Wednesday, June 27, 2007

Do Residency Restrictions Limit Clinical Competencies?

“Good judgment comes from experience. Experience comes from bad judgment.”
-- Anonymous

“I have missed more than 9,000 shots in my career. I have lost almost 300 games. On 26 occasions I have been entrusted to take the game winning shot, and I missed. And I have failed over and over and over again in my life. And that is precisely why I succeed.”
-- Michael Jordan

Ask any doctor in practice today what they think about residency programs, and most will tell you they do not represent medical reality. But then, residency should not represent independent practice, should it? This week, the New England Journal of Medicine has two articles describing the dilemma faced by the residency training programs: residents’ work hours and continuity of care. Residents want shorter work hours by sharing care of patients with other residents, but frequent handoffs of care may result in as many medical errors as created by an exhausted resident.
Kevin Volpp, an assistant professor of medicine and health care systems at the University of Pennsylvania, is conducting a large national study of patient outcomes that attempts to examine the impact of the (Accreditation Council for Graduate Medical Education) rules, using data on millions of patients in the Medicare and Veterans Affairs systems. "We're basically looking at the net effect of reduction in sleep deprivation versus reduction in continuity of care," he said. "One of the big challenges is figuring out how to tease this apart and examine the tradeoffs." Volpp said the evidence is compelling that assigning residents to shorter shifts reduces errors caused by fatigue. However, shortening residents' shifts requires adding staff such as physician assistants, nurse practitioners, and hospitalists, and he noted that despite receiving Medicare subsidies for residency training, teaching hospitals operate on slim financial margins and have recently seen substantial reductions in Medicare funding. Considering the cost of further reducing duty hours, Volpp asked, "Is this the best use of resources that could be targeted to reducing medical errors?"
But is reducing errors really what we should be striving for in residency programs? Will further reducing work hours limit exposure to eduational experiences? Will residents have enough opportunities to stumble, trip and fall in a protected environment like residency so they can later succeed as attending physicians? Or is achieving a residency utopia in training with no medical errors more important than later clinical competency as an attending physician?

Certainly worth pondering…

...especially when good judgment comes from lots of experience.



Anonymous said...

Kevin MD referenced Retired Doc's reference to your thoughts re: restricted house office hours and kicked off some angry comments.Some of Kevin readers thought that Retired Doc and you thought tired resdients was a good idea or at least the price of a good medical education.

DrWes said...

Anony 12:00PM-

Thanks for the heads up. I don't think any of us want residents that are exhaused and error prone. Certainly patients don't want such an individual working on them (I wouldn't). But my point is that to strive for an 'error free' training program might, by its very nature, cause attendings to restrict what they permit residents to do on patients in the interest of patient safety, even though that resident might be completely competent and well-rested. There has to be a happy middle ground and unfortunately, those on the extremes (work too much to not miss a case or work too little to avoid any chance of ever being tired) are both probably wrong.