Let’s critically examine what residents are doing while in training

Recently, I was having a discussion with a colleague about being a doctor. She confided in me that if someone asked her about becoming a doctor, she would tell him or her to become a nurse practitioner.   After reading the emotional open letter to our policymakers in Washington DC, it may sound like a reasonable suggestion.  After all, why go into this much debt and spend so much time in training if your prospects are not much better?

More recently, the New York Times article points out job prospects for radiology trainees are thinning, meaning the well known “ROAD” (radiology, ophthalmology, anesthesiology, and dermatology) to success may soon become a road to nowhere if there are no jobs.

There in lies the question, why become a doctor? If the answer is to make money or to have an easy life, then you probably need to look for a new profession.   With healthcare payment reform, doctors can expect lower salaries as bundled payment and cost cutting measures are instituted.  Moreover, the demand for healthcare will go up as more patients have insurance, leading to higher patient volumes and the expectation to see more patients with the same amount of time.

So, why become a “doctor”?  Simply put, the decision to become a doctor includes a sense of calling.   The decision to become a doctor means accepting your duty to at times sacrifice your holidays, weekends, nights and other personal time to help someone else.   This sentiment is best reflected by the motto of the coveted Alpha Omega Alpha medical student honors society, “worthy to serve the suffering.”   A recent New York Times Magazine article about giving reminds us, the joy in medicine needs to comes from the job itself, taking care of the most vulnerable people in our healthcare system, our patients. And as tough as being a doctor can be at times, it pales in comparison to the tough life of being a very sick or chronically ill patient.

Unfortunately, too many of us may forget this somewhere in training. Burnout is rampant among physicians, an epidemic that threatens the profession.   Faculty, who could be powerful role models, instead become too burned out to emphasize the positive of their profession.  Medical students who are thinking about going into primary care get burned out during their training, and decide to go into lifestyle oriented subspecialties.  Practicing physicians who are burned out decide to leave the profession altogether.  Not surprisingly, those with a stronger sense of calling are more resilient to burnout.

Given the long dwell time it takes to train a physician, creating systems that allow doctors to live up to their calling to serve while avoiding burnout is critical to ensuring a healthy workforce and safe care.   Unfortunately, the recent debates over new residency duty hour studies this week highlight our failures in this mission.   While resident work hour restrictions limit the number of hours worked, the lack of dramatic improvements does not come as a surprise to anyone in medical education.  Insiders know that the pace of work and intensity has gone up while many residents often care for similar numbers of patients, but in less time.   While some have proposed a controversial move to extend residency training, it is worth considering another solution before we tack on more debt to our graduates.  The solution sounds simple:  change the type of work residents do to align with meaningful doctoring.

recent study led by one of my colleagues demonstrates virtually no difference in the types of resident activities have performed in 20 years!   A bevy of studies show that at least one third of resident time is spent doing something of “none or marginal educational value” that could be performed by someone else … and that someone else need not be a nurse practitioner or a hospitalist …  it could be a clerical worker!   While technology could make things easier, adoption of electronic health records has added to the time charting, tying our physicians-in-training to the iPatient, and distancing them from their real patients who could remind them of their calling.  Just as there are serious discussions going on in the healthcare community about “working at the top of your license,” we need to critically examine what our residents are doing when in training.  By redesigning the activities of residents to align with their calling, we can instill in today’s medical trainees the duty to doctor in the context of duty hours.

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

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