Long time readers know that I worry about GME with current changes in residency training. On Friday, I did an interview for a reporter about this issue – I expect a very interesting article soon – which may or may not include my thoughts. So Friday night at dinner the conversation drifted to residency training. On the golf trip we have a businessman, 2 lawyers and 5 physicians – a CV surgeon, 2 Ob-gyns, a gastroenterologist and your truly.
Like most physicians of my generation, the other physicians worry about the adequacy of patient exposure during residency today. As the surgeon said (and I paraphrase), he did not need to do 100-200 routine cases to gain expertise. Rather he need to do 100-200 routine cases to see the 10-20 unexpected issues that make a great surgeon.
All the physicians immediately nodded consent. While walking the course with the gastroenterologist yesterday, he talked about doing about 12 procedures each morning. On average 1 of those 12 was unusual or difficult.
This is precisely the issue that the Long Tail or Pareto Principle predicts.
Our challenge – the long tail Our training takes time because it takes time to see enough patients.
Many “experts” advocate shortening training. My friends advocate the opposite. They see physicians enter the work force incompletely trained. Now we all know that as we mature we embellish the “good old days” and decry the failings of the younger generation. So how do we figure out the middle ground.
One of my favorite phrases is that tests can only evaluate knowledge (and test taking skills), while we all want physicians who possess wisdom and knowledge. Wisdom can only come from experience.
I worry that we might make residency training too easy. It must remain difficult because our job is a difficult one. Our profession is too important to accept short cuts to training. Volume matters.
A couple of my golf buddies had just read Outliers. This book came into our discussion. In medicine we need physicians who strive for excellence. We need to put in the necessary hours. The work hour rules make this more difficult. We must look at the benefits of work hour limits, but we must also examine the potential impact on the care of future patients.
I believe we must demand more rigorous residency training. Residency training is difficult because it must be. Becoming a skilled physician is that important.
Thanks to my golf buddies for a stimulating conversation. Their insights as practicing physicians are invaluable.
And oh, by the way, the golf venue (Bandon Dunes) is simply spectacular.
{ 4 comments… read them below or add one }
I used to moonlight during my 3 year FP residency to gain extra experience, and I would ask the front desk to add on patients as same day appointments to my schedule. The more I saw, the more I learned. I was glad that I saw a lot during residency, and I contnue to learn in the real world across the last 7 years.
I have noted many of the community physicians become complacent with time. My residency had a 99% board certificaiton rate. One third of my colleagues did get board certified or did not maintain certification in my suburuban community. Many of them are not familiar with maintenance of a diabetic patient and various labs/studies/exams that meet national standards of care.
Extending residency is not necessarily the best option, but maintaining and adding clinical knowledge and skills should be stressed among all physicians lifelong.
Your proposal seems to recommend making residency better by using a more orthopedic approach. We really don’t need to tackle the problem with brute strength however. The overwhelming majority of those outlier cases could be predicted just by looking at the chart and knowing a few key details ahead of time. As it stands too many programs use their residents as a “doctor lite” if you will, if anything enriching for cases that are routine, by the book, and too simple to have a “real” doctor tackle. Raising hours as you propose is one option but another as used at my university, UCDenver, is to give every resident an assistant either a dedicated RN for interns or PA for full residents. This helps clear up the busy administrative work and streamlines the routine cases while still leaving plenty of teaching/learning time for the residents and especially the attendings. The sole physician as the only employee of his practice is a thing of the past we should have training that reflects that. Besides why go back to an archaic system which we fully know leads to inferior patient care and also ostracizes mothers and other non-traditional applicants. We have to and should have the expectation of ourselves to come up with better options.
Sentimental drivel.
“…making residency too easy?” Please…The amount of information, science, policy, rules, billing and coding regulations that young physicians must digest is exponentially higher today than in previous decades. All of this occurs in a far different medico-legal environment as well. Any honest medical educator will admit that training was simpler 30 years ago than today. It was easier to know what your job was as a house officer in those days than now.
Residency programs are training physicians for jobs that no longer exist. The skills that residents acquire in large tertiary care academic medical centers often does not translate well into the community medical setting. Instead, we need to analyze what practicing physicians do on a day-to-day basis and train resident for those duties.
Residents are a cheap source of labor. They will never buy in to the idea of working these (necessary) long hours without compensation beyond minimum wage.