Residency training is like James Cameron’s Avatar

Dr. Carolyn Clancy, head of the Agency of Healthcare Research and Quality, recently highlighted the definite need for enhanced patient safety and training on healthcare IT for residents who will be the practicing docs of the future.

At the very end, she compared the future of residency training to James Cameron’s Avatar – an epic battle followed by enlightenment.

Because I am a huge science fiction fan and working in graduate medical education, I was especially struck by that comment. So, I continued to think about this analogy during the meeting –- and even after I came home and saw the Oscars and saw James Cameron’s science fiction 3D-blockbuster lose to ex-wife Kathryn Bigelow’s critically acclaimed war movie, The Hurt Locker.

So does the analogy work?

Well, in Avatar, you have some militant members of a species (humans) trying to preserve and protect their world. On the other side, you have a new and evolved species who value working in teams and have a symbiotic relationship with their environment. Interestingly, you also have a doctor and a paralyzed soldier who go undercover to initially understand the species and then they both end up becoming one of them in the process, with one of them ultimately leading the new species to victory.

Here’s how it applies to residency training.  At one end, you have Baby Boomers who are leading residency education and often long for the “way it used to be.” Contrast that to millenials (current interns and students) who are more used working in teams, value balance in their lives, and also have a symbiotic relationship with technology (namely, their smartphone).

There are also Gen X’ers (this would be me) in the middle who may be trying to understand the millenials. Are there a few Gen X’ers who will literally fall in love with the idea of being a millennial and help them get their way? It’s starting to look possible.

What is the epic battle? Not a surprise here – it’s about how long residents should work. There is a lot of public pressure being exerted on the ACGME to adopt the IOM recommendations. But there are also a lot of program directors who voiced concerns about what will happen to resident education and where the resources will come from to ensure patients are cared for. Everyone was also trying to figure out if 16 hour limits would be put into place or not. The only thing that anyone could say with certainty is that new proposed standards would be released this Spring (as early as April) with a public commentary period followed by approval in September and full implementation expected by July 2011.

What will the enlightenment be? One possibility is better supervision – not about total hours, but about enhanced learning and patient safety through better supervision. In the words of Dr. Bertrand Bell who chaired the Bell Commission in the wake of Libby Zion’s death that ultimately heralded the NY State duty hour restrictions for residents, “Supervision, not regulation of hours, is the key to improving the quality of patient care.”

This has led some to suggest that supervision got lost somewhere along the way and the focus has really moved to hours. The tide appears to be turning since even the IOM report includes the title “supervision” and actually goes so far to recommend that there is 24/7 on site supervision by a qualified supervisor.

Will this happen? Well, it already does in some specialties – OB/GYN and emergency medicine in particular. Will this happen in across the board? I don’t know for sure, but I do know that we could be doing better to train faculty to provide better supervision at night. This is one reason we have been working to develop videos and teaching tools to highlight barriers to supervision and how to better address these barriers.

So, does the future of residency training look like Avatar? Well, it’s certainly better than resembling Oscar winner The Hurt Locker.

Vineet Arora is an internal medicine physician who blogs at FutureDocs.

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  • http://fastsurgeon.blogspot.com JF Sucher, MD FACS

    Appropriate supervision to ensure optimal patient safety is important, but ultimately is not the real problem facing medical education today. The problem lies in the educational process that enhance the student physician’s ability to make appropriate and safe decisions.

    In our quest to improve patient safety, by providing increasing oversight, we have attenuated the resident’s ability to make autonomous decisions. I am share a growing concern that some residents who leave training lack this important skill of professional decision making. This may be leading us to a worsening patient safety problem in the long run.

    Our challenge is to identify and implement solutions that ensure our graduates have optimal skills, knowledge AND autonomous decision making capabilities. I am not sure that more oversight is that solution.

    JFS

  • http://paul@paul.com paul

    come to think of it, my residency director was *totally* like that military dude with the big scars on his face. “my job is to make sure you all survive residency. i will not be successful.”

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