~Albert Einstein

Over the past few weeks, I have been looking at a number of different blogs and internet forums. I do this in interest about what people are interested in and to find out what the "word on the street" is. A very common topic I have come across is about residency work hours and how medical training is inefficient. It has even be broken down to the amount of money made per hour if you work a 80 work week. There have been a number lawsuits against academic medical centers, as well as the ACGME and NRMP. People discuss how hard residency is and the meaningless tasks that they are made to do. Although I mostly agree with the sentiments about low pay and meaningless tasks, I ask how would someone propose to make the system different?

One proposition is that we get more mid level providers so that residents and medical students can get more "educational value" out of their time in the hospital. They would not have to do menial tasks such as discharge summaries and dressing changes. Then the residents could concentrate more on patient care and learning about disease processes. I wonder when they plan on touching a patient in this scenario. May be the attendings should do the work with a mid level provider and when we find an interesting case we can page you so you can watch how treatment is performed. This is a good way to learn because all of the patients follow the book exactly. Their symptomatology and disease progression is classic. The response to every treatment is the same for every patient and outcomes all the same. You know there have been many a board exam that has saved a patient's life. Hmm, let's try something else.

Another proposition is to decrease the hours to say a 40 hour work week. How about no call, no weekends, and no pager. That would be awesome. See as we all know, the human body only has problems are normal working hours and therefore, every physician / resident will get all of the experience s/he needs during the normal working hours. I have actually never seen a trauma come after 5pm or on a weekend. I have definitely never seen a code before 8am or after 6 pm. Hmmm, but may be there is another way.

OK, I got it. We will work in shifts. Like a tag team wrestling trio. We will do 8 hour shifts, just like the nurses do. Work never slows down during shift change. In the transition, information is never lost. There is never a slow down in services because someone has just come "on shift."

OK, I hope you can feel the sarcasm in my above statements. None of these systems are perfect. Training in the past was not perfect. It did provide the patient volume necessary to give a physician adequate experience from which to build upon. This volume was provided in true volume of hours in the hospital. There were/are inherent inefficiencies in the system cause by resident inexperience, attending staff not being present to prevent slow downs, ancillary staff who won't perform their duties because they know eventually a resident will do it. So how do we reach a happy medium.

Can resident education become more streamline? Probably, but there are somethings that we can't get around. In the surgical subspecialties, you will have to have a certain number of surgical cases to graduate. In the future, I do see that your credentials will be directly tied to your resident surgical experience. For example, you will have to do X number of total knee arthroplasties (TKA) in residency or fellowship to be credentialed to do a TKA in practice. As a surgical service, we are at the mercy of the patients. Sometimes the procedures come and sometimes they don't. I can't guarantee you will get to see 10 pelvic osteotomy cases. This is the ebb and flow of medicine and patient care.

Medical education is inefficient. As an educator, I am interested in increasing the efficiency of the resident learning. Unfortunately, the only thing that I have seen to this point that makes a difference is time and experience. The more time a resident has the better they are at incorporating new information. I have read a number of different points of view on this and hear many of the learners who feel that they "know" what they need to learn. This is like my 18 year old son who already knows everything. He knows exactly how to do things, I have no idea of what he is going through or what things he needs to accomplish to get where he needs to go. This is true, I don't know what the resident is going through. I am years from the end of my residency. What I can say is I know what mistakes, misjudgments, and errors I have made. In educating residents all I can do is lead you in a direction and hopefully you will not make the same errors. For all the learners, remember this, if your educator does something a particular way it is usually because of previous experience.