Guest Post From David R Schwartz MD:
As a physician educator practicing in the ICU/hospital environment for >15 years, I have noted a steady decline in the average resident’s knowledge base, clinical skill and efficiency, bedside manner and overall motivation. I am a harsh critic with extremely high standards, though I’ve supervised and been responsible for student/resident/fellow ICU rotations from an educational standpoint throughout. The vast majority of my colleagues throughout the nation have supported this observation. More telling, daily report from the ICU nurses has chronicled a perennial erosion of their confidence in housestaff!
If true, this poorly documented but worrisome phenomenon combined with the anecdotal, but near universal, acceptance of increasing complexity and acuity of hospitalized patients is a prescription for failure. Explanations are numerous and pervasive.
1) The public regard and economic rewards classically afforded physicians have dwindled dramatically. While this may select for a less gifted cohort entering our medical schools, I believe the effect on the finished “product” far exceeds any deterioration in raw materials. Our new medical students and young physicians are still gifted.
The “system” must be failing– and is doing so in the face of myriad “Improvements”.
2) “High-tech” has arrived. Medical schools house cutting-edge computer and simulation centers. Anatomy can be taught without having to spend countless hours in a dim lab reeking of formaldehyde. Physiology can easily be brought to life on a video screen and Physical Examination skills can be learned in the absence of carefully examining and interacting with “patients” under the watchful eye of an expert mentor. In fact, much of the coursework can be done in the comfort of home.
3) With the explosion of Information Technology, many students who would previously be forced to endure the arduous, mind-expanding tasks of understanding the foundations and principles of medicine can, with the aid of a working knowledge of the internet, smartphones and a decent memory, “get through” school.
4) As such, demand for dedicated and brilliant instructers has declined. In line with the nations overriding philosophy on education, appreciation of the vital importance of a skilled teacher has faded dramatically, no doubt influencing career choices and impacting medical school faculty.
As the US Department of Education declared ‘No one will be left behind’.
5) In the face of unregulated and excessive trainee working hours, widespread knowledge of some significant medical errors, (later even EEG evidence of housestaff asleep on their feet), The Accreditation Council for Graduate Medical Education, in stepwise fashion, passed new regulations to limit total and continuous working hours for trainees. The previous rigorous schedule had not been documented to result in more medical errors, reduce overall quality of patient care or significantly impact subjective measures of housestaff quality-of-life. In contrast, there is no doubt that “shiftwork” has destroyed the vital continuity of care that was the result of resident’s schedules being entrained to their patient’s condition and stability. The resulting vacuum has given rise to many new jobs and and redundant and complex systems to designed to assure adequate transfer of patient information and ensure hospital safety. Unfortunately, it seems medical errors have not been mitigated; rather, there is recent data suggesting they are the third leading cause of US hospital mortality!
6) When I trained at Kings County Hospital in Brooklyn and Belllevue in NYC change had begun; still, with determination, fear of failure and the initiative that comes with responsibility (maybe even excess responsibility) we quickly “earned our white coats”, priding ourselves on providing equal or better care to our patients than the grey-haired experienced “private” doctors down-the-road. Now, the culture of safety has provided enough supervision to diffuse responsibility, limiting invaluable experience and initiating a vicious, vicious cycle. Interns are coddled slightly less than students, complex and important procedures and cases are handled by senior residents or fellows, if not by the attending. The system discourages independence in our new doctors, delaying or frankly preventing necessary expertise.
7) Hospitals and healthcare are big business. Even the best teaching hospitals frown upon (unofficially) inexperienced residents performing procedures on or managing the “VIP” patient. Without “ownership” of the patient, housestaff morale falls and apathy can creep in. Without being the “doctor in charge’, the power of the sacred doctor-patient relationship is sacrificed. Less need breeds less personal interaction, and, with less practice, less skill.
8) Surveys on level-of-satisfaction are often dominated by the mismatch between the perceived (and actual) value of documentation and it’s inverse relationship with time spent interacting with the patient. “Ensuring” safety, and avoiding exposure and money spent or lost on litigation has led to diminishing time at the bedside. This requirement, both resource and time consuming, detracts from quality, has not seemed to decrease medical errors and is easily perceived by the healthcare consumer. “Where is my doctor?” In the off chance their identified “doctor” is a resident, it is almost a forgone conclusion that he is at a computer terminal and/or on his phone.
WHAT MUST BE DONE
If each year brings another step in the wrong direction, we will eventually produce a cadre of physicians incapable of caring for their patients. Unpopular as this editorial may be, the train we are on has momentum- in the wrong direction. Despite the enormity of the problem, the solution, in principle, is simple. Put on the breaks, slow the train down and eventually go in reverse. Everyone making decisions will have to have foresight! Focus on what we already know and trust that the bottom line will be fine. Lip service is not enough– we must produce health care professionals that are confident and capable of providing the best possible medical care in the most compassionate way. Dedicated, skillful teachers need to be supported and revered. Medical education must begin with, and never loses sight of, the primacy of understanding basic concepts. Medical students and residents must be held to higher standards. Technology should be used to facilitate and supplement, not to replace and depersonalize. We must be flexible. Housestaff should not be shiftworkers– there must a model whereby a resident can be empowered, spending time at the bedside, observing and impacting the course of the patient’s illness while maintaining a safe environment for all involved. We must start another vicious cycle- in the opposite direction.