First Posted on his blog on 5/30/2013
It is unfortunate, but now medicine is “on the clock”. We now must not only battle disease, but we must also battle time. Physicians are asked to do more in less time. Innovations such as EMR (which in theory are supposed to increase efficiency) sometimes actually slow clinical practice to a halt. Additionally, ongoing debate exists as to how best train medical residents and prepare them for the practice of medicine. Technology and mhealth applications are changing the way in which doctors and patients interact. Training programs have been evaluated multiple times over the last 20 years and sweeping changes have occurred in the way in which the ACGME regulates the working hours of physicians in training. These changes have a significant impact on the way in which physicians practice once they have completed their residency and fellowship commitments.
Medicine, more than any other profession, is best learned through experiential training. “Hands On” contact with patients and families allows residents to immerse themselves in disease and the continuum of care. Studies from the late 1980s (published in the New England Journal of Medicine) suggested that although resident hours were long and arduous, much of their time was spent doing paperwork and tasks such as drawing blood and transporting patients–even in the era of the 100+ hour week for interns only 20% of the work time was spent in direct patient care. In the early 2000s with increasing pressure from politicians and other organizations, the ACGME issued a statement limiting the work hours of housestaff to 80 hours per week. The arguments that led to the limitations in work hours revolved around mistakes and errors during times of sleep deprivation. Citing patient safety and resident “burn-out” advocates for change stressed that care and learning would both improve if rules were put into place to limit consecutive as well as cumulative work hours. However, a recent study in the Journal of General Internal Medicine explored the difference in mortality pre and post reform. Interestingly, there was no overall change in mortality pre and post reform. In fact, when interviewed, residents and attending physicians complained about the dangers of the “patient handoffs”. In the old days, the “sign outs” would occur only once a day–in the evening to the on call team. Lists were prepared from every team and a verbal sign out would occur doctor to doctor and team to team. In the morning, the on call doctors would discuss the overnight patient events with each team and ensure a proper continuum of care. In the new system with trainees coming and going at different times, there are many opportunities for miscommunication and sometimes important patient care issues get lost in translation. Many times the night call team is not even associated with the particular service they may be covering and may only cover a night or two here and there–resulting in zero continuity of care and no investment in the overall outcome of the patient. More importantly, trainees never truly understand the entire course of a disease process as they frequently only see a portion of the span of therapy due to work hour limitations.
Clearly, the current system for training physicians is lacking. Neither pre reform guidelines nor post reform guidelines are adequate. This week in the New York Times, author Pauline Chen provides a nice review of the course of reform in medical education. However, near the end of her essay, Dr Chen makes her most important points–ultimately, by limiting time spent with patients, we are working to eliminate the formation of the doctor patient relationship. In fact, some data suggests that in addition to a training curriculum for residents most institutions also have a “hidden curriculum” that affects the attitudes of physicians toward their patients once in practice. If the institution is heavy on paperwork and intern “scut work” there is little time for direct patient interaction. These training experiences can shape the way in the doctor relates to patients throughout his or her career. It is essential that we continue to teach doctors how to be healers. No matter what the working hour limitations may be in the future, we must continue to foster skills for building healthy doctor patient relationships in our physicians in training. In addition, we must help residents with time management and discover ways to improve the time that they spend in direct patient care while in training. If we do not, we will find that the art of medicine may in fact be lost forever.