Restricting resident work hours decreases deliberate practice

Pauline Chen has once again written a brilliant piece in the New York Times: Are Today’s New Surgeons Unprepared? While many comments miss her underlying question, her exposition makes the problem clear.

How do we gain expertise? Current theory supports the idea of deliberate practice. How do we conceptualize deliberate practice? Start with a sports analogy. You are trying to learn to make a 6 foot putt. In scenario one you practice putting 6 feet, but you have no hole for the ball . You putt 100 times — excellent practice. We then add a hole, and you still have mediocre performance.

In scenario 2, you practice putting the ball into the hole 100 times. On the test you do much better.

In scenario 3, you practice putting the ball into the hole 100 times, but you also have a coach how gives you feedback on your form. The coach gives instruction, and now you practice a modified putting stroke. On the test you do even better.

I hope this makes the principles of deliberate practice clear. You must do repetitions with feedback and immediate instruction.

Becoming a surgeon (or any other physician specialty) requires deliberate practice. Volume matters. Following the patient from the beginning to the end of the clinical incident makes a difference. Let’s imagine the problem of abdominal pain due to appendicitis.

To really learn about appendicitis, the surgical novice must examine many patients with abdominal pain, learning to recognize the surgical abdomen. The novice must then learn the evaluation of the surgical abdomen. In the best scenario the novice goes to the OR with the patient and learns first the cause of the pain (nothing like actually looking at the inflamed appendix), and the learning step-by-step how to remove the appendix. Of course sometimes the problem is not the appendix, and learning that and what to do next becomes part of the education. Finally the novice must care for the patient during the post-operative period to totally understand the disease and surgical process.

While that seems complex, the above paragraph actually is a bit too short and incomplete.

Medical interns must learn to recognize community acquired pneumonia and clearly know when the patients does not have that diagnosis. They learn the usual response to antibiotics, and hopefully understand that when the response is not usual, perhaps the initial diagnosis is incorrect.

Too often, in an attempt to meet somewhat arbitrary work hour restrictions, training programs unlink the steps of the disease process. We have one group of trainees admitting the patient, another group following the patient, and a different group seeing the patient after discharge. All three groups have decreased learning as a consequence.

We have developed systems to hopefully improve the resident’s quality of life, but have we designed those systems to allow adequate deliberate practice. We who trained in the “bad old days” worry about the current training model. We have a responsibility to raise these questions.

How do we provide our trainees with satisfactory volume and satisfactory continuity? How do we help them with their deliberate practice? The answers are not easy, despite the protestations of those who did not go through the old process.

Congratulations to Dr. Chen for clearly outlining the problem.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • rbthe4th2

    There is a fine line between practice and working someone to death. Maybe taking the interns and residents off the computer and more on patient care would help?

    • Robert Centor

      If you read my post carefully, I do not advocate “working someone to death”, although I did work 100 hours per week 38 years ago as an intern and am still alive (insert sly grin here).
      The problem is that most programs meet the letter of the rules, but do not make adjustments to enhance deliberate practice. We need programs to rethink call structures and responsibility structures.
      I do think that selected 24 hours shifts help education, despite the sleepiness. It is important to see disease progression and learn from that.
      We need (and believe we have) good supervision of interns.

      We have a major future problem if our trainees are inadequately trained. For they will become our own physicians soon.

      Physicians have great responsibility, which we accept gladly. We need superb training, unencumbered by inflexible rules. We need creativity in designing our training programs, and I personally believe that many programs are stuck with models that meet ACGME standards while impeding practical education.

  • MM

    It seems to me, a non-physician, that there are some possible third paths.
    What about extending residency a year?
    What about decreasing work hour restrictions as the resident gets more experienced? I imagine that much of the fatigue felt by first year residents is due to the fact that everything is new, everything involves enormous mental energy and anxiety. When you get more experienced, doing the same tasks is no longer as exhausting.

    • rbthe4th2

      and they’d get better at it.

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