Wednesday, April 30, 2014

How should residents spend their time?

As everyone knows, residents are now restricted to working 80 hours per week. One of the lesser known side effects of this work hours limitation is the drastic loss of educational conference time.

Since at least one third of the residents must now go home after morning rounds, afternoon conferences are no longer possible. Most residency programs now devote part of at least one morning per week to dedicated educational time.

A new paper from JAMA Surgery describes how one program chose to comply with the mandate to teach some of the more fuzzy resident core competencies. Their weekly didactic schedule of 1 hour of grand rounds and 1 hour of small group learning now includes 10 hours per year [representing 10% of the 100 hours allotted to formal teaching] on practice-based learning and improvement, interpersonal and communication skills, systems-based practice, and professionalism.

From the paper's Table 3, the specific topics are structure and policy of US health care, advocacy, medical economics and finance, history and consequences of major legislation, innovation in health care, health information technology, comparative effectiveness, health care disparities, basic management principles, quality, performance improvement, patient safety, coding and billing compliance, legal issues, litigation, risk management, clinical practice models, contracts, relative value units (RVUs), personal leadership styles, power and influence: organization psychology, negotiation and conflict resolution, communication, ethics, and last but certainly not least, one of my favorites—Six Sigma. [What, no mention of "Lean"?]

I don't mean to disparage the authors of this paper. They're only trying to follow the rules. I'm just glad I'm no longer a residency program director having to commit 10% of my program's precious educational time to things like organization psychology, history and consequences of major legislation, and Six freakin' Sigma.

But I guess it could be worse. At this year's meeting of the Association of Program Directors in Internal Medicine, the following slide suggesting books that should be read by every chief resident was shown.

I would love to meet the chief resident who had not only the time, but also the inclination to read all 17 of these books.


Joe Niemczura, RN, MS said...

ummmm... a bit tongue in cheek about six sigma? hmmm?

maybe they can also use their new time to become - Reiki Masters!

The book I see missing is "Marcus Welby, MD"

Skeptical Scalpel said...

Joe, thanks for the comments.

Six Sigma and Lean don't even work in industry. Toyota has recalled about 15 million vehicles in the last 5 or 6 years. Neither has been shown to work in medicine, which is much harder to standardize. Patients are not the same as widgets. Reiki is about as useful as Six Sigma so your suggestion appeals to me. :-)

Today's generation doesn't know who Marcus Welby is. The more I think about it, the book all residents should read is "House of God."

John Mandrola said...


Part of me understands...Yes. Yes. I get it. But, now, after 20 years, I sometimes feel like doctors suffer from a deficiency of Updike. The life and times of Rabbit Angstrom teaches us a lot.

Morever (I know you love that word), I love Kahneman.

But, perchance, I love this stuff now because I was too busy learning cardiac action potentials, and exactly how hard you could push a catheter against the hear without perforating when I was young.

Good post. As always.

JMM -- Resident at the Academy of the Obvious.

artiger said...

Scalpel, they only have to work 80 hours a week (or less). That leaves 88 hours a week (or more) for reading. 17 books in a year shouldn't be that big a deal with that kind of time.

As far as having the inclination for that collection of books, I can't comment there.

Anonymous said...

HEY I know who Marcus Welby is! Probably not in the same way you do ... as on DVD. :) I even know Medical Center and Joe Gannon. :)

That being said let me thank you from the bottom of my heart for this reading list. Now I know why I have had to correct so many MD's on blood work interpretation & what they don't know. I spent a couple hundred hours all total in research at the library in UpToDate, StatRef, ClinicalKey, and the NLM Pubmed & journals, just on that one subject.

To this day I've got doctors who have been out of school 20 years that would LOVE to take a scalpel to me ...

and no cauterization ...

Anonymous said...

What? No "If Disney Ran Your Hospital"?

Skeptical Scalpel said...

Thanks for the comments.

John and Artiger, I have nothing against the list of books. I've read a few of them myself, including "Thinking Fast and Slow." I'm just not sure I would have had the time to read them as a chief resident. I was informed on Twitter that IM chief residents apparently have more than enough time to read all of those books and more.

First Anon, I was a big fan of Joe Gannon who always wore a perfectly ironed, well-tailored scrub suit.

Second Anon, the Disney book should have been on the list.

DrDEG said...

This boggles the mind....but if we're talking about consequences of health care legislation, why aren't they getting schooled on the debacle that is the "Affordable Care Act"? Sheesh.

Also, it took me quite a while to get through Thinking Fast and Slow, even though I'm an attending with oodles of time on my hands to read (not). I did enjoy it, though.

I loved Marcus Welby (in real time, not DVD) and had forgotten all about Joe Gannon--like him, too.

Now, back to my widgets (er, patients)

Skeptical Scalpel said...

DrDEG, I thought Thinking Fast and Slow was a bit heavy too. They do need to add an hour on the ACA and another on medical neighborhoods.

hope said...

I love reading, and I do think that both non-fiction and literature help to broaden one's perspectives and inspire the mind. Like it's mentioned about though, it's hard to find time to work it into the exhausting schedule we have.

Whatever happened to putting emphasis on LIVING LIFE and finding enjoyment and happiness in the things that make people human with our free time? Connections with family, friends, emotional investments, travel. Meeting people, traveling to new places, getting your heart broken, taking a risk, coming face-to-face with nature...all these things are wonderful parts of being human and I really think that doctors are better people with more perspective, patience and compassion when they're encouraged to be a human being during their downtime. I don't know about you, but if two surgeons were technically the same, I'd rather go with the one who was a little bit nicer and made me feel at ease, rather than the one who can't make eye contact and runs out of the examining room. Further, I'd rather work with co-workers who know how to take things in stride, get serious when they have to be, but also know when to relax. Sometimes it puzzles me that as surgeons we're supposed to know everything except how to live.

Skeptical Scalpel said...

Hope, good points. I did not mean to imply that non-medical books should never be read. I just wonder about recommending so many of them.

jocdocnh said...

Well, I've been out 30 and my observation is that doctors have really shifted the paradigm lately. When we hire a new ortho doc now for our group there is NO interest in practice building, only how much time off and what guaranteed salary. We have a strict you eat what you kill practice model but it's dying fast.

Skeptical Scalpel said...

Jocdocnh, you might be amused by some of my posts under the headings "surgical residency training" and "medical education." The millennials think we are nuts and resent being criticized.

Tx Doc said...

Yeah, but Ben Casey MD was the Real Dude...

Skeptical Scalpel said...

Tx Doc, yes he was quite a stud.

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