As most of us are aware, medical education is a long-term endeavor. Medical schools provide students with the informational foundation and thinking skills necessary to be a doctor. Residency forges the knowledge into a usable skill set that builds the final product: a clinician. Like a hand-thrown pot being placed in the kiln to achieve the final step—that is, hardening with a lustrous glaze—newly graduated medical students take their place in residency programs to gain the experience necessary to practice medicine. It is a system that has worked for generations.
It has worked—but at a price. Many older physicians “put in their dues” at a cost of brutal working hours—often exceeding 120 hours per week—with no patient volume caps, no days off, and absolutely no regard for the resident’s home life or family. In recent years, changes have been made in residency programs to limit the hours worked per week and the number of patients a physician in training is expected to admit and cover; primarily, these changes have been imposed on institutions to address issues of patient safety. It may be time to take a fresh look at residency programs and develop creative work plans that accommodate the changing needs of physicians and twenty-first century medicine.1
What has changed? Everything. The patients changed, the doctors changed, our society changed, and the knowledge base changed; literally, nothing remained static. Increasing demand for patient participation in medical decision-making, increasing requirements for medical documentation, and increasing demand for proof of quality performance while concomitantly paring back the working hours permitted per resident have stressed a rigid system to its breaking point. Creative ideas, such as having residents admit to a single hospital floor, are new innovations to adapt quality teaching to the required 80-hour week.1
Additionally, in the past 25 to 30 years, medicine changed from a “man’s career” to a near gender-neutral profession. In 1970, about 7% of physicians were women. By 1980, women accounted for 11.6% of the workforce, and in 2004, women physicians comprised more than 26% of the total.2 With medical school matriculants numbering women and men at near parity—women have made up 45% to 49% of medical school classes since 1999—it is reasonable to assume that the percentage of women physicians will continue to rise annually.3 This process, the feminization of medicine, has created new needs and demands that have not traditionally been identified.4
As previously noted, medical education and training constitute a long-term process that extends into an individual’s later 20s and 30s. Deferred life issues such as marriage and children can wait only so long, and for women the biological clock imposes an earlier time frame than the one for men. Women often want to start a family before the end of their residency training. The traditional residency system was not designed to support multiple extended absences. In most residency programs—77% of programs in one study—maternity absences are handled by requiring the other residents to pick up the slack, an obviously less than happy arrangement.5,6 In the same survey, 83% of residency programs acknowledged that maternity leave had a significant effect on scheduling, despite the fact that 80% of programs had a maternity policy in place.5
It is time for innovative thinking for residency training. New plans must accommodate system needs as well as individual needs and must retain the teaching function necessary to develop the required clinical skills. This can be done, but it requires planning and flexibility. Most residency programs have a maternity policy.5 This policy defines the length of time allotted for maternity leave—free leave, or time off with no make-up requirement. Some programs, such as the one at the University of California at San Francisco, have incorporated a flexible option to accommodate longer absences using flexible make-up time.7