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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