons was "When you encounter this, close the patient and send them to a tertiary medical center."

I was appalled beyond belief. I assume he was an academic surgeon, and wanted to scream at him "What in the hell have you guys done to the residency programs over the last 20 years that your graduates can't even handle a hard gallbladder?" But more importantly, I am very concerned about how I or my family members are going to fare should we require surgical services in the future, which we certainly will.

Skeptical Scalpel said...

Anon, thanks for telling us about that. I would have fallen out of my chair. I strongly agree with your last paragraph. I have written a lot of posts with similar conclusions.

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