MDWhistleblower wrote this comment yesterday.
It is self-evident to any thinking individual that reform of residency training is in order. I didn’t buy in to the specious arguments that working 36 hrs straight was necessary training and preparation to face emergencies at odd hours as a practicing physician, or to follow the natural history of acute disease,. The reasons that this inhumane system has survived has much more to do with $$$, machismo and perpetuating a tradition of abusive training, than is does with actual medical education.
I like that he starts his rant with confidence – it is self-evident. Obviously he makes an assumption that everyone agrees with him.
I disagree with his assumptions. We have reformed residency in major ways over the past 30 years. We should make intelligent reforms. However, we must not let reform interfere with the goal of training excellent physicians
My rant focused more on the practical implications of various strategies at reform. If we care about education then we must focus on several fundamentals.
- We cannot learn medicine without caring for patients
- The number of patients that a resident sees does matter
- Practice without feedback does not lead to improvement
- Medical training is too important to short change
Taking call is a long time tradition in medical education. Patients do not respect banker’s hours. They come to the ER at all hours, and need admission at all hours.
We know that seeing the patient at the time of admission does matter for both patient care and education.
I reject the tired refrain that blames long hours on money. Residency training is hard, and should be hard, because it is so important. We could decrease the hours, but then we would likely have to increase the duration.
The real question is the best structure. If we have residents covering a service, do we do better with shift work or 30 hour call nights?
The IOM focuses on the problem of tired residents after all night call. My rant focuses on the assumption that work is the only reason residents get tired. Too many residents have told me that they prefer the every 4th call to the night shift for a period of time.
So I ask our writing colonoscopist, are the residents wrong? Why do they prefer bolus call over shift call? Several residents told me that the new shift system that we are trying is less humane.
The total hours are the same. The off days are the same. The educational environment has deteriorated. Supervision is actually more difficult. But no resident works more than 14 hours in a row.
I believe that the unintended consequences of avoiding call nights are undesirable. Interns and residents miss 1/4 of morning reports in the new schedule – and that conference is widely endorsed as the best teaching conference. We spend much time rushing through patient supervision in the morning in order to get the resident out on time. I have had to insist that residents leave, and they have argued with me.
Should we apologize for difficult residencies? I do not think so. Excellence requires hard work with feedback. We owe the public excellent training of their future physicians.
So I disagree with the Whistleblower. It is not self-evident on how we should reform residency training. I do love the debate though.
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It is self-evident that academic physicians, who are hospital or medical school *EMPLOYEES*, use house-staff (who do not have due process rights or collective bargaining powers and are not technically nor legally considered employees) as “RVU multipliers” in the service of large health care corporations. I can think of no other sector in our economy that utilizes human capital this way.