Changes in Medicine: Fellowship

Reference as: Robbins RA. Changes in medicine: fellowship. Southwest J Pulm Crit Care 2011:3:34-36. (Click here for a PDF version)

Pulmonary fellowship in the late 70’s and early 80’s was largely unstructured.  I had the advantage of doing two fellowships. One was at the University of Nebraska Medical Center and was predominantly clinical. There was one other fellow and we spent our time going to clinic, reading pulmonary function tests, supervising exercise testing,  doing consults, and providing inpatient care both on the floors and the intensive care unit (ICU). We became involved with most of the patients in the ICU who were there for more than a day or two. The work was long and hard. We were mostly autonomous and only loosely supervised.

The attending physicians relied on us to call when we needed help or there was something we thought they should know. Call was at home but it was unusual to leave before 8 PM. The fellows alternated call every other weekend making it tolerable. There were plenty of procedures.  I did over 150 bronchoscopies my first year and performed sufficient numbers of intubations, thoracentesis, chest tubes, pulmonary artery cathers, etc. to be comfortable. There was little time or emphasis on research or other scholarly activity.

The other fellowship at the National Institutes of Health was the opposite. Research was clearly emphasized and most of our time was spent in the laboratory. Patient care was confined to patients on research protocols or consults to other services who had patients with incidental pulmonary problems. Procedures other than our research based protocols were rare.

At the time there were few critical care fellowships.  A fellow interested in the ICU usually entered a pulmonary fellowship or more rarely a cardiology fellowship. Anesthesia also practiced in the ICU at some institutions. Pediatric ICUs were left to the pediatricians. The American Board of Internal Medicine did require 36 months of fellowship but only 12 months needed to be clinical which was largely undefined.

A number of regulatory agencies entered fellowship regulation during the past 30 years. Most importantly has been the Accreditation Council on Graduated Medical Education (ACGME). As with residencies, the ACGME accredits the fellowship, and therefore, makes the rules. ACGME now recommends 24 months of clinical activity with a host of training requirements pertaining to patient care and medical knowledge (1). In addition, requirements now exist for competencies in practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.  Procedural training such as bronchoscopy (minimum now at 100) and the newer procedures such as sleep studies and ultrasound are also recommended or required. Fellowship directors are familiar with the ACGME’s program information form (PIF) which now extends to at least 75 pages describing the program. In addition, much of the PIF is devoted to answering questions such as “Describe at least one learning activity, other than lecture, by which residents develop a commitment to carrying out professional responsibilities and an adherence to ethical principles” or “Describe the learning activity(ies) through which residents achieve competence in the elements of systems-based practice: work effectively in various health care delivery settings and systems, coordinate patient care within the health care system; incorporate considerations of cost-containment and risk-benefit analysis in patient care; and, advocate for quality patient care and optimal patient care systems and work in interprofessional teams to enhance patient safety and care quality”. So the educational requirements to meet patient care and medical knowledge requirements as well as the newer requirements have been greatly extended leaving little time for scholarly activity or research. Many, if not most, fellows now leave their fellowship having never conducted a research study nor authoring a peer-reviewed manuscript.

Other organizations such as the Joint Commission of Healthcare Organizations, American College of Chest Physicians (2) and a variety of insurance carriers have waded in on credentialing requiring certain numbers of procedures for fellows to be certified as competent. Although these requirements are not unreasonable, they are arbitrary and the evidence basis on which they were formed is unclear.

The amount of paperwork regarding fellowships has undoubtedly increased for both the fellowship programs as well as the fellows themselves tracking procedures, etc. The number of personnel necessary to administer these regulatory activities has also undoubtedly increased. Supervision of fellows has also increased with attending physicians having more input into patient care. However, whether these lead to better trained physicians or better patient care is unknown. My suspicion is that it has not, at least there appears to be no evidence that anyone benefits. On the other hand, the amount of resources spent on supervision and documentation may actually lead to a decrease in the resources available for important educational and patient care activities actually result in harm to the fellows and possibly the patients. Regulatory agencies should investigate before mandating or even recommending educational requirements. More commonly the agency convenes a group of “experts” for advice. Often there is no reliable data, and therefore, the “expert’ panel makes recommendations based on their opinions. Not only the regulatory agencies but the panels of experts need to show restraint in making recommendations when there is no data. We often tell our fellows that it is alright to say “I don’t know”. Regulatory agencies and expert panels should also be willing to admit their limitations.

Richard A. Robbins, MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. http://www.acgme.org/ (accessed 8-8-11).
2. Ernst A, Silvestri GA, Johnstone D. Interventional pulmonary procedures: guidelines from the American college of chest physicians. Chest 2003;123;1693-1717.

Changes in Medicine: Residency

Reference as: Robbins RA. Changes in medicine: residency. Southwest J Pulm Crit Care 2011:3:8-10. (Click here for a PDF version)

The most important time in a physician’s educational development is residency, especially the first year. However, residency work and responsibility have come under the scrutiny of a host of agencies and bureaucracies, and therefore, is rapidly changing. Most important in the alphabet soup of regulatory agencies is the Accreditation Council for Graduate Medical Education (ACGME) which accredits residencies and ultimately makes the governing rules.

Resident work hours have received much attention and are clearly decreasing. However, the decline in work hours began in the 1970’s before the present political push to decrease work hours. The residency I entered in 1976 had every third night call during the first year resident’s 6-9 months on general medicine or wards. It had changed from every other night the year before. On wards, we normally were in the hospital for our 24 hours of call and followed this with a 10-12 hour day before going home and getting some well needed sleep. The third day was again a 10-12 hour day before repeating the cycle. This averages over 100 hours per week. There was one week of paid vacation and days off were rare. Both days off and vacations were expected to be done on electives.

First year residents were often poorly supervised despite a senior resident being on call with every 2 interns. Attending physicians were never in the hospital at night. I remember being told by a senior resident, that he was going to bed but I could call him if there was an emergency I could not handle-but he expected me to handle any emergency. I got the message not to call him.

The reduction in work hours was driven by residency directors trying to recruit sufficient residents to fill their slots. Residencies that required every other night call or had indigent level salaries were quickly becoming noncompetitive. By the time I left residency after 3 years, call had decreased to every fourth or fifth night and salaries had risen from about $10,000/year to $14,000/year for first year residents.

The reduction in work hours was brought to public attention and accelerated by the Libby Zion case of 1984 (1). The 18 year old Zion died from a complication of the monoamine oxidase inhibitor she had taken prior to hospitalization exacerbated by administration of meperidine and possibly by cocaine. When her father, Sidney Zion, a journalist/lawyer, learned that her doctors had been medical residents covering dozens of patients and receiving supervision only by phone, he became convinced his daughter's death was due to inadequate staffing at the New York teaching hospital where she died. Determined to ensure that others not fall victim to the same gaps that he blamed for his daughter's death, he crusaded to change resident work hours and supervision with frequent editorials and public appearances.

Over several years a sequence of events occurred to keep Zion’s death in the public eye: a grand jury was called to investigate Zion’s death; the New York State health commissioner appointed the Bell Committee to make recommendations regarding work hours; and a civil lawsuit against the doctors and hospitals was filed by Sidney Zion. All deemed the hospital negligent for leaving a first year resident alone in charge of 40 patients that night. The Bell Commission recommended that residents could work no more than 80 hours a week or more than 24 consecutive hours and senior physicians needed to be physically present in the hospital at all times and these recommendations were adopted by New York State.

The ACGME under political pressure to deal with resident work hours, appointed the Work Group on Resident Duty Hours and the Learning Environment in September 2001. The work group recommended new ACGME standards that were remarkably similar to those of the Bell Commission and these were adopted by the ACGME in 2003 (2).

The rationale behind the work hour reduction is that by working fewer hours and under greater supervision the care delivered by more rested and supervised residents will be better. A tragedy, in addition to Ms. Zion’s death, is that 27 years later we still do not know if this basic premise is true. Although the reduction in resident work hours and the in house presence of attending physicians has undoubtedly increased costs, the impact on length of stay and mortality remain largely unknown (3). The observational, retrospective research that has been done on the impact of resident hour reduction has been sufficiently flawed to make conclusions difficult (4-6). This is unfortunately part of a common trend in administrative medicine, i.e., to initiate changes based on political pressure and later attempt studies to justify the changes.

Concern has been voiced that reduction in work hours and autonomy due to increased supervision may compromise resident education (7). Although there would appear to be little evidence to date supporting this one way or another, I add my voice to those who raise this concern. Making independent decisions is vital to the maturation of residents to independent physicians. The present trend of reducing work hours and increasing supervision, may delay that learning experience to the first year or two of independent practice where correction and constructive criticism are unlikely to occur.

As work hours of residents decline, as medical knowledge expands, and as medical care becomes more complex our residencies will be hard pressed to train competent physicians. One approach is to lengthen the residencies to compensate for the reduced work hours (8). Adding another year or two of residency and/or fellowship is nothing more than extending the indentured servitude of residents to teaching hospitals. 3-6 years of post-graduate training is enough and extending the resident’s time may be more to provide adequate in house coverage than to improve the residents’ education.

I would recommend some carefully designed studies to investigate the impact of shorter work hours. The impact on mortality and length of stay should be examined along with the resident’s fund of knowledge. Perhaps armed with some sound data policy makers can make sound decisions regarding resident education, something we might call evidence-based medicine.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Lerner BH. A Case That Shook Medicine. The Washington Post, November 28, 2006. Available at http://www.washingtonpost.com/wp-dyn/content/article/2006/11/24/AR2006112400985.html

2. Friedmann P, Williams WT Jr, Altschuler SM, et al. Report of the ACGME Work Group on Resident Duty Hours. 2002. Available at: http://www.acgme.org/DutyHours/wkgroupreport611.pdf

3. Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, Escarce JJ. Cost implications of reduced work hours and workloads for resident physicians. N Engl J Med. 2009;360:2202-15.

4. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004;351:1838-48.

5. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Wang Y, Bellini L, Behringer T, Silber JH.. Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298:975-83.

6. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Canamucio A, Bellini L, Behringer T, Silber JH. Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298:984-92.

7. McCoy CP, Halvorsen AJ, Loftus CG, McDonald FS, Oxentenko AS. Effect of 16-hour duty periods on patient care and resident education. Mayo Clin Proc. 2011;86:192-6.

8. Larson EB, Fihn SD, Kirk LM, Levinson W, Loge RV, Reynolds E, Sandy L, Schroeder S, Wenger N, Williams M; Task Force on the Domain of General Internal Medicine. Society of General Internal Medicine (SGIM). The future of general internal medicine. Report and recommendations from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine. J Gen Intern Med. 2004;19:69-77.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.