Medical Residency's Decline

Although I never considered myself as an "old-timer" in medicine, I guess the fact that I was trained before the new Residency Review Committee's work-hour limits makes me just that: an old fart in medicine.

The Wall Street Journal's Health blog has a review of an article published in the Archives of Internal Medicine regarding the perspective us "old-timers" have on residency training. The comments that ensued on that blog demonstrate the fervor that residents feel regarding the cheap labor and long hours they provide for hospitals, and certainly, no one wants care provided by an individual who can barely stay awake.

But some old-timers, trained by The Man, also feel that residency experiences have declined because they don't suffer like we did. What are you, wimps? You're missing all the good cases!

But has residency training suffered just because of the RRC's restrictions on work hours? I don't think so. It is just too easy to blame work hour restrictions on the decline of residents' training. I certainly agree that care has become fragmented, in part because of these restrictions. But I would argue that there are other more powerful forces in play.

I see many, many more patients shunted to in-hospital hospitalist services that are productivity-driven. These eager inpatient attendants to health care are a formidable challenge to managing inpatient teaching services: patients are seen quickly, decisions expedited, and lengths of stay minimized, making a powerful inducement for hospital systems to employ these services. Teaching services are rarely as efficient since teaching takes time and, regrettably, time is money. After all, exceeding lengths of stay and the razor-thin cost margins that hospitals must work within to make ends meet are quickly upended. Where is the financial incentive for the teacher to teach? Training hospitals get a reimbursement bonus for training from our government, why not our teachers?

And lets not forget the Electronic Medical Record. Careful decisions regarding the appropriateness of tests have been supplanted by order "panels" that remove decision making from the doctor. Just push a button and the "critical pathway" orders are automatically generated. No thought needed. Zillions of often unnecessary and waistful tests created in the blink of an eye. What, you DARE to remove a checkbox? Off with your hand!

Academic centers across the US are all confronting these challenges as cost escalate, reimbursements decline, and centers are squeezed to find good teachers willing to work for non-reimbursed time. The impersonal technology, from EMR's to robots, has supplanted the bedside touch. It is no wonder that residency education has suffered in kind.

-Wes