By: Julia Callaway,
on 2/19/2015
Considerable variation in quality exists among residency programs in the United States, even among those in the same specialty, such as surgery, pediatrics, or internal medicine. Some are nationally and internationally renowned, others are known regionally, and still others are known only locally.
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By: Catherine Fehre,
on 1/2/2015
The country has long had too many specialists and subspecialists, so the common wisdom holds. And, the common wisdom continues, the fault lies with the residency system, which overemphasizes specialty medicine and devalues primary care, in flagrant disregard of the nation’s needs.
It was not always that way. Before World War II, medical education practiced birth control with regard to the production of specialists. Roughly 80% of doctors were general practitioners, only 20% specialists. This was because the number of residency positions (which provided the path to specialization) was strictly limited. The overwhelming majority of medical graduates had to take rotating internships, which led to careers in general practice.
After World War II, the growth of specialty medicine could not be contained. The limit on residency positions was removed; residency positions became available to all who wanted them. Hospitals needed more and more residents, as specialty medicine grew and medical care became more technologically complex and scientifically sophisticated. Most medical students were drawn to the specialties, which they found more intellectually exciting and professionally fulfilling than general practice (which in the 1970s became called primary care). The satisfaction of feeling they were in command of their area of practice as an additional draw, as was greater social prestige and higher incomes. By 1960, over 80% of students were choosing careers in specialty medicine — a figure that has not changed through the present.
The transformation of residency training from a privilege to a right embodied the virtues of a democratic free enterprise system, where individuals were free to choose their own careers. In medicine, there were now no restrictions on professional opportunities. Individual hospitals and residency programs sought residents on the basis of their particular service needs and educational interests, while students sought the field that interested them the most. The result was that specialty and subspecialty medicine emerged triumphant, while primary care languished, even after the development of family practice residencies converted primary care into its own specialty.
This situation poses a perplexing dilemma for the residency system. More and more doubts have surfaced about whether graduate medical education is producing the types of doctors the country needed. No one doubts that having well-trained specialists is critically important to the nation’s welfare, but fear that graduate medical education has overshot the mark. Ironically, no one knows for sure what the proper mix of specialists and generalists should be. A popular consensus is a 50-50 mix, but that is purely a guess. One thing is clear, however: The sum of individual decisions is not meeting perceived public needs.
At the root of the problem is that fundamental American values conflict with each other. On the one hand, the ascendance of specialty practice service serves as a testimony to the power of American individualism and personal liberty. Hospitals and medical students make decisions on the basis of their own interests, desires, and preferences, not on the basis of national needs. The result is the proliferation of specialty practice to the detriment of primary care. This situation occurs only in the United States, for the rest of the Western world makes centralized decisions to match specialty training with perceived workforce needs. Medical students in other countries are not guaranteed residency positions in a specialty of their choice, or even a specialty residency in the first place.
On the other hand, by not producing the types of doctors the country is thought to need, there is growing concern that graduate medical education is not serving the national interests. This would be a problem for any profession, given the fact that a profession is accountable to the society that supports it and grants it autonomy for the conduct of its work. This poses an especially thorny dilemma for medicine, in view of the large amounts of public money graduate medical education receives. Some medical educators worry that if the profession itself cannot achieve a specialty mix more satisfactory to the public, others will do it for them. Various strategies have been tried — for instance, loan forgiveness or higher compensation for those willing to work in primary care. However, none of these strategies have succeeded — in part because of the professional lure of the specialties, and because of the traditional American reluctance to restrict an individual’s right to make his own career decisions. Thus, the dilemma continues.
Headline image credit: Hospital at Scutari, 1856. Public domain via Wikimedia Commons.
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By: Julia Callaway,
on 10/3/2014
Residency training has always had — and always will have — a dual mission: ensuring the safety of patients treated today by doctors-in-training, and ensuring the safety of patients treated in the future by current trainees once they have entered independent practice.
Surprisingly, these two goals conflict with each other. That is because proper graduate medical education, as I have explained in an earlier essay, requires doctors-in-training to assume responsibility for the management of patients. It is not enough for residents to watch senior physicians evaluate patients, make decisions about diagnosis and therapy, and perform procedures. Rather, trainees must learn to exercise these responsibilities themselves during their residency, lest their first patients in practice become victims of inexperience and inadequate preparation.
For this reason, the needs of today’s patients and those of tomorrow’s are not necessarily the same. Future patients depend on having well prepared doctors who gained extensive independent experience as residents. Their needs are served when inexperienced trainees manage complicated patients or perform major operations today, so once in practice doctors will be able to serve patients maximally. However, today’s patients benefit when they are cared for by the most experienced physicians available. Thus, residency training must consider the safety of both present and future patients. The challenge of achieving this balance has become particularly great during the last generation, as hospitalized patients have become much sicker, hospital stays much shorter, and medical practice ever more powerful and complicated. Mistakes of omission and commission now carry potentially greater consequences.
The key to maximizing the safety of both present and future patients is by providing house officers effective supervision in their work. Many studies have found that closer supervision of residents leads to fewer errors and improved quality of care. One review observed that increased deaths were associated with poor supervision of residents in surgery, anesthesia, emergency medicine, obstetrics, and pediatrics. Another study showed that the impact of better supervision on patient safety was particularly marked with less experienced residents. Despite the contemporary furor surrounding the issue of residents’ work hours, proper supervision has consistently been found to be much more important to ensuring patient safety than house officer fatigue.
We have much to learn about supervisory practices in medical education. However, current evidence suggests that the supervisory relationship is the single most important factor in the effectiveness of supervision. Especially important in this relationship are continuity over time, the supervisor’s skill at discharging oversight responsibilities while preserving sufficient intellectual autonomy for trainees, and the opportunity for both trainees and supervisors to reflect on their work. Other qualities of effective supervision have also been identified. Supervisors need to be clinically competent and knowledgeable and have good teaching and interpersonal skills. The supervising relationship must be flexible so that it changes as trainees gain experience and competence. Residents need clear feedback about their errors; corrections must be conveyed unambiguously so that residents are aware of mistakes and any weaknesses they may have. Helpful supervisory behaviors include giving direct guidance on clinical work, linking theory and practice, joint problem solving, and offering feedback reassurance, and role modeling. Ineffective supervisory behaviors include rigidity, intolerance, lack of empathy, failure to offer support, failure to follow trainees’ concerns, lack of concern with teaching, and overemphasis on the evaluative aspects of supervision.
Good supervisors, like good teachers, are made, not born. One advantage of proper supervision is the role modeling it offers residents for the supervision that they themselves may later provide. In addition, there is evidence that faculty can taught and motivated to be better teachers and supervisors.
It should be noted that good clinical supervision, like good teaching, is time-consuming. Many faculty members today find it difficult to provide the time necessary for close supervision and effective teaching because of the pressures they are under to increase their clinical or research “productivity.” For better supervision to flourish, medical schools will have to be willing to place a higher priority on the educational mission than in the past. This will entail a greater institutional willingness to promote clinical-educators, as well as the adaptation of “academies of medical educators,” mission-based budgeting, and other strategies to raise or identify funds to pay for clinical teaching and supervision. If patient safety is the goal, this is an effort worth undertaking.
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By: Alice,
on 9/5/2014
America’s system of residency training — the multi-year period of intensive clinical study physicians undergo after medical school and before independent practice — has dual roots. It arose in part from the revolution in scientific medicine in the late nineteenth century and the infatuation of American educators of the period with the ideal of the German university. However, it also had roots in medical practice, particularly in the apprenticeship system. Accordingly, it developed many characteristics of an institutionalized apprenticeship. These dual roots of the residency system account for its defining dilemma: the tension between the responsibility of residency training to provide high-level professional education and the desire of sponsoring hospitals to extract as much inexpensive labor from their residents as possible.
The “education versus service” tension has shaped the residency system in America at every moment of its development. Graduate medical education has always imposed on house officers a vast amount of chores (called “scut work” by interns and residents) that easily could be done by individuals without the MD degree. These include drawing blood specimens, starting intravenous lines, carrying blood to and from the blood bank, remaining physically present throughout a blood transfusion, filling out routine forms and requisitions, labeling specimens and carrying them to the laboratory, transporting patients to and from the X-ray department or procedure rooms, holding retractors during surgery on patients they do not know, and performing a variety of chemical, bacteriological, and hematological tests. Since the 1990s, traditional chores have become fewer, as many hospitals have hired more phlebotomists, IV teams, transport personnel, and laboratory technicians. However, house officers have increasingly found themselves with a much larger burden of administrative chores, such as scheduling tests, arranging for procedures, calling for consultations, and handling all discharge arrangements. “Scut work” has not disappeared, though it has changed in form.
The burden of “scut work” has never fallen on all house officers equally. In general, interns and junior residents have been burdened with a far larger amount of chores than more senior residents. The amount of “scut work” has always been much more in some fields, such as general surgery, than in others, such as psychiatry. The burden of chores has always been the greatest at small, private, community hospitals not affiliated with a medical school and at city and county hospitals, where funds available for support personnel are often scarce. However, even at the most prestigious teaching hospitals, house officers have never been strangers to “scut work.”
The problem with these activities is not that they are unimportant to patient care. Rather, it is that they can be done equally well by ancillary staff without medical training. These duties can be effectively performed by phlebotomists, transport personnel, laboratory technicians, nurses, and clerks. In doing these tasks, house officers are working far below their levels of competence. These chores typically come on top of their medical duties and hence easily interfere with their learning and care of patients. The work usually gets done, but the cost is frequent exhaustion and frustration.
The tension between education and institutional service requires all involved to remember certain points. House officers and faculty alike know that “education” does not simply mean spending time at conferences and lectures. Rather, they understand that most learning comes from the direct care of patients, with discussions, reading, and reflection supplementing the process. In addition, house officers and faculty know that the sine qua non of a good residency is the opportunity for house officers to assume responsibility in patient care. This means, among other things, that the responsible house officer will do anything necessary for their patients’ care, even if it is not really in their job description. Thus, the responsible house officer will draw a sick patient’s blood at 2 AM if no one else is around to do it. What distinguishes work that is legitimately a part of clinical responsibility from “scut work”? Common sense. It is one thing for an intern to draw blood at 2 AM from their own patient. It is quite another to come in an hour or two early every morning to draw blood from every patient on the floor because the hospital does not wish to spend the money to have a phlebotomy team.
Over the past century, medical educators have been keenly aware that house officers have been saddled with many tasks that carry little educational value. Yet, the economic exploitation of house officers has continued unabated.The reason for this is not hard to find: hospitals and faculties alike benefit too much from the work of house officers. Hospitals benefit financially. With house officers, hospitals can hire fewer clerks, dispatchers, orderlies, laboratory technicians, and phlebotomists. Private practitioners, both at teaching and community hospitals, know that a good house staff allows them more efficient days in the office and calmer, more restful nights and weekends at home. Full-time faculty members similarly benefit. Relieved by house officers from many details of patient care, they are free to devote more time to research, scholarship, and their own private practices.
Thus, exhortations to reduce the service burden of residency have accomplished little because no one has addressed the underlying financial issue — that is, how to pay for the services rendered by house officers. Since Medicare became the primary funder of graduate medical education in 1965, house officers have seen their salaries rise, but their working conditions have remained brutal as they continue to care for patients with too few nurses, orderlies, ward clerks, phlebotomists, and other important aides. Accordingly, the residency system has plodded along, its house officers desperately overworked. Many commentators over the years have wondered why the residency system has seemingly been so resistant to change, particularly in terms of lessening the workloads of house officers. The reason is that medical staffs and hospitals have been unable or unwilling to provide the necessary funds to do so.
Featured image: RCSI Bahrain White coat ceremony by Mohamed CJ. CC-BY-SA-3.0 via Wikimedia Commons.
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