How to best train resident doctors

On March 4, 1984 college freshman Libby Zion was admitted to 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.  Issues were raised of inadequate medical care, much to long residents’ working hours and improper supervision by the attending staff.  Case was litigated.  After long and acrimonious proceedings culpability was divided equally  between hospital and the plaintiff (her previous drug use become a factor). The family was awarded $375,000, which amount her father addressed as a travesty of justice.

One of the fallouts of this verdict was restriction of residents’ working hours.  From then on they couldn’t work more than 80 hours per week.  This was based on presumption, that non well rested medical staff makes more mistakes.

Fast forward 30 years.  A few months earlier two studies were published in JAMA, an official organ of American Medical Association.  These papers compared physical and mental condition of residents in 2003 with their counterparts in 2011.The second group was working in a highly regulated conditions of no more, than 80 hours per week and 16 hours of continuous work shifts.

The results were stunning.

First of all medical errors increased 15-20% in the group with less work load.  When shifts were shorter,young doctors still didn’t sleep any more.  They weren’t happier and didn’t study more than 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 from my experience in one of most grueling specialty of cardiovascular and thoracic surgery.  My general surgery residency was on Dr Altemeier’s program in Cincinnati General Hospital in late 70’s.  We were on call every other night, which meant 36 hours in hospital and 12 hours off.  This account for more than 100 hours per week being on duty.  During fellowship in Charlotte Memorial Hospital on cardiac surgery program open heart cases lasted quite 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 is a certain amount of knowledge to be acquired in limited (yes, limited) amount of time.  Future doctor has to see and do enough to be able practice on his or her own.  The physical and mental stamina are very important 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.  Surgeons graduating from busy programs are generally better prepared for practice.  For some however no amount of training  can compensate for technicals and social deficiencies.  Like with athletes, I wish we would be able to predict surgical competency much earlier, before 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.  Well intended, seemingly logical rules applied emotionally to real life scenario quite often backfire.

Medical profession is noble one and public is holding us in high esteem, at least  it used to in the past.  Medical environment is changed and more is to come.  There are no shortcuts however for becoming a doctor and bright minds intending to go in that direction have to know that.

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