Redesigning residency training: The evidence is lacking

Three-year program residents graduating in June 2013 like me represented a unique cohort in medicine. As interns we experienced the 2003 ACGME duty-hour restrictions and the 2011 ACGME changes as residents. For example, I took thirty-hour call with a resident my intern year and ended residency with a dizzying iteration of a mixed call/shift system composed of multiple handoffs, residents, and interns. But this story is a call to more informed innovation, not the lament of the challenges that came along with duty-hour reform.

This past year, I eagerly read duty-hour change studies and commentaries. I was even a research participant in one of the largest studies reported on the impacts of the duty-hour changes. A commentary in JAMA Internal Medicine particularly resonated with one facet of my residency experience and colleagues of mine around the country. The editorialist wrote that residents were doing more work in less time for sicker patients than in previous eras in American medicine. Another study showed that despite no change in the overall allowed hours to work, residents felt compromised in their education, less prepared for senior roles, and perceived having worse schedules since the 2011 ACGME duty-hour changes. Although illuminating, I found many commentaries and study discussions insufficient.

By the end of my training, I felt convicted that my peers and I trained in an environment that history will look back on critically. And so my colleagues and I had conversations on what might be done to improve our training experience. If you want to ignite passionate resident discussion, discuss whether or not residency should be extended by another year. Given the sheer amount of knowledge and decision-making science associated with today’s medical environment, one thought included lowering weekly hour caps further, expanding residency class size, and adding another year for training, possibly with tracks for primary care or hospitalist training in that final year. Would this be enough to change attitudes about training among stakeholders, especially residents?

It was not until I spoke with friends training in residency-equivalent programs in Sweden, Netherlands, and Canada that I felt I was thinking too narrowly about change. From work force issues to scheduling policy, from work-hour caps to length of training, they felt less ambivalent about their training process and overall more satisfied with their training. These anecdotes led me to do some research. You might think that there are multiple studies comparing the US with other countries that would in turn justify the American system of training. In fact, the paucity of commentaries and data comparing training programs among higher income countries astounded me.

A number of provocative questions arose for me. What evidence-based educational or patient care advantage did I have over a Swedish colleague who did not take twenty-eight hour call during his training? How does my knowledge acquisition in residency stack up against a differently trained physician in Canada? How do patient outcomes vary across these countries if you can control for access to care and other variables? These are just a few questions for which I could not find answers.

Recent studies and commentaries fixate on the traditional twenty-eight to thirty hour shift. One current mantra includes the need to see patients evolve. In reality, research gaps exist about what even constitutes an optimal shift in order to sufficiently learn about patient care, with the understanding that optimal shifts may vary from service to service in the hospital.  Might there be a number of ways to learn disease evolution given the different training models in other countries?

If we move beyond the confines of what is lost in changing the twenty-eight hour call, greater innovation for medical education may await us. In the meantime, we need to strengthen research in medical education and continue evaluating resident attitudes and patient outcomes with the current duty-hour system. We especially need more researchers to engage in rigorous cross-country comparisons to look at what works and does not work in other countries. America’s future doctors deserve the best evidence based training possible.

Justin List is an internal medicine physician and a member of the Robert Wood Johnson Foundation Clinical Scholars program.

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  • Cataract Surgery

    Great info, thanks!

  • FFP

    The main difference compared to Europe is duty hours. A European resident will work 60 hours/week if not less, compared to the 80 hours/week in the US. Their training might last 1-2 years longer, but when you are rested you learn so much more.

    I remember being a resident in Europe. I NEVER dreaded going back to work. I enjoyed every day. I never had the patient count I had in the US, and never felt threatened by malpractice, so I did not even know what defensive medicine was. It was a joy I still miss, even as an attending,

    The entire system is sick. There is no way you can fix residencies, which are the new slavery system. In my home country, if you took out the residents from the hospitals, nothing would have happened; they were supposed to work under the attendings, not instead of them. Here, if you take out the residents, the hospitals will crumble, Medicare will not be accepted anymore etc.

    • Guest

      Thanks for sharing your experiences. A depressing account for sure. I trained here in the US before the work hour restriction, and if I was asked to repeat that period I’d find another line of work. The stress and fear were overwhelming. It would be wonderful to have a system more like Europe where medical training and practice was actually enjoyable.

      • FFP

        Don’t worry, with the current populist doctrine of “you don’t need a doctor – a nurse practitioner/PA/homeopath etc. is good enough for that”, Europe is slowly going the way of the US, too. Same narrow-mindedness about cutting costs by cutting quality, instead of cutting too expensive technologies and medications (because the pharmaceutical/biomedical company will send the hospital administrator on a nice and long vacation, but the doctors won’t.)

        But at least they don’t have the malpractice terrorism that American doctors enjoy.

        • Cyndee Malowitz

          But if you’re NOT cutting quality, what then? Why on earth would anyone pay more for the same level of care?

          • FFP

            We need to cut the middlemen, especially the ones in the management positions. Healthcare insurance should be catastrophic (including emergencies), like most other insurance. Everything else should be direct pay, patient-to-provider, quoted upfront. The market should be less regulated, and all these stupid corporate-type bureaucratic rules and bureaucrats should disappear (and they would, in a true market economy, because nothing makes one more nimble than real-world competition).

            As a patient, I wonder about how much of the money I pay does my doctor see as income? Because that’s his incentive and I know it’s about 15% on average. Much of the rest is bureaucratic overhead, and it’s not OK. That”s why healthcare costs so much. And now Obamacare is destroying the very medical businesses which were the cheapest: the private practices.

            When people report that they suddenly have to pay $1500 for the cardiac echo that until a few months ago cost $600, in the same office, with the same people, just because the practice has been bought by a hospital in the meanwhile, you know that something is very-very wrong.

            At the same time, the poor (many of which are uninsured) are incredibly subsidized by getting healthcare for peanuts (compared to the real costs) and wasting an incredible amount of resources in the hospital, without anybody ever telling to them: isn’t that a bit too expensive? (That’s how they do it in those countries whose healthcare we so much admire.) But then the local politicians (many of who are closely-connected to hospital administrative boards) would lose their electoral support, ain’t it true?

            Those who pay are paying for the care of those who really don’t (when you look at the real expenses). It’s wild socialism, where “the poor” steal from “the rich”, all under the guidance of some very well-paid leaders. The leaders are happy, the selfish leftist base is happy, it’s just the healthcare workers and the hard working middle-class who are squeezed in-between and pay for all the fun.

    • Guest

      European doctors also don’t get paid as much as American doctors do, especially in the specialties. They may get an easier ride during residency, but that pay for that for the rest of their lives. It’s up to doctors to decide whether the trade-off is worth it I guess.

      • amohtap

        Not having any school debt goes a long way towards peace of mind. And doctors still make a very comfortable living in Europe, which is 3-5x the median income, depending on the country.

        • FFP

          In the end, if one did not go to medical school for the money, one can still make a more than decent living as a doctor working 40-50 hours/week. That’s the European model.

          Unless one is greedy, in which case s/he will never be happy, because s/he will always want more. But that’s why the 39.6% tax rate exists, for sucker A-types like that.

          • Matt

            The average American doctor, if we had a French tax system, would be paying up to 75% tax. You want European socialism, then you pay European taxes! Where do you think the money comes from for “free” university educations and med school etc??

          • FFP

            What has socialism/the tax system to do with working hours? One can be a capitalist and still live a normal life; one just has to stop chasing money, buying/leasing a new car every year, buying more house or anything than a normal person needs etc.

            I am glad you guys are all superhumans, but I don’t like the idea of anesthetizing my patients after 12-16 hours of work. It’s just not safe, naps or no naps. As a patient, I definitely would not want a tired doctor on my team, not even a dermatologist.

          • Guest

            Discussing sleep or *gasp* lifestyle is verboten amongst the old school or hard core.

            I trained before the 80 hour work week, and while I work about 40 hours per week now (part time in medicine), I am glad I did not have work hour restrictions during training. Sure, I was dog tired and emotionally spent, but I knew my patients and followed them through surgery, ICU, transfer or death. I saw and learned about so many disease processes including those with unique presentations to my specific patients.

            I’m not superhuman either, and I am glad I do not have to work like I did in training. That said, I feel bad for those training now. They are not learning; they are focusing on the wrong types of things (hand offs). They are in for a rude awakening upon graduation.

            Patients are in for an even ruder awakening.

          • Suzi Q 38

            I agree.

      • Mengles

        It depends how valuable your sleep is to you.

    • PoliticallyIncorrectMD

      I remember my residency, here, in the U.S. I worked 80+ hours. I felt tired, often dead tired. I still enjoyed every day. I still do, frequently working 80+ hours as an attending physician (and I do not make residents to do my job for me). Being a physician is a privilege and nobody said it will be easy. Thats why you are paid $$$ at the end. It would be odd to hear a policeman or a soldier to complain they are being shot at. Why do I hear physicians complain all the time that their work is stressful and tiring. Yes, it is. Don’t like it – get out! Find some cushy 9 to 5 consulting job. Don’t embarrass the rest of us.

      • FFP

        80 hours in some specialties can be way less stressful than 40 in some others. ;-)

        The other thing is that you work to live, not live to work. There is a balance that a NORMAL person likes to achieve. The fact that Americans are slaving for their employers for many more hours than their European counterparts does not make it NORMAL. It has nothing to do with cushy; it has to do with quality of life.

        The same way a terminal ICU patient with 1000 tubes and monitors stuck into her does not have a LIFE, a person who works 80 hours a week should not be proud about his “existence”, regardless of the money s/he makes. It has nothing to do with passion, and a lot to do with greed or lack of a normal family life.

        • PoliticallyIncorrectMD

          The assumptions you have made are all wrong. I do practice very “stressful” specialty. I enjoy great family life and me and my wife are raising four beautiful children. I am not motivated by greed either, as my compensation is not tied to my productivity. And, I am very proud of my “existence”.

          Now, back to my point. Once upon a time, people wanted to become physicians not because of the lifestyle, but in spite of it – to make their patients their priority, no matter what. I bet when interviewed for a residency position you did not bring up the lifestyle at all, but rather claimed you wanted to help sick people and sacrifice yourself for others. You talk the talk, now walk the walk. Or move to the side and allow those with right motivation to go forward.

          • FFP

            Is your wife employed?

            I somehow doubt that you work 80+ hours and do 50% of raising four children at the same time. Excuse me, Superman.

          • PoliticallyIncorrectMD

            Good argument!

            Unfortunately, so far the available data suggest that presumed safety gains from decreasing work hours may be offset by the lack of continuity of care.

            Also, it is not the hours that I have problem with. It is the “lifestyle argument” that rubs me the wrong way, however you might be the exception to my rule. ;-)

            P.S.: I don’t mostly cut and sew either and use my brain at times.

          • FFP

            What I meant is that, during a procedure, time might fly faster, there might be a lot of muscle-memory and automatism involved, and there might be less fatigue in the end.

            I do have a good amount of (dis)respect for some surgeons, though. :-)

          • Guest

            Why do you assume that “PoliticallyIncorrectMD” has a wife?

          • FFP

            Because it fits the psychological profile. :-)

          • Mengles

            Blame it on less doctor autonomy, decreased reimbursement, increased govt. mandates, etc.

      • Mengles

        It’s idiots like you that make students run for ROAD specialties.

        • PoliticallyIncorrectMD

          I can feel lots of anger. Too many patients? Not enough sleep? Have to actually work for your money?

          • IndigoBoy0

            Mengles is angry at everything and everyone and must be a miserable primary care provider who I would NEVER want anyone to see.

          • PoliticallyIncorrectMD

            Agree… He in fact proves my point – one should not enter the profession for lifestyle / $$$ or they will be miserable like Mengles blaming everything and everybody for their failure.

          • Mengles

            No anger at all. I applaud people who pursue and are able to get ROAD specialties. It’s people like you I feel sorry for.

        • PoliticallyIncorrectMD

          What makes students run for ROAD specialties is laziness, greed and wrong motivation. They should not be entering the profession to begin with.

          • Mengles

            Such jealousy on your part when those are the ones winning the game.

          • PoliticallyIncorrectMD

            Can hardly call you a winner… whiner seems more appropriate

      • Mengles

        It’s morons like yourself which are the reason students are sprinting towards ROAD specialties.

        • PoliticallyIncorrectMD

          Dude… You are repeating yourself… Have you taken your meds?

  • PoliticallyIncorrectMD

    When was the last time you saw public policy based on data? Most of them are designed to make public FEEL better. No evidence needed.

  • John McNamara

    In my experience I feel like the thirty hour shifts, although grueling, allowed me to learn more and feel more comfortable making decisions about patient care because I knew more about the patients and their trajectory of disease. When handing off after a few hours its barely enough time to get to know a patient much less adequately manage their acute conditions. The limiting factor in extending residency training right now is simply student debt. When looking at more than 200,000 dollars in debt, working for an additional year on a resident salary is tough to swallow.

    • FFP

      The problem is with the resident salaries. As long as a resident is paid about 40% of what CMS pays the hospital for her education (not to speak of the income a resident generates for the hospital), there is no incentive for the hospital not to milk that cow as much as possible. Same goes for the “educators”, many of them using residents as their slaves, not as their mentees.

      • Suzi Q 38

        No wonder the residents were always asking me to pay for their meals.
        -former pharmaceutical rep.

  • Tiredoc

    The problem with a 30 hour shift is that it fails to allow residents to see a patient in the presenting state, formulate a diagnosis, and see the results of the initial treatment.

    Training requires an exposure to a minimum number of patients’ disease process.

    In my opinion, residents should be required to treat a minimum number of patients to graduate. The amount of time and the length of shift should be negotiated between the resident and program, and compensated according to the normal overtime rules of employment.

  • patricia kelly

    I think it is amazing that Canadian Family Medicine training is two years long in its entirety (after medical school) and that GPs in the UK train for two foundation years and then three or four years as GP “residents”. Five or six years vs. two. Outcomes for the two countries do not even remotely reflect this disparity, and GPs in the UK do not hospital work or OB, nor do they generally staff emergency rooms.

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