By Lynfa Stroud
“When I was a resident ….”
– Almost every faculty who ever lived
It’s a refrain that I hear from faculty from time-to-time. It’s essentially the physician’s version of, “the good old days” or “kids these days”. It is usually the start to a discussion about how something was done better in the past – either with respect to individual resident performance or to the structure of education / clinical training; but occasionally it does connote recognition that things have changed for the better. As the new group of residents excitedly started their academic year in July, it made me reflect on some of the changes that have happened in the relatively short time since I was a resident. Most of these have undoubtedly been improvements, but have also had some unintended consequences that have led to other challenges in other areas and challenge us to continually evolve.
To pick three random areas where there have been significant changes that, while largely better for either patient care or resident wellbeing (and sometimes both), may have also had unintended consequences, I would select some of the changes that have occurred with work hours, care models, and technology. For this post, I’ll briefly muse about the change in work hours, and then in a subsequent post I’ll follow-up with thoughts about care models and technology.
Fairly progressive and reasonable duty hour limits existed when I trained. But they were rarely adhered to. It was typical to stay post-call to finish working the entire day. One of my surgical colleagues was scheduled for 72 hours of straight call – though not on paper where this could be scrutinized. Changes in duty hours and closer adherence to them has undoubtedly improved resident wellbeing and is entirely appropriate (there’s a lot of arrogance in thinking your performance is as good after being up for over 24 hours as it is when rested). Of course, I am sure that adherence is not 100% and that many residents still work beyond what they are meant to, but I like to think less egregiously than in the past.
This shift though has had other knock-on effects though, such as potentially less continuity of care and a greater reliance on faculty to provide patient care. Neither of these is a necessarily a bad thing, but have relied for us to consider their implications and possible ways to mitigate their impact. For example, there is now much greater attention to sign-over than there ever was when I trained – and residents are actually taught how to do this! Faculty may have to adjust their commitment to other activities to be more directly involved on the front-lines of patient care, which certainly can be argued to have many benefits, although alternatively can have the unintended consequences of diminishing faculty’s time for other activities or reduce the autonomy of residents in decision making. Other possible solutions to ensure the provision of clinical care could include re-allocation of resident staffing or the use of physician-extenders. However both of these in-turn also have potential pros and cons, with the latter being taking residents away from one activity to another and the cost incurred from hiring other professionals.
I would not want to return to the adherence (or lack thereof) to duty hours when I was a resident, or even worse the hours endured by those of prior generations. However, in making this improvement, we’ve been challenged as a profession to ensure that we manage the outcomes and, in particular as educators, to mitigate the unintended negative consequences for learners with new curricula.