“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

Saturday, March 31, 2007

Training ... hey where is my cheese?

“There is nothing wrong with change, if it is in the right direction.”
~Winston Churchill

Every morning I wake up and I have the same routine. Alarm rings at 430 am, I put on my running shoes; I make my cereal and cup of coffee; I check my email; and then I set off for another run. This is what I do. I am in training. I don't think I am ever not training for something. Every morning I wake up, I wonder why I am doing it. I have nothing to prove. But, something drives me to be better, to run faster.

I find that endurance training is very much like residency training. There is a lot of time placed into doing tasks that seem not to matter. Long shifts and busy work seem to be without use. How will this train you to be a better surgeon? Discharging patients and giving excuses for work and school, these are social work tasks, I am a surgeon, this is below me.

Each week, I have a set mileage goal. It is on my schedule. Short (4-5 mile) runs for speed; medium runs (7-10 mile) at tempo pace; and the long runs (14-22 mile) for endurance. All of these runs serve a purpose in completing the ultimate goal of finishing a race and/or improving on a previous time. There are many different ways of preparing yourself for an endurance race, such as a marathon. There are many books to read and philosophies to follow. There are also different goals that people have. Many years ago, people trained intensely, many running over 100 miles a week. Over time, the training elite have realized that that is not necessarily important and alternate training schedules have come out. Rest and diet have become a key component of optimal training for the endurance athlete. Mileage goals and speed of training has changed; cross training implemented. Most people now believe that depending on you goals, high mileage (total weekly) breaks you down more than builds you up.

Residency is endurance training and the 80 hour work week a philosophy change. The training elites, the attending staff, will have to adjust to the changes in philosophy. There will of course be many who will resist. Of course for many years, high hours where seen as a rite of passage, a test of you character, and necessity for your growth as a surgeon. The truth is that it is probably not necessary for overall growth of a surgeon. The system does need to become more efficient and more streamline. Change is painful.

Many of the old guard in medicine are asking, "who moved my cheese?" Many are like Hem, they do not want to change; and others are like Haw, somewhat resistant to change, but once they can see that change is needed. People like Haw realize that the change is better and that with the change there is growth.

So will the change be a success? I think it will. I think hospitals will become more streamline and efficient. More support staff will be present to assist in some of the busy work. This takes time. It is a large systemic change. Like increasing a patients potassium, we can't just push the medication. It has to be dripped in slowly so that the body can adjust. As the system adjusts, so must the training physician. Like the marathoner, although you don't have to do 100 mile weeks, you still must put in the miles, otherwise you will not complete the race. Consistency is one of the keys to successful training. So every morning, like it or not, the alarm rings; I put on my running shoes; I make my cereal and cup of coffee; I check my email; and then I set off for another run.

“What you leave behind is not what is engraved in stone monuments, but what is woven into the lives of others.”



Anonymous said...

I just discovered your blog from a link on SDN. You seem like an interesting fellow, I especially enjoy your use of quotes. My wife trained at duPont for pediatrics, she seemed to enjoy it.

I'm not going into ortho, but I really think your opinions are worth reading.

Anonymous said...

I'm wondering how this entry works with a previous one on the same subject - the failure to imagine post. How will a newly-minted ortho attending be able to take a weekend of call (say he's one of a few orthopods in town) when he's never done so in training?

Someonect said...

well anonymous, this is something i fear. i do feel that many in residency feel that their practice will be like residency. it is not. every practice is different. some will require longer than 80 hr/wk and others less.

my biggest fear is the creation of a "shift worker" or an hourly worker. in practice, things are not always on schedule, shit happens. i do believe you do need to train appropriately for it. the question then is what is proper training?

Anonymous said...

Medicine is moving to shift work. Hospitals are big and reimbursed better. Collectively they will always have more influence. Physician rely on professional societies, etc. Those organizations have too many interests. Physicians cannot unionize. Plus hospitals are run my guys with MBA's whos professional life is dedicated to making money for the hospital - period. Their contemporaries are all trying to do the same. Collectively, they will be able to buy a louder lobbying voice. We're busy fighting over OR time and call schedules.

So what does that have to do with anything? As purse string tighten the hospital looks even better relative to a more independent practice. More physicians will be hospital employees, seeing patients from the primary care physicians in the same system and probably keeping busy. There will be bonus systems and means to satisfy state and national policy regarding the corporate practice of medicine, but nothing special. Institutional and professional fees will largely go to the hospital. Most importantly, so will all ancillary revenue. When reimbursement on imaging and cardiac care starts taking a squeeze, the physician who bought the magnet or invested in the specialty hospital will be hosed; the hospital will be more capable to predict, recoupe, and reorganize.

Patients will start to be system patients as much as the doctor's patient. The Norman Rockwell image of the doctor is gone. There is a great Scrubs episode that highlights this - Kelso treats a young patient sitting there with her PDA anticipating all his quips.

We'll probably all be under government contracts shortly after the election anyway, so its probably mute... the Democrat candidates need to distinguish themselves from one another. We all know what they think about the war, universal healthcare will be a perfect avenue.

Anonymous said...

ACGME allows 80hrs/wk
Ave ortho resident probably gets 3wks vaca, 1wk conference, est 2wk worth of holiday days off or slow time b/c national/regional meetings, etc.

52 - (3+1+2) = 46wk/yr x 80hr/wk = 3680hr/yr

3680hr/yr x (5-1)ortho yr/residency = 14720hr/residency

The training program has just shy of 15,000 hours under the new work restrictions to teach ortho residents how to prepare for life outside of residency and the possibility of a greater than 80hr week. The ACGME has laid down one rule. If those nearly 15,000 hours are not enough, and the excuse is that one rule, its possible the teachers may need to look closer at their end.

I would also challenge anyone to prove that they regularly put in over 80hr in the hospital a week. (Home call doesn't count the same as in-house for us either so "being on the pager 24/7 doesn't constitute a 168hr wk)

The regulations were meant to be a quality control measure. Maybe you shouldn't be in the hospital greater than 80hrs in a given week even if your practice dictates it. You might not be as good at hour 85 on a Sunday as you would be at hour 15 the following Tuesday.

Someonect said...

well mr. anonymous,

i personally don't think the 80 hour rule is the problem. we can calcuate all we want, but speak to most who are in medical education and they will express to you that there is a change in the mentality. it is like what unionization does or being a government worked. the system is not bad, it is the culture that develops.

resently, we had a faculty meeting and discussed the residency, how to make changes, what is needed to be added to improve the resident's experience and what ancillary staff need to be added to help in the transition (we have added another hospital to our groups practice so my department takes 90days ov call a month). we have realized that more and more the experience in residency is diluted. and it has nothing to do with hour restrictions. we have casts techs who do the casts; we have PAs that take ER call and so the clinic work; and they have protected time during the week (attendings run their on cases and clinics). people in training say, "well that is great, then we won't have to do busy work."

hmmmm, busy work, i always found that interesting. "i don't want to do X Y or Z, that's just busy work." my argument is "we all have to do it." i have to do it as well. let me tell you the busy work that i have to do everyday when my residents leave: FMLA forms, work forms, school forms, calling back patients, calling back insurance carriers about refusal of MRI or brace, calling back physicians, dictating all OR notes (our residents do not dictate OR notes), signing and correcting notes so they meet HCFA guidelines, billing sheets (coding as well), preparing lectures for the residents & medical students, and committee work.

i have no problem with the 80 work week. i do have a problem when people come to lecture or a case and have not prepared (and i know they were not on call). see we have pre and post op conference so our residents have no excuse about not knowing about a scheduled case. people argue all the time that the educators should adjust to the new rules. well, with more hours off, i woul also expect a resident or medical student to take some of that time to learn / study his/her craft. it is not my job to spoon feed you information as it is not your job just to be a worker. it is a 2 way street.