How to best train resident doctors

On March 4th 1984, they admitted college freshman Libby Zion to the New York hospital with high fever and agitation. Despite efforts of medical intern, medical resident and attending physician, she died the next day. Her father, a prominent NY lawyer and journalist Sidney Zion, was obviously devastated. The death raised the issue of the inadequate medical care, much too long residents’ working hours and improper supervision by the attending staff. The case was litigated. After a long and acrimonious proceedings, culpability was divided equally between hospital and the plaintiff (her previous drug use become a factor). They awarded the family $375,000, which amount her father addressed as a travesty of justice.

One fallout of this verdict was the restriction of residents’ working hours. From then on, they couldn’t work over 80 hours per week. This was based on a presumption that sleep-deprived medical staff makes more mistakes..

Fast forward 30 years. They published the two studies in JAMA, an official organ of the American Medical Association. The papers compared physical and mental condition of residents in 2003 and 2011. The second group had regulated conditions of no more than 80 hours per week and 16-hour work shifts.

The results were stunning.

First of all, medical errors increased by 15-20% in the group with less work load. When shifts were shorter, the young doctors still didn’t use the extra time to sleep. They weren’t happier and didn’t study more than a group with longer hours. Actually they learned less, because first group’s teaching sessions were arranged during working hours. Incidence of depression was close to 20%, similar in both groups.

I would like to comment on my experience in one of the most grueling specialty of cardiovascular and thoracic surgery. My general surgery residency was on Dr Altemeier’s program in Cincinnati General Hospital in the late 70s. We were on call every other night, which meant 36 hours in hospital and 12 hours off. This accounted for over 100 hours per week being on duty. During fellowship in Charlotte Memorial Hospital on cardiac surgery program, open heart cases lasted often 12 hours and more. So when I came back to see my father in Poland, when he was sick, his question was, “And when do you have time to go to the bathroom?” I didn’t think of that much then, but I understand what was he talking about.

During surgical residency, there’s a certain amount of knowledge to be gained in a limited (yes, limited) amount of time. Future doctor has to see and do enough to be able to practice on his or her own. The physical and mental stamina are a significant factor in development of a competent surgeon. Obviously, not everyone is (nor should be) cut out to be a cardiac surgeon. Lowering of standards, as studies show, does not improve results of training. And we see it very well in private practice, when new doctors right after training are joining out medical staff. The surgeons graduating from busy programs are generally better prepared for practice. For some, however, no amount of training can compensate for the technicals and social deficiencies. Like with athletes, I wish we could predict surgical competency much earlier, before the start of a program. Learning to be a doctor doesn’t conform to rules and regulations designed for a factory workers. Teaching cases do not come on schedule and one can only learn so much from books. Intended with a good faith, logical rules applied emotionally to any real-life scenario can often backfire.

Medical profession is a noble one and public is holding us in high esteem, at least it used to in the past. The medical environment is changing and there is more to come. However, there are no quick routes to becoming a doctor, and aspiring minds who wish to pursue that path must know this.

Related article

Changes needed to reduce fatigue of Canada’s medical residents: report (ctvnews.ca)