nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Thursday, April 7, 2011

Training Doctors: More Rested, But Less Experienced?

It's accepted that limited work hours leaves doctors-in-training more rested (and alert?), but some research and anecdotal data suggests that patient safety hasn't improved and fewer hours means less experience.

A review of research on working hours versus patient outcomes, published in the British Medical Journal (Mar 22), put the good face on reduced hours by saying that reduced hours have not made patient safety worse.  Well thanks for the obvious, but our real question is why reduced hours haven't made patient outcomes any better?

And some research is surfacing that fewer hours disrupts continuity of patient care (patients get handed off several times to different doctors) and in some specialties doctors aren't seeing enough cases of uncommon diseases (so when those diseases occur later in their career they are less prepared to diagnose and manage the different presentation and course the diseases could take), nor doing enough surgical cases of each type of procedure to reach a good level of technical competence.  None of this was anticipated by the "Reduced Hours=Patient Safety" reformers.

The proponents of fewer working hours have been telling us for years not to worry about these issues.  The benefit in patient safety outweighs any such concern.  But now the data is starting to emerge that the promised benefit isn't surfacing.  See the editorial in the British Medical Journal that asks, "How come?"

But you tell me:  do you want your appendix taken out by a newly trained graduate in general surgery who has done 10 appendectomies, or by one who has done 50?  These numbers are illustrative and not from any data I possess, but you get the idea (see Archives of Surgery, Jun 2010, for survey results from reduced surgical training hours in Switzerland).

Doctors have strong feelings on both sides of this question, and argue with the same intransigence as the politicians do about the budget crisis.  Attitudes on both sides are sometimes silly ("If I did it, they can do it" is not a reasonable argument).

I confess to have done my training in an era when there were long working hours, and the culture insisted that any off-duty time was "as opportunity arose."  This meant 100-120 hour work weeks in the first years.  I sometimes did not leave the hospital for three days.  One rotation on the cardiovascular surgery ICU (60-bed) required that the resident stay in-house for two months.

And I was often tired.

Sounds insane.  But, on the other hand, I got to see ALL the patients, from start to finish.  Nobody sent me home in the middle of an operation because I had reach my work-hour limit (anecdotally, this is happening).  I did my own appendectomies, amputations, hernia repairs, breast biopsies, gall bladder surgeries, and assisted on major the first year.  After the end of my first year, I had seen and learned more than I could have imagined possible, and performed procedures over-and-over again, fine tuning my skills.

But, "Safety!", you say.  What about the poor patients who had to suffer through me learning on them?

Here's how it worked.  I evaluated the patients first.  Behind me was a more senior resident who saw them again, and checked my work, gave me feedback or criticism.  Then there was a chief resident to oversee both of us, monitoring what we did and approving or modifying our plans.  Then behind all three of us was a staff physician, who was often an academic, who supervised and taught the whole team.  It was a step-wise increase in responsibility and authority, with oversight at every level.  We never hesitated to turn to the next in line when there was a difficult diagnosis or a question about what to do.  It wasn't perfect, nothing is.

But I sure would have had a good time working  a maximum of 48 hours a week.  Instead of having a "lost decade" from the first year of medical school to the last year of training, I could have seen a few movies, dined out occasionally...maybe a trip to the beach every once in a while.  To this day, I can't tell you what went on in the country during that, politics, movies....zilch.  Jimmy Carter was what?

My spouse worked and children didn't come along until late in the process.  That's the only reason relationship and family survived.

We've crossed the Rubicon on training hours, though.  Regulatory agencies have taken charge, and any violation of work-hour limits is punished by residency-credentialing authorities.

Either way--fewer hours/less experience versus longer hours/more experience--there are problems.  One benefit of fewer hours is clear:  trainees now have a more enjoyable life...and fewer breakdowns under pressure.  But guess what?  The pressure is life-long, not just during training.

Some insist that the answer is to lengthen the training.  But it already takes 7-12 years after college.  I earned my first paycheck, in my own practice, just shy of 30 years old.  I'm not sure that's the answer.

The answer remains elusive, but one thing is clear:  actions have consequences.

And reformers often turn a blind eye to the unintended consequences of their grand plans.

Doc D

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