Blog | Thursday, May 23, 2013

Time to redesign residencies


Once upon a time (actually when I did my residency), we worked long hours, were taught well and learned from our patients. Residency training had minimal rules. When we looked for a residency we took work load into consideration. Some residencies were more challenging than others. I choose a busy residency because I thought (back then) that I needed to see sufficient numbers of patients to become a good internist.

Our progress over the subsequent 35 years (since I finished my residency) is dubious. Pauline Chen, MD's wonderful article in the New York Times today, "The Impossible Workload for Doctors in Training," tells part of the story--no adjustment of work load as work hours have changed.

What does not make this article is the never ending paper work that program directors must document. What does not make this article is a reluctance to reconsider call schedules.

When the rules change, then the system must change. We have to adjust call schedules for the benefit of continuity. We need call schedules that value "ownership" and patient responsibility. We have to help our residents function as a team, with different members of the team working different shifts.

We who work in residency programs can do a better job at designing the residencies.

This will not solve the ACGME problems and will not solve the major problem of not enough funding to expand residency training slots. CMS has fixed the number of residency positions. Private insurers up to now have not made contributions to training--yet they benefit from well-trained physicians.

Residency is hard. It has always been hard. It is necessary if we want well trained physicians. But it does cost money. We do not have enough residency slots and that is a major societal problem. And no one is really addressing that problem.

For those who want to blame the AMA, the AAMC is responsible for medical student numbers, and they continue to increase quickly. They have increased so much that many U.S. graduates did not find an internship that past year (I have heard numbers ranging from 500-800). This does not count DO graduates, off shore graduates or IMGs. Can you find a new doctor? If you cannot, do not blame the AMA or the AAMC. Blame those who fund residency positions.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.