In June 2010, the Accreditation Council for Graduate Medical Education (ACGME) announced new program requirements, calling for a further reduction in duty-hours for first-year residents, an increase in in-house supervision, and an augmented focus on transitions of care. Though not a major change in comparison to the first duty-hours regulations enacted in 2001, it has again raised the question of whether the 36 months of residency training is sufficient.
The fear, of course, is that with less time spent in training, graduating residents will be less competent upon graduation. The reality, however, is that few, if any, residents ever leave training fully competent. The days of “full mastery” of the profession upon graduation have long since passed.
Residency from its inception was not meant to be the end-all of establishing competence; it is three years of “setting the trajectory of the bow”: teaching residents methods of observation and problem-solving, establishing core competence in the fundamentals of the profession, ensuring that essential self-teaching and professionalism are acquired, and then “releasing the arrow,” such that he or she continues to learn and perform the art as part of their practice.
Pundits argue that the duty-hours restrictions lessen the time of ensuring the “accuracy” of the arrow’s aim. But this assumes that every hour of training is equivalent. As an attending physician who used to watch his residents fall asleep during post-call attending rounds (pre-duty-hours regulations), I can assure you that very little learning ever took place in the waning hours of a 36-hour shift (or at the end of a 100-hour week). What did take place were mistakes—mistakes that were subtly integrated into practice patterns.
Lengthening training time to compensate for training hours that were functionally meaningless outside of their service benefits, therefore, has no merit.
Even so, there is the financial question no one is prepared to answer: Who will pay for this additional training time? With federally funded positions capped in 1997, and with a financial climate leaning toward less, not more, compensation in GME funding, it seems unrealistic to think that there will be the 33% increase in GME funding necessary to support an extension in training. And to extend the financial theme, one wonders if the “best and brightest” medical students might cost-adjust their decision in favor of higher-paying professions as the length of training increases to a duration consistent with that required of ophthalmology, radiology, and dermatology.
I propose that instead of lengthening training, we think about the way in which we integrate newly practicing physicians into practice. Despite their innate abilities, these are not the same physicians as veteran hospitalists. Independent of the duty hours, we have to develop a better paradigm of assimilating newly practicing physicians into the profession, with a spectrum of greater supervision of new physicians, extending to greater autonomy as the physician demonstrates his or her skills and abilities in practice.
At the end of the day, with reference to training time, it’s not about quantity, it’s about quality. A fourth day in the hospital for a patient with pneumonia does not ensure better outcomes if the first three days were conducted properly; it just costs more money. As stewards of the profession, it is upon us to think of the way in which we supervise, teach, and empower our resident physicians. TH
Dr. Wiese is associate professor of medicine and residency program director at Tulane University Health Sciences Center in New Orleans, and president of SHM.