Will resident autonomy disappear completely in the future?

Recently, our residency program had the excellent fortune of hosting Dr. Bob Wachter as a visiting speaker. Dr. Wachter is considered a pioneer in the hospitalist movement and has built his career around inpatient quality and safety. During lunch with Dr. Wachter, some of our residents, and hospitalist faculty, we discussed the topic of resident autonomy in the hospital.

In the glory days of residency, I imagine that house officers experienced autonomy in its truest sense of the word: self-rule and utter independence. At least that’s the impression I have from Stephen Bergman’s (a.k.a Samuel Shem’sHouse of God … a Lord of the Flies–like island inhabited by unsupervised and uninhibited junior physicians.

We all know that the 21st century’s inpatient environment leaves less room for such resident independence — and shenanigans, for that matter. Through regulatory and advisory bodies, patient advocacy groups, and our own recognition, we are now rightly focusing on other domains of hospital care. The main priority is not to “just let the doctors take care of patients how they want.” With this sea change, resident autonomy has evolved accordingly — both in practice and as a concept.

In case you haven’t heard, the quality and safety era is here to stay. Because true autonomy and “learning by doing” can potentially stand squarely at odds with quality metrics and the safest possible outcomes, I have to wonder:

  • Will resident autonomy disappear completely in the future?
  • How has autonomy changed already?
  • And how will trainees learn to practice independently with all of this change?

Anyone that works in graduate medical education knows that duty-hour reform fundamentally shook the resident learning experience and thus affected autonomy. Since the additional 2011 duty hours changes were enacted, teamwork has become the name of the game. Residents routinely are forced to pass off decisions or depart before the implications of their decisions materialize. Attending physicians now seemingly shoulder more of the clinical workload, too, when residents’ shifts are truncated by a requirement to leave the hospital.

There is also probably universal agreement that the imperatives to reduce hospital length of stay and to facilitate safe discharges affect resident independence. As an attending, I know the pressures that the hospital is under, and I often feel compelled to be very directive about making prompt discharge a reality.

I doubt that residents would feel that either of these changes has eliminated their autonomy completely. Often in medicine, there is no single correct way to achieve an end. For this reason, residents can still safely be given leeway in many clinical decisions. There is still some art in what we do, and autonomy lives to see another day. But there are looming changes on the horizon that might threaten resident autonomy even more. Those that spend time in the hospital training environment recognize that all participants in inpatient care will increasingly be measured by how well they do their jobs. It is hard to conceive of a system in which residents and the attendings that supervise their care will be spared from aggressive quality improvement.

The stakes are simply too high nowadays. Health care is expensive and still unacceptably unsafe and unhelpful. With mounting pressures to provide higher value care, residents’ decisions are likely to undergo more scrutiny. Why is resident A ordering more CT scans than resident B? Why are resident C’s patients staying in the hospital 2 days longer than resident D’s?

In my own experience as a chief resident, I know that residents still want autonomy. Heck, autonomy was my top priority in evaluating residency programs myself. As I have interviewed and met a number of applicants to our program during this residency match season, I sense that soon-to-be trainees are also putting autonomy high on their list of values. I like to tout my program’s emphasis on autonomy. I try to foster resident growth while attending on service by relaxing the reins. I know the term autonomy doesn’t mean what it once did. Yet I do have hope that we can still give residents the leeway to “learn by doing” while preserving the health of the patients we serve and the financial stability of our healthcare system and our country.

Paul Bergl is an internal medicine physician who blogs at Insights on Residency Training, a part of NEJM Journal Watch.

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  • http://www.ronsmithmd.com/ Ron Smith

    Hi, Paul.

    Good article and I can’t agree more.

    Duty hour limitations have been detrimental to the goal of achieving the leadership qualities that often cannot be learned any other way. Knowledge can be come by anytime, but critical decision making only comes by being on the scene at the right time.

    I remember when I was a Pediatric resident at the University of Oklahoma, Tulsa Medical College, we rotated among three hospitals. The largest of these was St. Francis and it rose like a high tower covered in pink marble. It was 1000 beds then.

    As a resident, third year I think,I remember being called to take over a code on a child in the ER there. As soon as we Pediatric residents arrived and took over, all the ER physicians stepped away and left!

    Critical decision making can only fully be learned in the middle of critical situations.

    To be honest, nobody likes to work long hours, and especially me at that time. Stacy and I had a newborn at home and I was on call every third to fourth night at a hospital, and every other night at home! Shifts were thirty hours long.

    But there was something amazing that happened to me.

    When I finished residency, I felt so competent, especially in level three neonatal care, that I continued doing it in a private solo practice…for six and a half years! Critical thinking had become a way of life as did 12hour+ days. I remember the smallest baby was a pound and thirteen ounces, got Exosurf at delivery (before it was ever released), and went him in about three months with really no problems! The town only had 25,000 and the hospital about 150 to 200 beds as best I can remember.

    I feel for residents today, and I don’t know how to rectify the need to learn critical leadership and the reduction in duty hours. I remember talking to a good friend from Arkansas Children’s Hospital which was first on my residency match while at UAMS in Little Rock, Arkansas. I was hearing horror stories about residents who did not know how to treat status asthmaticus.. The recipe for aminophyllin drips was pounded into us and I never lost an asthma patient…never even close.

    Well aminophyllin drips are a thing of the past, but the critical thinking behind it must never go away.

    I would be very interested to know what duty hours others experienced both in the far and near past?

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

  • Patricia Thomas

    Relaxing “the reins,” not “the reigns.”

    • http://www.kevinmd.com kevinmd

      Thanks, this has been fixed.

      K

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