Tying the attendings hands ...

“Wisdom is knowing what to do next, skill is knowing how to do it, and virtue is doing it.”
~David Starr Jordan

The 80 hour work week restriction has gotten a lot of attention over the past 5 years. Many believe that these are the only changes that have significantly affected resident and medical student education. Over the past 20 years there have been a number of things that have change the way physicians practice. As much as the 80 hour work week was a shock to the training system, there have been small changes in requirements for billing, resident supervision, and reimbursement, that have probably affected resident education in a more subtle way.

In the early 90's, many academic medical centers were evaluated by CMS and levied huge fees on a number of academic medical centers. From these evaluations, a number of new guidelines were set for billable encounters in teaching situations. The changes have require more of an attending presence in clinical and surgical procedures. Although this did not directly change resident education, it changed the attendings participation in patient care. The days of (billed) resident run clinics went away. The days of (billed) surgical procedures without attending presence are gone. These changes are good for patient care, but changed resident education. It increases the duration of the learning curve. There is no room for allowing the young surgeon to figure out how to get through the cases. I call this the "futz factor." Young surgeons need to "futz" to figure out what works best for them. With attendings present, they tend to become impatient with "futzing" and take over the case. Most young surgeons need to do, observation is not as helpful unless you have the experience on which to build. This change the resident attending interactions and cause many attendings to become more hands on.

Along with increased requirements for billing came a decreases in physician reimbursements. Decreases in reimbursements caused an increasing need for surgeons to become more clinically active. Department chairmans began to see the departments overall income decreasing. Systems to encourage increase clinical production (incentives) were set up. Now, you income became more like true private practice. The mentality of "you eat what you kill" began to creep into the mentality of new attendings. The days of seeing few patients, doing a couple of cases and getting a large salary are gone. With less overall (clinical) income, salaries became effected. It has caused attendings be like Snoop said, "with my mind on my money and my money on my mind."

The question may be posed, "why would this change resident teaching?" You would assume that more attending presence there should be better education. You would assume that more cases and more out-patient and in-patient experience would be better for resident education. Unfortunately, I don't see this as being the case. What I see is more patient being seen in clinic and less time for teaching. What I see is more cases being done with a limited amount of time, requiring more attending participation and less time to "futz". What I see in an increasing number of different procedures and increasing complexity of these procedures with less time to learn them. I see residents being over extended because of the increasing demand to produce clinically. I see the use of PA's and other physician extenders taking away residents ability to learn some of the basic skills, such as casting. With money being the driving factor, education suffers. Teaching does not pay, therefore education suffers.

So, as much as I harp on the "new generation" and on the 80 hour work week, I also think that our ability to educate well has also been affected. I think that we are not educating as well. Our ability to spend time educating our future surgeons has changed. We will have to develop new techniques for educating them. I fear things will get worse before they get better. I worry that we may be graduating future surgeons who are less prepared than in the past. Is this better for patient care?

“Real education must ultimately be limited to men who insist on knowing, the rest is mere sheep-herding.”
~Ezra Pound