The questionable competency of today’s medical and surgical residents

What does it mean to be competent at something? Competency may be defined as the ability to do something successfully or efficiently. When it comes to determining if a physician is competent in his profession, no one, board, no organization, no government, no residency training program or hospital actually will state that an individual is competent. There are significant legal ramifications to declaring someone as competent to practice medicine, and a maloccurence happens. Would the organization that states a physician is competent become legally responsible?

In medical school, residency and fellowship programs, trainees need to demonstrate proficiency in core competencies specific to medicine. The ability to gather information, interpret the information and form a management strategy along with the ability to perform a variety of interventional tasks are inherent to the role of being a physician. Medical students must pass national subject exams, national board exams, mock patient interview and physical exams. Residents and fellow must pass annual in-service exams for advancement and board exams regulated by the American Board of Medical Examiners to become board certified. To take the board exams, one’s residency director certifies that the trainee has completed and met the requirements of the training program.

The state mandates that physicians are licensed to practice medicine. One’s application includes diplomas from medical schools and residency programs, and a certificate of completion from the national board of medical examiners. One then is licensed to practice medicine and surgery. Most physicians practice beyond the four walls of their office and may have admitting and or operating privileges at a hospital or surgical center. The assumption is that licensure and having one’s boards is a measure of competency, and, for the most part, it serves well.

In 1989, New York State enacted the 405 regulations limiting resident work hours, as the result of a commission evaluating the causes of the death of the daughter of a prominent journalist at New York Hospital. The commission blamed resident work hours and poor supervision for the death. This was a controversial finding with little data to support such sweeping changes.

I was a junior resident at St. Luke’s-Roosevelt Hospital Center at the time, and we were very concerned about the impact on our training as surgeons. A surgeon has to know a lot and do a lot. Fewer hours in the hospital meant fewer chances to perform surgery and follow patients. We worried that when on-call were covering far more patients than we normally did. Patients that we did not normally cover, so we were at a disadvantage in providing care. We used to joke that “405” meant the 4th or 5th-year residents now did all the work, while the intern and junior residents went home. The choice was between having a tired doctor that knew you versus a less tired doctor that had never seen you before.

In 2003, the Accreditation Council for Graduate Medical Education made the cap of an 80-hour work week mandatory nationally. The length of shifts were limited. Time off between overnight shifts required. In a surgical residency, what had been a full-time duty, had become shift work with penalties to the training institution for violation. As a faculty member of a university, I was concerned that we were making a major change to how we train physicians without first defining how competent our current product was and not knowing if the decreased “time on topic” would result in less competent trainees.

In a recent article in the New England Journal of Medicine, the end points of patient mortality and complications along with resident satisfaction were compared between surgical training programs that adhered to the work hour mandates versus more flexible policies that waved the rules on maximum shift length and time off between shifts. The results were that there was no difference in patient outcomes among the groups. No mention or measurement standard was applied towards assessing resident competency.

Shouldn’t the competency of residents be the subject in a training program?

Gary B. Nackman is a surgeon and owner, NJ Vein Care.

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