In 2008, the IOM study on resident work hours came out and in the years that followed the Accreditation Council for Graduate Medical Education (ACGME) subsequently implemented a gamut of “recommendations.”
As a medical student, I remember thinking it was a much needed change – why wouldn’t it be a good idea to improve patient safety and decrease resident fatigue?
Alas, as a newly minted intern growing up in the era of work-hour regulations, it’s become apparent that many of these changes may actually make life harder without achieving their main goal of improving patient care.
The 80-hour work week cap is fine; it’s been in effect on its own since 2003 and overall it seems to have made residency more humane. Most programs have found reasonable ways to limit work hours to this full-time-times-two amount, at least when hours are averaged over four-week periods.
However, the additional bullet point “recommendations” from 2010 seem to play out very differently in real life than they do on paper. Many of them seem to be arbitrary lines drawn in political sands hiding behind a facade of patient safety, but that’s another blog for another time.
So, what do the bullet point regulations look like in the hospital?
They look like: Interns can’t work 24-hour shifts.
So, what used to be a two-and-a-half shift weekend turns into a four shift weekend. At a four intern/year program like mine, that means instead of two people splitting the weekends and having a post-call day after 24 hours on, one intern is committed to night-float six nights/week for a month while the remaining three interns take the three leftover weekend shifts.
The result: Fewer hours at a time in the hospital, but more working days in a row and more days/month away from your family.
More than a century of American medical history was turned on its ear last week by the announcement that the groups that accredit medical residencies will unify their standards. Don’t be too hard on yourself if you failed to understand the significance (or notice at all).
But this should be viewed as good news across the land. As someone who trains doctors from both ‘traditions,’ I certainly welcome a more level playing field.
First, a little background:
Osteopathic physicians (those with a D.O., or Doctor of Osteopathy degree) have a history dating back to the 1800s. They comprise slightly more than 10% of practicing doctors in the United States. Currently, there are 35 osteopathic medical schools, compared with 135 ‘allopathic’ institutions, the kind that confer the M.D. (Doctor of Medicine) degree.
Though historically the two educational paths varied in principles and practice, there aren’t many remaining differences. Both disciplines now use biomedical science as their core.
Originally, osteopathy relied on manipulation of bones and joints to diagnose and treat illness.
This tradition, known as Osteopathic Manipulative Treatment (OMT), lives on in the osteopathic curriculum, though it’s now mostly used as an adjunct for treatment of chronic musculoskeletal conditions. Today, most D.O.s leave OMT behind after they finish their training.
Yesterday at the faculty meeting, we learned that the first year residents in anesthesia will now have to take AND PASS a written exam at the end of their first year. They will have a certain number of tries and if a resident can’t pass it by the third try they’re either out of the program or held back in some way. Now, it used to be when I was a baby resident that the first year residents took the certification exam that the third years took, and it was graded on a curve based on year. You didn’t have to pass it or get a certain grade; it was sort of a reality check, to see how you were doing. I don’t know who’s brilliant idea this new test was, other than the people who administer and charge for the test. It might be a solution in search of a problem, I have no idea.
Here’s the thing. Testing freaks residents out. They have been taking high-stakes tests their whole entire lives. In high school they had to get As and score a 1400 on the SAT. In college they still had to get As, but also had to ace the MCAT. In med school the tests might have been pass/fail but USMLE Steps 1 and 2, both of which are taken during med school, certainly weren’t. Results of those had bearing on what residency you got into. The result of all this standardized testing is that every resident has PTSD about tests, and every resident has had years to figure out how he or she can most quickly cram in the amount of information necessary to do well on the test. Residents are masters of this. There is absolutely no reason to read the textbook, which is likely 8 years out of date anyway, when you can go straight to the review books and practice exams online. Especially if the threat of expulsion or repetition, both of which are disasters on multiple foreign and domestic fronts, is held over their heads.
Lost in the weeds of President Obama’s budget proposal is a 10-year, $11 billion reduction in Medicare funding for graduate medical education (GME). GME is the “residency” part of medical training, in which medical school graduates (newly minted MDs and DOs) spend 3-7 years learning the ropes of their specialties in teaching hospitals across the country.
Medicare currently spends almost $10 billion annually on GME. One-third of that is for “Direct Medical Education” (DME), which pays teaching hospitals so that they in turn can provide salaries and benefits to residents (current salaries average around $50,000/year, regardless of specialty; there are variances by region). No problem there.
The proposed cuts come from the Medicare portion known as “Indirect Medical Education” (IME) payments. Though IME accounts for two-thirds of the Medicare GME pie, it’s not easy for hospitals to itemize what exactly it is they provide for this significant amount of funding. Instead, hospitals bill Medicare based on a complex algorithm that includes the ‘resident-to-bed’ ratio, among other variables.
A 2009 Rand Corporation study commissioned by Medicare to evaluate aspects of residency training called on the government to tie IME payments directly to improvements in educational and hospital quality, lest the money be perceived to be going down a series of non-specific sinkholes. That idea has caught on, and legislators in both parties now see the healthy IME slice of Medicare education funding as a plum target for cost-cutting, as the direct benefits are difficult to enumerate, let alone quantify.
This has medical educators very worried that we will have to do more with much less (disclosure: I am one).
After the mayhem and jubilation of celebrating a successful match at the Pritzker School of Medicine with our students, I went onto Twitter to follow the #match2013 hashtag to understand what the reactions were. Most were positive, but one headline caught my attention ‘In Record-Setting ‘Match Day,’ 1,100 Medical Students Don’t Find Residencies.”
It is true this was the largest match because it was “All-in” – programs either were in the match for all their positions (including international medical graduates or IMGs) or they were not. Obviously, many programs put more positions up for grabs in the Match. After I reposted this article to Twitter, there were many theories and questions about who these unmatched students were and why – some of which I have tried to answer to the best of my ability below. I welcome your input as well.
Who are these unmatched students? Why didn’t they match?
-Are these IMGs? This number is US Senior medical students who have been admitted and graduated from US medical schools but now have no place to go to practice medicine.
-Does this include those that entered the “scramble” now called SOAP. Technically, those that entered SOAP and were successful would have been counted as “matched” on Friday. Last year, 815 Us seniors went unmatched after the SOAP.