“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Wednesday, April 18, 2007

How do you know what you need to learn?

“The only thing that interferes with my learning is my education.”

~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.

“Experience is the name every one gives to their mistakes.”

~Oscar Wilde


Anonymous said...

The hospitals previously "residented" by the DMC/WSU program adjusted very easily to life without them. Across the board, though, people at those hospitals commented on the need to eliminate busy work. Not pass it on to the attending like in your scenarios, but eliminate and streamline it. Eliminating a lot of hospital mandated repetitive paperwork like the 3 d/c summary sheets all telling people not to cross their legs after THA or not swim with their cast on. Using (and studying) the risks and benefits of pre-printed pathways and protocols. No, not every patient is the same, not every ORIF ankle is like every other. This is not an attempt to cookbook medicine, but 99% of elective cases get certain things. There is not a need for 5 copies of home meds to be in the chart. Using an intake one from a pre-op interview (not the pg-2 trying to copy it again at 7:05 without being the one sited for the reason for case delay) and continuing or discontinuing as appropriate in the hospital by checkboxes or EMR. No more trying to remember or rely on cheat sheets: does Dr X like coumadin or lovenox? Do they go home with a CPM or home PT?

Is it possible these things may be better for patients too?

Common things are common. A lot of the busy work involved in the care of these things should require little more than a signature and the little things specific to occasional cases. There may even be a way to keep them legible this way.

The point is no one would have thought the processes could be streamlined until the pre-paid work force had left (the hospitals kept the money though). There were no huge upheavals as pertained to how business was tended to. Contrary to your typical scenario descriptor, when there was no resident to do it, the attendings didn't take to the floor and do things like change dressings and write notes, they realized things didn't need to be done sometimes or could be done differently.

Briefly to work hours:

I believe they are implying that having the guy on his 30+ straight hour awake should be operating more. If I can't drive that well after bad call nights, how am I really helping myself or anyone else with a scalpel in my hand? Their conclusion hints at the opposite. Shouldn't some things be served better by the involvement of the senior resident? Maybe I am reading that wrong, but I don't think so. Plus, if you are not doing as many of these cases early (haven't you in some way supported that idea - warning the "early operative experience" seeking student in other forums) doesn't that just start the learning curve later, not elongate it? Further, I thought the learning curve was a skill y-axis, number of cases x-axis phenomenon.

md007 said...

As I enter my internship, I am a beginning learner, so-called "early learner" by Dreyfus' hierarchy of competency (although probably still a novice on most things). I am so sick of memorizing recipes, and hearing the stories of others who have been in the kitchen. Their tales of what can go wrong when you don't have enough flour or butter or sugar, or your oven doesn't work quite right. How they handle these situations make interesting stories, but in all honesty, I really can't relate, and really don't understand.

I am very excited to finally get my chance to cook and actually learn something. It will be hard, but the more time I spend in the kitchen, the better I can take the heat!

I enjoyed your comments...in my experience the best teachers are those who try to remember what its like to be the student. They rarely can truly understand or relate, but I appreciate those who try. ?Perhaps? our education is so inefficient because we aren't using the same part of our brains when we read the cookbook as we do when we mix the dough.

Midwife with a Knife said...

In obstetrics, so many of our real problems where you have to know what you're doing in order to change the outcome for the better (i.e. severe shoulder dystocias, severe postpartum hemorrhages) are so rare that if you don't spend a lot of time in the hospital, you may never see them. As it is, many people graduate without having done a c-hyst simply because they're rare. What happens when people are out at Podunk General and they're the only obstetrician in the hospital or in the town, and their general surgeon back-up is on vacation, and a woman tries to bleed to death from a uterine rupture? I think that if you haven't seen a uterine rupture, you might be screwed, and hanging around in the hospital, maybe a lot, maybe for years, is the only way to get the core of experience you need to deal with situations like that.

I honestly don't think the hours are the problem with medical education (although certainly there are abuses). I say this as a fellow, who no longer falls under the 80 hour/week protection. I mean, it sucks to be exhausted all the time, and it's hard to learn if you're exhausted, but there should be a certain rigor to training.

Someone interested medical student and resident education. said...


i would have to agree with your comment that without residents things become more streamline. the hospital is forced to become more streamline otherwise the attending staff leaves. so i guess it is streamlining by necessity. it is not a new concept seeing many other hospitals have become more protocol driven. it takes drastic change to cause drastic change.

as for the 30 hours in my personal experience, not much operating occurs with any frequency at night. it doesn't surprise me that there is not an increase in cases. on of the unfortunate things is that orthopadic surgery is amostly an elective specialty and therefroe most cases occur during the day. the problem with the whole call thing is that it helps with you ability to take care of ER issues (fractures etc.) but it doesn't increase your number of operative cases.

thank you for the input.

md007, what up dog? i am glad you are looking at things from the beginning learner prospective. as an educator i have really learned from my mentors on how to handle the different levels of learning. i have become more able to appreciate the deferences and accommodate the limitations for the different levels. it is tricky when you deal with multiple level residents, i am always readjusting my thought process, my expectation level, and question difficulty. keep striving to improve and you will always be satisfied.

Midwife with a Knife

thanks for the comment on the site. also thanks for some of the comments on other's sites which have helped clarify my points and give me some justification. i usually go to those other sites and take a good ole fashion woopin. as you are at the end of your resident/fellow career, you can see some of the reason to the rhyme in the whole training process. it is a little difficult to justify the hours. but there is something to be said about time. maybe we should refer to it as volume needed not time needed.

thanks all for you comment. sorry for the delay in posting i was out of town without access to a internet line. my blackberry got worked.

Midwife with a Knife said...

I've heard rumors that the DMC is planning to start its own ortho residency away from Wayne. So they can keep the federal $$. I don't know if it's true or not.

The other thing is that there may be a disincentive for hospitals to bother putting busy-work free systems into place. Because they would need fewer residents. With fewer residents, you get less $$. So, unless there's some catastrophe (like the WSU/DMC ortho program), there's no incentive for hospitals to change stuff, which means that even well meaning program directors are screwed.

Someone interested medical student and resident education. said...

i think the DMC rumors are probably true. they are aligning themselves with michigan states DO program it looks like. they are not accredited for a MD program this year.

as far as the paper work, many hospitals and network systems have been in the process of developing universal care plans for years. some quicker than others. decreasing the amount of paperwork is helpful at cutting cost. that is the ultimate driving force. the other driving force is what the government (medicare) and JACHO says. there is some mandate coming from those entities that will effect some of the change.

things are still a little like a moving target. somedays an OR h&p is good for a month; then it is changed to 2 weeks; then 1 week; then attendings must sign and date on the same day of surgery and dictated a note. next thing will be that the H&P must be don in front of a nurse as a witness and a lawyer reading it and editing it as you right it. ok that was a bit of a rant, sorry

Anonymous said...

I find it impossible to believe that the ACGME ever sited a training program for insufficient busy work, let alone would change their allotted number of trainees as a result. Similarly, no potential program trumpets their busy work on their PIF to justify trainees.

The fact the hospital is "forced" to become more streamlined when there are fewer residents speaks clearly of what the hospital thinks of the residents in the first place. The CMS money rolls in in 2 years no matter what. Shouldn't they seek to be more streamlined regardless... or only when the replacements have contract provisions that could pay them overtime?

Someone interested medical student and resident education. said...

from what i have seen in many hospital systems is that they are trying to streamline for cost. i really don't think that they care so much about the resident or attending physician for that matter. i do feel that money is what really drives the system.

Anonymous said...

Especially as it is becoming linked to medicare reimbursement.

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