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Residents can learn with fewer supervision training guidelines
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Last summer, The New England Journal of Medicine published “The New Recommendations on Duty Hours from the ACGME Task Force” online. The training of future physicians is among the most important things we do as academic physicians. Not only does it ensure the future of the profession, but also ensures that future patients will have caregivers ready and available when needed.
The main idea of the recommendations is that residents work too long without breaks and under too little supervision, which leads to errors. There is a two-page table with plenty of detail outlining levels of supervision and what level of supervision residents must have. Residents can work no more than 16 consecutive hours and first-year residents (interns) must be supervised directly (level 1, attending in the room) or indirectly (level 2a, attending in the building).
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Some interesting points come to mind. How many interns can a single attending supervise? How physically close do I need to be? How much detail of the plan must I know? This will require a very high level of organizational complexity.
Prolonged adolescence
One of the most interesting aspects of this movement during the past 7 years, starting with the 2003 recommendations, is a sense of prolonged adolescence. When I think back to my medical school and residency days, what I remember most is the sense of increasing responsibility and accountability. As a sub-intern and for the early part of my internship, my major job was to gather information, report that information and then follow instructions. I took histories, did physical exams, drew blood and then chased down the results, and I brought this information to the senior. The senior then told me what to do.
I could soon anticipate beforehand what the senior would tell me. With time, my repertoire expanded beyond the care of the infant with fever, acute asthma and the painful crisis of sickle cell disease, and a senior resident emerged. The supervisory reins loosened to allow personal growth.
It is no different in industry. A crucial step in the process of a drug in development is the interactions with regulatory agencies, particularly the FDA. In my first interaction with the FDA, I was told not to speak. Because it was a teleconference, I was told I would not be introduced and the FDA would not know I was on the phone, so I better not speak. Listen and learn.
The next time, I was introduced on the call, but I was still not permitted to speak. By the third time, I was allowed to answer questions from the FDA if they were directed toward me, and in time, I eventually led such interactions on behalf of the company.
The parallels between medicine and industry are obvious. Ultimately, there is a balance between not wanting to make a mistake and allowing people to develop, for their own good and for the good of the organization. In medicine, the organization is society. Society needs physicians who are competent, confident and able to work independently when needed.
The question I have about the current recommendations is how will they facilitate the development of competent, confident, independent physicians? Will too little time with too much supervision stunt the growth of trainees? I think they will, but time will tell.
What if we started from scratch? I went to school for 27 years. The first 13 grades spanned kindergarten to my high school graduation. Grades 14 to 17 were spent in college; grades 18 to 21, medical school; 22 to 24, pediatric residency; 25 to 27, hem/onc fellowship. I love the look of horror I get from a 12-year-old when I say my last year of school was 27th grade. Maybe there is a better way than watering down the first year of residency.
Two choices come to mind. The first is grade 21, the last year of medical school. Maybe the fourth year of medical school could be spent as a yearlong, perhaps rotating sub-internship with the hours and supervision recommended by the ACGME for first-year residents. That would prepare them nicely for the first year of residency and allow them to spend a year gaining competence, confidence and independence. The downside is that many students use the fourth year to explore areas of medicine (radiology, orthopedics, public health, any number of sub-specialties) outside the core of the medical school curriculum, often leading them toward a chosen career.
Another choice is to insert a year between medical school and residency. This transition year would follow the guidelines laid out by the ACGME. This would be a volunteer year to transition from medical school to residency, the goal being to acquire, under appropriate supervision, the skills necessary to make the most out of residency. The obvious problem here is we have just inserted a year between 21st and 22nd grade, making the process 28 years long. Adolescence has been extended to people well older than 30 years.
Skip last year of college
Here’s an idea to get the year back. I majored in physics in college. I really enjoyed it. Sadly, I have forgotten most of it, but mechanics and electrodynamics are still rattling around my head. I don’t think I would be much worse off if I had skipped my last year of college and went straight to medical school. I’ll venture to say that for many of my classmates, as much as they may have enjoyed the senior-level electives, those classes were not essential for their future success in medicine.
What if we let students apply to medical school in the third year of college, assuming that they have completed the requirements? This would serve two purposes. It would save a year of transition from medical student to resident. It would also save the expense of the fourth year of college. With most current medical school graduates owing more than $140,000 in debt, the $25,000 to $50,000 college tuition savings would help to reduce indebtedness.
I understand the concerns about patient safety that have led to the current set of recommendations. I hope they help reduce errors. But I also have seen, both in the training of physicians and in the training of pharmaceutical executives, the value of increasing independence and accountability in the creation of competent, confident and independent adults. Ultimately, this has to be the goal of both the ACGME and the training programs. The question is, how best to get there?
Michael N. Needle, MD, practices at the Morgan Stanley Children’s Hospital of New York-Presbyterian, Columbia University Medical Center.
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