A Better Way to Structure Training on the Wards?

Summary and Comment |
April 16, 2010

A Better Way to Structure Training on the Wards?

  1. Neil H. Winawer, MD, SFHM

Maybe, but finding the right mix remains a work in progress.

  1. Neil H. Winawer, MD, SFHM

One of the consequences of the Accreditation Council for Graduate Medical Education (ACGME) work-hour regulations has been substantial compression of residents' schedules. House staff now have less time to attend conferences, interact with faculty, and reflect on their practices.

To address these concerns, researchers designed an experimental inpatient service at a community hospital in Boston. The service consisted of two teams, each with two attending physicians, two residents, and three interns. The attending physicians (1 hospitalist and 1 internist or subspecialist on each team), selected on the basis of superior teaching ratings, supervised their medical teams daily during bedside rounds and throughout the workday. The two control teams each comprised one resident, two interns, and multiple supervising attending physicians who didn't accompany trainees on work rounds. Patients were assigned alternately to experimental and control teams.

During 12 months, per-intern workloads were significantly lower on experimental teams than on control teams (average daily census, 3.5 vs. 6.6 patients). Trainee satisfaction was significantly higher on experimental teams than on control teams (78% vs. 55%). Interns' work weeks on both team types averaged about 62 hours, but interns on the experimental teams had significantly more time for educational activities.

Comment

From this multisystem intervention, we can't determine which components contributed most to house officers' satisfaction. Was it lower patient census, lower frequency of overnight call, more time for reflection, dual attending physician arrangement, or higher-quality teaching? Some of these initiatives do not come cheaply, so determining which components of the intervention are most cost-effective would help teaching hospitals understand the applicability of these results to their own settings. Last, although satisfaction of house staff is important, we must consider whether an average daily census of 3.5 patients provides sufficient breadth of clinical experience.

Citation(s):

Reader Comments (2)

Anne M. Conyers-Hom, PharmD/MD

After obtaining my medical degree in 1999, I completed one year as a Resident in Internal Medicine and 6mo's as a Resident in Neurology. I received the PharmD degree in 1985 and continue to practice as a Clinical Pharmacist, because Residency training, for a mature student, was so workload-intense, and because severe, accumulated sleep loss produced physical symtoms which neither I nor my attendings could understand. "Chronic fatigue," "fibromyalgia," "early-onset Parkinson disease," multiple sclerosis, cerebellar dysfunction, memory loss, inability to concentrate, organize, and execute daily plans efficiently combined in a perfect storm with the re-appearance of frerquent asthma (which had been years in remission), bronchitis, sinusitis, and chronic, unremitting malaise--all of which, in facind my Resident's workload, produced feelings of helplessness and hopelessness, alternating with irritation that the transfer of medical knowledge was deemed "a priori" to REQUIRE this kind of unrelenting stress. I had been doing overnight call every 4 days, without stop, for all of my senior year, then internship year, then Neurology Residency. I was off for one month during Internal Medicine internship year for bronchial illness, and again x1 month during PGY-2 in Neurology, again for bronchial illness. Finally, saliva and blood tests showed that my adrenal gland function had become very low. I was livng proof of the association of adrenal axis hypofunction and depression. I "dropped out" of my Residency Program in Neurology, in which I had been subjected to Psychological testing due to my symptoms. I was prescribed "pep pills" by one of my attendings, in order to help with the fatigue. But every conversation I had with the Residency Coordinator regarding a cutback in workload, or a cutback in the q4d 30-hr "all-day-then-all-night-then-all -the-next-day" schedule met with denials. Rather than being offered a reduced patient load or a reduced call schedule I was offered a month off--which I knew would help in the short run, but not solve anything in the long run. I requested "half-time"--which the Program's self-description indicated was available- -and told the Program Director I was willing to take a 50% paycut! I thought "half-time" might mean 1/2 the number of days per week or month-- or 1/2 the number of patients. But I was told there really was no "half- time" option--then offered a month off, then 2 months of the same workload under intense supervision (which I knew would produce virtually the same symptomatology as always), then another month off, etc. This, I felt, was a betrayal of the Program's stated mission to TEACH medicine-Neurology. Can the teaching of Neurology not be done in a more user-friendly way, I constantly asked myself. Finally, I had to stop, for the sake of my health and that of my family--who had been incredibly patient and supportive, but who I had been ignoring in my daily grind of hospital/clinic, home to sleep, then repeat, ad infinitum. This left us with untold thousands of student loans and a loss of the income expected with which to pay them. I'm sure we will still be paying these bills throughout our working lives and all throughout "retirement." I had to deal with extremely painful self-esteem issues upon stopping my post- graduate education. I have never in my life, before this, stopped a project, once started. To this day, I wish to finish my training--but I could only do so in a Program designed to teach (!) Medicine(Neurology), rather than insist,phlegmatically, that all Residents learn their craft by dint of trial-and-error as they run, ragged and sleep-deprived, from one end of the hospital to the other, keeping up with a long list of patients daily, and then admitting more, and reporting on them when cortisol levels are lowest, after all-nighters that reoccur every 4 days, with no end in sight. That is not education, it is an exercise in physical endurance, which only young people in their 20's can endure without apparent injury. I submit that the study in question represents a well-designed, well-thought-out attempt to address the most basic of all issues in today's medical education--that of Residents who are too busy and too tired to question either themselves, their diagnostic and treatment options, or the status quo of their own education.. Fears of Residents "not being exposed to a broad enough patient base" after 3-5 years of 3.5 patients per day seem misplaced, if the simple math is done. Mature students who truly want to serve the sick, who are willing to forego more lucrative jobs in order to train in medicine, for as long as a given Board deems necessary, and who have achieved advanced credentials in fields that can only add to the physician's ability to diagnose and treat patients should be sought-after and nurtured. The fact that many of us have succumbed to 17th-century "house officer" traditions, however modified over the past 10 years or so, reflects poorly on those whose professional goal and mission is to provide the nation with strongly- credentialled, well-trained physicians. I am heartened to read about this effort to "think out of the box" regarding post-graduate medical training. I am hoping in my heart that such work bears fruit in time for me--and others like me. Believe it or not, at an age when others are starting to retire, I would still like to finish my training. Thank you for this opportunity to comment on the study by Ludmerer in the April 8, 2010 edition of NEJM. I appreciate your online edition and am, of course, a regular reader.

Competing interests: None declared

Kidnee Doc

I would suggest that the author of the above letter is on the extreme end of the reaction to workload. I was trained in the 80's, when we did every other night on call, and considered every third a luxury. I would never suggest going back to such an inhumane schedule - but overnight call is a necessity in order to learn the evolution of disease, and 3.5 patients is a laughable clinical exposure - no matter how hard we wish to deny it, part of medicine is an art, and the art of diagnosis is NOT something that can be learned from a book. One has to see many patients having an MI, to be able to make the decision as to how to interpret an unclear troponin and an indeterminate EKG, and not overtreat. What I see now, are many young doctors who order multiple tests because they simply don't understand differential diagnosis. And when the tests come back, they are even more confused, because they don't know how to look at the patient, and listen to the patient, and come to a diagnosis FIRST before ordering the tests. Perhaps the answer is to increase resident numbers but in this era of cost control, that will never happen. And as an Attending Physician at a teaching hospital, I will also say that there is nothing more frustrating than making rounds in the morning and asking "Does the patient look better?", and no one can answer, because no one saw the patient when he was admitted. I ask - is that good medicine?????

Competing interests: None declared

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