Are today’s newly graduated residents ready to practice medicine?

A newly minted physician, one who has just graduated from medical school, is not yet ready (or licensed) to practice medicine. The next phase in medical training is called residency, a 3 to 5 year span of time during which the new doctor is given teaching, supervision, and increasingly allowed to function independently in his or her chosen specialty.

Since 2003 residents have been limited to working 80 hours per week, averaged over 4 weeks, with no individual stretch being longer than 16 hours. The rationale for this time restriction is reasonable and difficult to argue with: It dates back to the famous Libby Zion case. She died, and analysis of the case implicated resident fatigue and lack of supervision as contributing significantly to her death. The tragedy focused attention on the ways that overworked, overtired, and poorly supervised residents can harm patients. We don’t want that. But we don’t know the right balance between the patient care service residents provide and their education.

There is no doubt that for many years residents put in too many long hours — well over 100 per week was common. I did that when I trained in the late 1970s. The first year, long called the internship year, was the most brutal. In my case that amounted to at least 120 hours per week, often longer. We got every third Sunday afternoon off — if it was quiet. Subsequent years were less onerous, but always were 100 hours or more.

There is also no doubt that medicine is a career you learn by doing, so sitting in a lecture hall until you see your first patient as a physician is not the way to train doctors, although it was once done that way a century ago in the era before the Flexner Report. Have we found the right balance among the competing claims of resident education, practical on-the-job experience, and patient safety? A recent review article from the Annals of Surgery,  “A systematic review of the affects [sic] of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes,” gives us some useful information about the question. It is particularly useful because surgery residents must have more than abstract cognitive skills; they also need quick and decisive decision making skills and physical dexterity, which they can only get through practice. The American College of Surgeons has been particularly concerned about the effect reduced duty hours has on resident skills.

The review linked above is what is called a meta-analysis. This is a technique in which many smaller studies are pooled together to yield a larger data set, in this case a total of 135 separate articles. The results were disconcerting for advocates of duty hours restrictions. First, there was no improvement in patient safety. In fact, some studies suggested worse patient outcomes. Resident formal education may well have suffered; in 48% of the studies resident performance on standardized tests of their fund of knowledge declined, with 41% reporting no change. Importantly, only 4% reported improved resident performance. Resident well-being is difficult to measure, but there are some survey tools that assess burn-out; 57% of the studies that examined this showed improved resident wellness and 43% showed no change. So the bottom line is that, for surgical residents, duty hour restrictions were associated with better rested residents doing no better, and often worse, on assessments of their knowledge base. Patient safety, a key goal of the new rules, did not improve and actually may have been worse.

What are we to make of this? I can understand how resident test performance suffered. It suggests to me that most learning takes place at the patient bedside or in the operating room; in this analysis the additional free time for independent study didn’t help, either because residents didn’t do it or it’s not as effective. But what about patient safety? Why did that actually go down in more than a few of the studies?

One reason my be the problem of handoffs of care. When duty shifts of residents are shorter they need to handoff care of their patients to someone else. It’s well known that these are potentially risky times since the resident assuming care probably doesn’t know the patient as well. Under the old system, I often would admit a sick patient and stay caring for that patient for 24-36 hours. When that happens you really get to know the details of your patients well. From an educational perspective, you also see the natural history of an illness as it evolves. Finally, you develop a closer relationship with patients and their families than happens if residents are continually coming and going.

For myself, I am conflicted over how well we are doing training residents under the new rules. I don’t want to be like an old fart sitting on the porch and yelling at the neighborhood kids to get off my lawn. The old days were not necessarily the good old days. The system I trained under was brutal to residents and sometimes dangerous to patients. But it also crammed an immense amount of practical experience into the available time. Today’s residents are denied that experience, and it shows. I am occasionally astonished by encounters with senior residents who have seen only a couple of cases in their lives of several not uncommon serious ailments.

What can we do? Some medical educators think that new advances in computer simulations and the like will substitute for lack of encounters with the real thing. Procedural specialties like surgery are particularly interested in simulations. We use them in pediatric critical care as well, and they help.

The bottom line is that the duration of residency has not changed in half a century or more, yet we are demanding that residents know more and more. Then we shorten their effective training time by duty hour restrictions; for some specialties it’s the equivalent of lopping a year off the residency. From what I have seen in my young colleagues, the practical result is that the first year or two of independent practice amounts to finishing the residency, acquiring the needed experience. Perhaps we should be honest about that and have the first couple post-residency years of being a “real doctor” be structured as getting mentorship from an experienced physician. As things stand, I think a fair number of finishing residents aren’t quite — almost, but not quite — ready to have the training wheels taken off their bikes.

Christopher Johnson is a pediatric intensive care physician and author of Keeping Your Kids Out of the Emergency Room: A Guide to Childhood Injuries and IllnessesYour Critically Ill Child: Life and Death Choices Parents Must FaceHow to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

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  • Dr. Drake Ramoray

    I am much more against the residency training hour restrictions than the author of this piece. Regardless, the absence of mentioning the current push to shorten residency training is a rather glaring omission in this piece.

    http://www.slate.com/articles/health_and_science/medical_examiner/2014/03/physician_shortage_should_we_shorten_medical_education.html

    http://virtualmentor.ama-assn.org/2005/06/oped2-0506.html

    http://jama.jamanetwork.com/article.aspx?articleid=1105095

    • http://www.chrisjohnsonmd.com/ Chris Johnson

      I make no claim in my blogging to be writing comprehensive topical essays or literature reviews. Do you?

      • Dr. Drake Ramoray

        I hardly expect you to write a comprehensive dissertation on the subject however as I pointed out above, albeit in retrospect too aggressively, I think it rates at least a mention in your piece especially considering that logic would dictate if board pass rates are dropping, you propose that residents aren’t ready for practice (we agree on this point), it would seem to be an extenuation of the given topic especiallay considering it has been a relatively frequent topic on Kevinmd as well.

        • http://www.chrisjohnsonmd.com/ Chris Johnson

          I don’t write for Kevin–nobody does. He mostly uses blog posts folks put up elsewhere (mine was on my blog) and collects them together here. He runs an aggregation site, and he’s very good at that. It’s a great place to survey what people are thinking about.

          Since you seem to dabble in a bit of snark, I’ll ask you what “logical extenuation” means. Some kind of well put together excuse?

          • Dr. Drake Ramoray

            So far your rebuttals to my points have been that you post isn’t intended to be comprehensive and pointing out a spelling/autocorrect error from a post on my smart phone at lunch.

            I have a much better understanding of your position on something you omitted that pertains to the bigger picture as it relates to your post.

            Strong work.

            I do hope yoy have a great afternoon.

          • http://www.chrisjohnsonmd.com/ Chris Johnson

            I am well and truly wounded. You win the comment thread.

            I’d love for you to stop by my blog and point out my many other errors of omission. I’m sure it would be very instructive.

            Pro tip — you might want to work on your logorrhea first, though.

  • ninguem

    Hippocrates had nothing but disdain for the class of 397 B.C.

    None of them knew their arnica leaves from digitalis purpurea, and you should have Acacius try to bleed that patient last week.

    By Agamemnon, I swear it took him all day to fill that amphora.

    Don’t even get me started on their crappy leech technique.

    I’m saving my drachmas and move to Rome and go to advocatus school.

    • http://www.chrisjohnsonmd.com/ Chris Johnson

      And you kids get off my lawn with your loud hippity-hop music, your pants hanging down to your knees, and those ball caps on backwards.

      Hurrumph.

  • http://www.chrisjohnsonmd.com/ Chris Johnson

    I didn’t know that — thanks. What happens if residents want to stay past their allotted time? Our residency program director gets upset — not so much for the residents as for the higher authorities might say. It’s kind of odd.

    • Dr. Cap

      What happens? Well if the ACGME finds out during a site visit, the program is placed on probation. If not remedied, your program loses accreditation. Then what happens? You have no program to finish.

  • DrTWillett

    The short answer is a resounding NO. As part of the class of 2007 (a wee baby!) I wasn’t prepared, and it wasn’t just work hours. I was prepared to go into a fellowship or become a hospitalist, not provide general primary care. Primary care involves different issues, paperwork, etc.
    I do think that there should be a separate track for those who wish to go through primary care only, with some decreased inpatient staffing responsibilities to allow for more actual time ‘practicing’ the art of primary care. There are plenty of chicken/egg arguments, but I recall as a chief resident feeling that scheduling my residents was all about staffing for various wards and not so much about getting them exposed to a broad swath of medicine. Case in point: 6+ months of NICU. I love ex-NICU babies in my practice, but I will never, ever wait on a delivery again or intubate said preemie if I can help it.
    And as much as it pains me to admit it, medicine is not usually shift work. The more time-protections get built in for residents, the fewer protections there are for the attendings.