Q&A: The pros and cons of work hour restrictions in medical training
Key takeaways:
- With work hour restrictions, there has been a decline in trainees’ procedural competency.
- An expert discussed the benefits and drawbacks of the restrictions and how the harms can be alleviated with mentorship.
Well-intentioned work hour restrictions in medical training have led to a less competent work force, according to an expert.
Increasing primary care procedures is a solution to this, according to Eleanor R. Menzin, MD. It would also reduce burnout while improving primary care practitioners’ reimbursement and patient outcomes, she said.
Menzin, a pediatrician and an assistant professor of pediatrics at Harvard Medical University, recently published a reflection in Annals of Family Medicine on medical trainees’ decline in procedural competency. The Accreditation Council for Graduate Medical Education established work hour restrictions in 2003, and Menzin trained before these were enacted.
“I spent hours mastering procedures that trainees today rarely perform,” she wrote. “The changing landscape of health care clinician roles, technology and work hour restrictions have all contributed to a remarkable decline in trainees’ procedural competence, which has significant negative effects for patients, health care systems and physicians themselves.”
Healio spoke with Menzin to learn more about the differences in past and current medical training and the balance of benefits and harms related to work hour restrictions.
Healio: What are the pros and cons to work hour restrictions in training?
Menzin: I trained before work hour restrictions came into effect, so I had a mostly every 4 night on-call schedule, but occasionally in the ICUs, we were every 3. What that meant was you got up in the morning and went to work, and you left — as an intern, usually around like 12 or 1 the following day, but as a senior resident, you really ended up working until 5 the next day. So, I suppose that was about 33 hours. And sometimes you got a little bit of sleep, but sometimes you didn't. And then you'd have 2 “regular work days,” and then you'd repeat the cycle. That was how things were for 3 years.
The challenges are that there's certainly a level of chronic sleep deprivation. I remember buying the Sunday paper with my husband, going to a park to read it, and just falling asleep. And it's hard to have much of a life outside of medicine when you're working that many hours. That's the downside.
The upside, I think, is almost the same as the downside: it's a completely immersive experience. And so there is an aspect of very deep learning when you are doing that for so many hours a week and not doing anything else. I certainly think from a procedural standpoint, there were just so many patients, and so there were so many opportunities to put in IVs and draw blood and do spinal taps and suture. There was just a wealth of experience in that I felt really comfortable doing all those procedures by the time I finished residency because I had done them so many times. But if you asked me to name a single movie that came out between 1998 and 2001, I can’t.
Healio: As you mentioned, there has been a “remarkable decline in trainees’ procedural competence” — but in a field with rampant burnout and work force shortages, what is the solution? What would high-quality procedural medical training look like in today’s health care landscape?
Menzin: I actually think increasing procedures would decrease burnout. If you talk to people in medicine about why they feel burned out, mostly what they talk about is this feeling of, sort of, these Sisyphean tasks that don't bring a lot of satisfaction but take a lot of time. So, things like arguing with insurance companies about reimbursement, or trying to figure out what's “low-tier medicine” and what's “high-tier medicine,” or spending all this time helping patients navigate sort of social determinants of health and feeling like you're not getting anywhere. Those tasks — which are generally not reimbursed, very time-consuming and have very unsatisfying results — are one of the major drivers of burnout and unhappiness.
In contrast, procedures are usually relatively quick. Patients are very happy and grateful with the outcome, you can solve a problem and you’re well-reimbursed. Procedures are, in many ways, an antidote to some of the burnout, especially in primary care.
Now, what does the training look like? Well, I could imagine a couple things. I could imagine increasing that in residency or potentially using elective time for residents who are not going to do a subspecialty but are going to do primary care spend 4 weeks doing procedures as a way of increasing their competence — which is sort of the current de facto situation; it becomes a post-residency training issue. But right now, that's sort of informal, and whoever hires you has to do that. I imagine it's possible to do conferences and formal post-residency training and procedures.
Healio: Nurse practitioners (NPs) and physician assistants (PAs) have been presented as a solution to the primary care physician shortage, but organizations like the AMA have fought against what they call “scope creep,” with a big part of their argument being about the vastly different training needed. What are your thoughts on this?
Menzin: I think there's a role for everyone. I have worked with five nurse practitioners who I think are phenomenal, but I do think the training is really different, and I think the number of hours worked and patients seen — if you count medical school and residency — is really different from NPs and PAs. I think we have to take that into account.
So, I think there's space for everyone at the table, but different trainings create different strengths and weaknesses in the practitioners.
Healio: You highlight mentoring as one of the ways to reemphasize the importance of honing these technical skills. How can current PCPs help incoming students?
Menzin: There's a few ways we can do that. First, by helping new trainees understand why this is important — why it's important to the patients, why it might be important for them and their job satisfaction, and why it's good for the health care system in general, and the medical home model. And then setting shared goals — “Would you like to learn to suture?” for example — and then making a plan: “If that's something that you would like to learn to do and get good at, then the next three times I'm doing it, let's have you come in, and then the fourth time, let's have you do it, and I'll be there, and I'll stand next to you and watch.” You can be really successful doing that, and I have seen that work well.
Healio: What is the take-home message for PCPs here? If nothing else, what should they get out of this story?
Menzin: In a world in which young trainees might have been undertrained for these procedures, and older physicians might feel pressed for time to not want to do them, many people gave up those procedures — and I think that's a mistake. I think it's a mistake in terms of what's good for patients, I think it's a mistake in terms of what could add to people's job satisfaction and I think it's a mistake in terms of reimbursement.
So, I would encourage people to think about reincorporating those procedures into primary care, because I think it's good for everybody.
Healio: Is there anything else you would like to add?
Menzin: Medical training generally takes place within the setting of institutions where there are lots of people to fill all of these roles. What medical training underestimates when it gets people ready for primary care is how steeply that access to other folks to do procedures declines when you leave the institution.
My practice is located exactly across the street from Boston Children's Hospital. Literally. You just have to go across the crosswalk. Yet, if I want someone to get sutured or get a catheterization, or things like that, that distance might as well be 50 miles. So, I think we forget how important it is in the real world, even when you're close to medical institutions, for primary care doctors to be able to do these procedures.
It's clearly much better for an anxious 5-year-old to get their chin sutured up in a familiar setting in my office than to go to the emergency room and sit in a waiting room full of really sick kids and wait for hours to have the same procedure done. It's really important that training programs try to get trainees ready to practice in a more real-world environment where there isn't always an emergency room or a proceduralist or somebody to do the procedure for you.