Building residency training from scratch: What would you do?

Back in the day, legend has it that when space programs were just developed, NASA soon discovered that ball-point pens will not write in zero-gravity. Unfazed, NASA spent a large amount of money developing pens that will work in space, while the Russians simply used pencils.

It turns out that this legend is only half true, but the lesson remains – sometimes, we get bogged down trying to solve a problem within its existing framework. Sometimes, it’s better to wipe the slate clean and start from scratch.

The problem I propose is residency, how our future doctors are trained. Imagine a shearing shed. On one end stands a line of plump, happy, fluffy sheep – metaphorically these are bright-eyed medical students, healthy, well-rested from the last year of light coursework in medical school, excited to finally be at the forefront of medical care.

After 3 or more years in the residency, the shearing shed spits out a scrawny, shivering ghost of a bald sheep – these are your doctors. They are burnt out, fatigued, unhealthy graduating medical residents usually without the same self-esteem, optimism or hunger for knowledge they used to have. This generalization has truth in it – poems, books, other forms of media have tried to describe this gruesome experience. I, for one, have never heard anyone said that they would want to do residency for the rest of their life, as a real job, because they love it so much and they never want to quit.

Maybe that is too much to ask – not every job in the world creates that kind of enthusiasm. But, considering the importance of the task at hand, should we not attempt to train doctors in a way that by the end, the sheep remain plump, happy, fluffy and, most importantly, medically smarter than before the shearing?

I propose that we build this alternative training program from scratch, so we can dream bigger without the constraints in the current system of what can and cannot be. My proposal assumes happy, fluffy sheep – meaning caring, upstanding medical students looking to learn real medicine so that they can provide the best care for patients on the job – this is not always true but that’s the topic for another day. With that assumption, a better training program will have the following characteristics:

1. Autonomy. Learners should be able to dictate the content and the manner in which they want to learn medicine.

1.1 Content. Not every medical student wants to be a pulmonologist, so why does every medical resident in the same program need to do the same amount of ICU time? Learners should tailor the type and duration of rotations to fit their career goals.

1.2 Manner. How many current residents, laboring in the trenches, work with ACGME on work hour regulations? I am going to tempt fate here and guess zero, or at least a very small minority if that, because there simply is not enough time in the day. So why are people sitting in an office far removed from residency deciding when a bunch of grown-up adults should take a nap, go home, come to work? Shouldn’t 25-something future doctors know when they’re at their best learning and when they need to take a break? If your future doctors need to rely on someone else to manage their work day, would you really want them to be your doctor, especially out after training when there is no one and nothing telling them when to take a nap, go home, come to work? The new work hour regulation is really misguided and quite a shame, because being able to follow patient progression over a 28-hour call is priceless – I wrote more about work hour regulations here.

2. Service vs education. There is a time for service in every doctor’s life, but residency should not be one of them. Medical students may have as little as 1 year to learn everything they need to know to be able to treat you on their own without supervision. None of that time should be spent learning the computer system or filling out paperwork, because many people can fill out paperwork without spending 4 years in medical school – it is low-yield. Progressive medical clinics hire scribes to write notes, enter orders, fill out paperwork, so doctors can focus on patients, look at them during conversation and treat them like respectable human beings. The diversity of cases is also important, which is why many reputable programs have medical admitting residents scouting for cases with educational values. There will be time to take care of patients admitted for pain control or alcohol withdrawal in the real world, but if a full-fledged doctor has never seen a case of pituitary adenoma during their training, would you trust him/her to care for you if you have one?

3. Evaluation. To become a full-fledged doctor, which is the goal of residency, you only need to spend a certain amount of time among a number of required rotations, and pass a multiple choice test. Failing other types of evaluations beyond these do not necessarily stop one from becoming a doctor. Other qualitative evaluations are performed mostly by doctors, a few by nurses, none (in my program) by patients, which seems backwards to me. It is important to know what your colleagues think, but isn’t it more valuable to see if your customers are satisfied? I don’t know of other thriving service industry where close to 0% of evaluations come from customers.

4. Equality. Residency is a monopoly, where medical students cannot become doctors without going through it. As a result, residents usually get the short end of the stick in everything that they do: slower computers, fewer medical assistants, more rectal exams. Being treated as a second class citizen should never be a rite of passage. Equality means respect, and the hidden curriculum in residency currently teaches us that it is acceptable to treat those with less experience without respect.

5. Add yours here. Wipe the slate clean and dream about how you want to make your doctors. One day, someone might actually listen and make your dreams come true.

“angienadia” is an internal medicine physician who blogs at Primary Dx.

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  • Shirie Leng

    I definitely agree with number 2. As an anesthesia resident, I was often used to “fill a chair”, doing cases with low educational value just because the schedule required that someone do it, while attendings did complicated cases alone. Lecture time always took a back seat to covering the OR cases. One whole rotation is devoted to paperwork. We need to stop viewing residents a cheap labor.

  • doublj01

    Can anyone shed some light on the acgme merger with the AoA and how that may impact future residencies?

  • azmd

    I am not sure that there is really anything wrong with viewing residents as cheap labor. They are providing cheap labor in exchange for having significant resources, for which they are paying nothing, devoted to teaching them to becoming full-fledged doctors.

    Of course there should be a balance. But I do not get paid extra for doing teaching rounds, for composing or giving lectures, for filling out evaluation forms, or for the time I spend sitting on numerous committees devoted to furthering the educational needs of the residents.

    I do all of these things in addition to carrying a full clinical workload. Having a resident on my service really doesn’t save me any time at all any more. I still have to see the patients and write my own pretty detailed notes. The only benefit to me in having residents around is the personal satisfaction I get from teaching, and not having to stay up at night taking call.

    Of course it would be great if we could continue to pay residents to learn their craft, while making sure that they had only high-quality learning experiences that did not stress them in any way. But where, exactly, do people think the funds for that are going to come from? And if the residents spend three or four years getting lots of sleep and getting paid to have a low-stress learning experience during their training, they will be in for a rude awakening when they become attendings.

    • EmilyAnon

      “They (residents) are providing cheap labor in exchange for having significant resources, for which they are paying nothing…..”

      Don’t forget the most important free resource given to doctors in training — the patient.

      • azmd

        At the risk of sounding churlish, I must respectfully disagree. I happen to think that there is very significant benefit to the patient in being treated in an academic setting. Not only is night and weekend coverage better, but the patient is attended to by more clinicians, and the care he or she receives from the attending is more current, since the attending is actively teaching and needs to be up on the latest developments in the field. Patients who do not feel that these are benefits should absolutely exercise their right to go and be seen in a non-academic center; there are lots of them available.

        I have always chosen academic settings for medical care for myself and my family, because I know the care we will receive is superior. The tradeoff is that the care will sometimes involve being seen by a trainee. You don’t get something for nothing.

        • EmilyAnon

          Why the lecture? I didn’t say anything about not wanting to be treated by trainees.

          Only wanted to add patients to your list of free “significant resources” supplied to doctors in training.

      • karen3

        I don’t appreciate being called a “resource” and honestly i don’t think my future health is a freebie for resident mess-ups. Please, please better training and more supervision.

    • angienadia

      azmd, thank you for your comment.

      In my humble opinion, the fact that we are cheap labors means we spend a significant amount of time (this is 80% of what I spent intern year doing) doing work that has nothing to do with learning medicine – filling out W10, calling rehab in order to discharge patients – none of these tasks require 4 years of medical school training. In a good program, all these tasks are taken care of by APRN/PA, but not every residency program is willing to spend that kind of money when residents can be pushed to do these for free. Hundreds of times in the past few years I’ve said to myself, I cannot make it to conference because I simply have too much paperwork to do. If I go, I won’t get out on time and break work hours. Service/cheap labor encroaches on my education often.

      I admire people who choose to stay in academia, because like you mentioned, you work on education for other health care professionals for potentially less pay than private practice, but the BIG difference is that you have a choice, you chose to stay in academia because of the satisfaction you described. Residents, on the other hand, do not have that kind of choice. To be a doctor, we *have* to do residency, there is no other way.

      I agree that stress is good – doctors need to be able to work under stress. I’m not saying residents should not be pushed to test their limit, but the way we are being pushed right now is through a heavy load of cases with low educational values, a heavy load of paperwork and vaccine injections which do not help me practice at the top of my license. I would be happy to be inundated with a big case load if they were something I haven’t seen before, because by the time I leave work I will feel like I have spent those limited years of residency towards preparing myself for independent practice.

      • azmd

        It’s hard for me to comment on your complaints about your specific training program, because I don’t work in it. If it’s true that 80% of your time is spent doing paperwork/scut, that’s unfortunate, because those activities are certainly less educationally valuable than others. However, the ACGME regulates residency training programs pretty tightly these days, so it is hard to believe that you are really spending 80% of your time doing paperwork. That would never fly with the ACGME.
        In my experience, even residents in a program where huge efforts are being made to ensure that they have a rich educational experience as well as protected time for academics will complain about the service aspect of what they do.
        I think it’s just part of being young, and having a somewhat limited perspective on what it takes to provide residency training education.
        Once you get to be an attending, you have more opportunities to appreciate what is involved in training residents, and have a better understanding of why it is necessary for those residents to provide at least some service in exchange for their training.

        • angienadia

          Thank you again for your interesting comment. Could you let us know how ACGME control how many percent of our time is spent doing scut work? Other than an hour conference on most work days (during which I get paged out constantly, forcing me to leave early), I’m not sure how ACGME can tell (again they sit in an office faraway from my hospital) how many percent of my work day is spent doing paperwork. I can say a majority of trainees’ days are spent in front of the computer and not with the patient, which I think goes to show how much of our training is scut work and how much is education.

  • karen3

    As someone with a pituitary adenoma, what drives me nuts is the doctors who have the green as can be fellows do the history, which is incredibly difficult, breeze in, get things completely wrong because the fellow has no clue whatsoever the technical information that has been provided, and then the attending starts giving instructions that are stupid. Attendings do histories, with fellows standing by, fellows can do the execution. The backwards way things are done now is how new doctors have no interest and no clue about a properly done history.

  • Arvind Cavale

    The discussion should start with assessing how the training program is structured and strengths & weaknesses of the faculty. Next, each resident should be interviewed and assessed on day 1 as to his/her aptitude towards academic versus clinical/community practice. This should be reassessed at 6 months to note any changes. Once a track is assigned, the resident should be required to stay on that track till completion of residency.

    For an academic track program, more basic research and education should be stressed. For a clinical track, a balance of academic and managerial skills should be found. For this to occur, the training program should have faculty with training in economics, finance and business management. The latter items should get at least 25% of teaching time.

    By the middle of the 2nd year of residency, residents should decide if they would like to specialize, so their 3rd year can be structured appropriately. Those that select primary specialty to practice should have a different pathway in the 3rd year.

    A similar pathway can be created for Fellowships too. Every training program that emphasizes clinical/community practice training should be in ongoing communication with area medical practices and use such practices to rotate their residents and fellows through. This will ensure meaningful connections between the training programs and community medical practices, something that is lacking at present.

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