Tuesday, March 28, 2006

Not enough time for medical training-A problem in Europe as well?

The restriction of work hours for residents has lead to complaints from several fronts and concerns from both sides of the Atlantic.

Aggravated Docsurg has recently discussed the issue and quotes an interesting article in the American Journal of Surgery. The article reveals that 89% of surgery residents who completed an anonymous survey reported they "cheated" on the 80 hour work restriction rule. That is- they worked longer but did not report the hours correctly. This also occurred in 74% of non-surgery residents.

The authors of the article seemed to be alarmed that surgery residents were placing their allegiance to the concept of individual responsibility for patient care above a team approach and to adhere to the rules. When did individual responsibility stop being a core value of being a physician or -in current jargon- a major element of professionalism ? Recent apparent revisions in the expressed views of ACME seem to point in that direction. I have written about that before. In 2003 the ACME eliminated the statement that is a touchstone of interning training:

"Physicians...Must recognize their obligation to patients is not discharged at any given time or any given day".

Are there competing visions- the individual responsibility physician versus the shift work doctor.?

The new work hour restrictions in Europe have generated concern that there is not enough time to properly train specialists.Summer's Radiology Site references an article in which British gastroenterologists report trainees no longer have time to perform the necessary number of endoscopies to become proficient due to the duty time restrictions. This lead to the following comments by one of the GI docs involved in a training program:

"You can't shoehorn more training and other work into less and less time and expect the same quality of training."

This statement echos the opinion of the training program directors quoted above who said:

"There is simply insufficient time to educate the internal medicine residents in the present regulatory environment."

This transatlantic meeting of the minds is sobering. The folks who make the rules (ACGME in the U.S.) and whoever in Europe ought to listen to the real life experiences of those program directors and the trainees who have to live by their rules before we have a generation of less well trained specialists who will go home at 5 p.m.


Anonymous said...

Hmm. Yes, but what about the large number of patient injuries that result from tired interns/residents? Aren't you asking the injured to bear the cost of med school training? Should the trainees themselves bear the cost (as they derive the benefit directly) and just make medical school training longer? Either the med students pay or their patients do--I say let the med students. (And no whining about debt; everyone has it. In relative terms, it hasn't changed much. Further, it makes no difference to the moral/economic argument)

james gaulte said...

One of the possible solutions to the problem of increasing educational requirements and decreasing time avaialable is to increase the length of residency training.IM is currently 3 years post med school, in the past it was 4 years and there was significantly less to learn back then.Why was the training shortened anyway?

mchebert said...

I am just not getting the complaints over this 80 hour workweek requirement. If a resident gets one day a week off, this translates into 80/6 or 13.3 hours a day. If the resident gets no days off ever, it comes to 80/7 or 11.5 days a week. But I doubt residents NEVER get a day off.

In 13 hours a resident should be able to do everything he needs to do, including substantial learning. Anyway, even if 80 is not enough, what is? 90? 100? I don't think very many people could work 100 hrs a week long term. Myself, I can handle 90 for awhile but the returns are diminishing rapidly at that point.

Caring for patients effectively means not just quantity, but quality. Certainly residencies can figure out how to efficiently mange the time of their residents. Efficiency matters in every job, medical and non medical.

I have to scoff at the idea that there is not enough time in 80 hours to get enough colonoscopies. An experienced endoscoper can do a scope in about 20-30 minutes. If a resident devotes 2 hours a day to endoscopies, that would be 4 studies a day, and well over 1,000 studies a year. That, to my knowledge, is enough to qualify for licensure.

I am not against lengthening residencies if programs feel they need more time. However, the longer a residency is the more medical students will be tempted into specialties and away from primary care. Who wants to spend 5 years becoming a family doc when the same time investment will make you an ophthomologist and double your income?