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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  • David McFeeters-Krone

    Do you feel that burnout is related to the level of documentation and if so do you think that medical scribes can be an answer

    • Suzi Q 38

      The physicians time is valuable. Physicians should not be office workers. Maybe one medical scribe can serve 5 physicians or so.

  • Coconutskinss

    GREAT post. Nice to hear an educator at the top positively advocating for residents instead of throwing us under the bus. Thanks for thinking about how to move ALL of us forward instead of lamenting over how it’s no longer the past (which has only created a tired workforce and a broken healthcare system). Too many attending physicians posting here have a ‘toughen up’ approach instead of accepting the reality that times have changed and so should the work and the education. It’s not just the access to care that we need to confront but the type and style of care we are providing for patients while in an educational environment.

  • azmd

    Does it really make sense to reorganize residency training to try and ensure that time spent in “none or marginal educational value” is minimized? After all, after those residents graduate, much of their time as attendings will be spent in tasks of low academic and clinical value.

    Why are we not talking about a general effort to reorganize all of medicine so that ALL doctors can spend as much time as possible doing what they went into medicine to do: care for their patients.

    • trinu

      That would require putting insurance bureaucrats in their rightful place, something which the insurance lobby will never allow.

    • Coconutskinss

      This is like saying “why bother potty training a child when most of their time wont be spent in the bathroom?”

      Because it’s essential that they learn to do somethings on their own so they won’t become bitter attendings who think all their time is filled with “low academic and clinical value” activities.

      • azmd

        How is it any more bitter for an attending to point out that a good amount of his or her time is spent on clerical/bureaucratic tasks these days than it is for a resident to make the same complaint?

        It’s a logical, not a bitter, response to those who deplore the fact that residents spend a lot of time on low-value activities. If we kid ourselves that it’s only residents who have this problem, we are that much further away from getting together to insist that changes be made in the way that work in our profession gets accomplished.

  • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

    Why would a residency program hire a secretary at 40k per year plus benefits when they get FREE money from the federal government to pay for residents to do the same thing?

    Exactly how does that make financial sense to the hospital or residency program?

    The choice for the hospital is either to “hire” a resident whose funding is provided by the federal government, OR to pay a secretary 40k out of their own pocket. That’s an easy choice.

    Get rid of the federal govt paying for residents and you’ll start to see more efficient use of labor (i.e. hiring clerical workers to do the crap residents do)

    • http://www.facebook.com/shirie.leng Shirie Leng

      Jason is right. Doing the right thing for residents does not make financial sense for hospitals.