With the absolute absurdity the residency process, and the focus entirely on new doctors just after that residency, I have to wonder how much of this just corresponds to whoever's lucky enough to be the kind of high-powered mutant who can survive multiple years of 80- to 100-hour week schedules designed by a man who was high on cocaine and morphine 24/7 (seriously, look it up, it's true). There are going to be a lot of people who need an extended sabattical to recover from that before they'll be effective at anything at all, which makes any kind of baseline of test scores really suspect to me.
Does the difference matter in this context, though? Medicine isn't like other professions where it's no big deal to have some fraction of the workforce be bad at their jobs. I'm not so status-quo-biased that I'd support 100 hour residencies, but I'm skeptical of reform proposals that focus on doctors' working conditions rather than patient outcomes. If some filtering process leads to better patient outcomes, I think we should retain it, even if it's quite stressful for the doctors who have to go through it.
Fair point. There's some data showing patient outcomes are worse when managed by overworked residents-in-training, but I think you're referring to outcomes post-residency. i.e. Physicians should squeeze as much training as possible into the allotted years. This is reasonable, especially for surgical specialties where procedural reps are a commodity for trainees.
I'd be more open to this line of reasoning if physician's salaries had kept pace with inflation over the last 30 years and if if we hadn't tacitly accepted a much, much lower standard of training in the form of DNPs, CRNAs and PAs who are now practicing independently in a lot of regions. You can't demand that people make extraordinary sacrifices without extraordinary compensation.
For contrast, most European countries have a much longer post-residency training process that is more humane. Caveat being that students enter medical school directly from high school and don't have student loans.
It's also worth pointing out that in the US a LOT of those 100 hours are not spent in direct patient care. They're spent doing chores ('scut') that are not directly tied to patient care. Think: Calling insurance companies for prior authorization for your supervisor or filling out FMLA paperwork for one of your supervisors' patients. As a resident you don't have the ability to say "no" to these tasks.
> i.e. Physicians should squeeze as much training as possible into the allotted years. This is reasonable, especially for surgical specialties where procedural reps are a commodity for trainees.
It's mixed, though. We don't know how much "squeezing as much training" helps or hinders future performance. We do know that sleep debt hurts retention of new knowledge and skills.
So I'm not positive whether "50% more training, but with not enough sleep during most of the interval" will result in better outcomes.
> I'd be more open to this line of reasoning if physician's salaries had kept pace with inflation over the last 30 years
Doctors in the US are artificially scarce and artificially expensive compared to the rest of the world. The artificial scarcity of residencies also contributes to the unusually harsh residency work conditions.
Doctors in the United States are paid more than doctors in Norway and Switzerland even though those countries are richer and our doctors aren't better.
Your comment sounds reasonable, but it doesn't allow for nuance.
If a hellish residency improves patient outcomes by 0.1%, at the expense of every single resident suffering twice as much as they need to (and likely leading to some stimulant addictions and deaths among the resident/doctor population), that's not a fair tradeoff.
Medical workers don't exist solely to sacrifice themselves for others; they are humans also and their needs should be weighed as important like everyone else's.
As it so happens I think some of the strain of medical residency is related to supply shortages in the health care industry. If it's not crystal clear that working 80+ hours per week is necessary to significantly improve patient outcomes, and it is clear that working 80+ hours per week makes a lot of people choose other careers (limiting supply artificially), then reform here is imperative.
Oh I'm not saying it does, the person above seemed to be suggesting that we should focus on figuring out the residency conditions that lead to the best patient outcomes, rather than improve the conditions for residents, which suggests they believe worse conditions for residents may be better for patients.
Just to point out the obvious, people doing 80 hrs/week for 2 years (lower end of residency term I believe) are going to have twice as much 'experience' as people doing 40hrs/week for 2 years.
I suspect most of us here know more hours worked doesn't directly correlate with more retention of information and best practices, but that's the thinking.
I'm arguing that even if 80hrs/week residencies was the optimal amount of pressure to turn our fledgling residents into battle-hardened physicians, if you can get 99% of the effect with 40hrs/week, maybe do that instead. And again, I'm not even suggesting this is actually the case.
The idea is that the stress and sleep deprivation are not sources of permanent impairment (even though they are), but rather a filter that selects the strongest candidates.
I don't necessarily think the relationship is "worse residency conditions predicts higher board exam scores"? It could be that residents with more time to study or whatever score higher. It could be examinees with scores close to the threshold are accounting for the association. Or maybe it is resiliency. I have no idea.
My general impression is that the evidence overall is really not supportive of harsher residencies in terms of patient outcomes. I also think that rigor does not have to mean masochism or hubris; there seems to be this assumption that any change to residencies would mean dumbing it down or making it easier, as opposed to improving things overall. I'm also a little skeptical of minor tweaks to residency that might have happened somewhere now being representative of a more wholesale restructuring.
The often unacknowledged factor in the background is that hospitals and residency locations are getting free labor with no chance of repudiation of their situation by workers. Hospitals are getting physicians whose salaries are paid for by the federal government, where those physicians are essentially unfree to move if they're unhappy. So of course there's going to be an attempt to milk them for everything. It gets whitewashed as "selflessness" and physicians are encouraged to boast about it or something, instead of calling it out as exploitation. No physician wants to make that claim, for a whole host of reasons, even if it is true.
Imagine what would happen if hospitals had to bear the costs of residency training completely, like just about any other healthcare profession, and residents were able to move freely like most employees.
I get despondent about so much in US healthcare. There's so much focus on invoice costs per se, and payment by insurers, and not enough on monopolies in service delivery, and problems with educational structures. Any attempt to address these issues is met with resistance by various groups with conflicts of interest, who aren't called out on these conflicts of interest.
Another thing about residencies constantly on my mind from other settings (institutional tracking hours in the moment versus recalled hours later) as well as personal experiences with residency in the past is that people are notoriously bad about reporting past work hours and conditions, and tend to exaggerate. I'm not saying that anyone in particular is necessarily being dishonest in describing their residency experience, but I suspect there has been drift over time in conditions that reflects a kind of biased memory of things on the part of residency directors. "I worked 120 hours a week" when that wasn't actually the case, or is distorted, then becomes residency policy for the next generation.
Sometimes I feel like the logical conclusion, given the way these discussions go sometimes, is the only one being legally able to practice is someone with an MD who has completed a residency working 140 hours a week for 6 years, with perfect board exam scores. It just doesn't add up.
> he was able to hide his addiction under a veil of eccentricity and a pyramid of residents
Which means "created an environment to allow himself to be high at work" to me. It's not impossible that he held it off at home, but I don't see why he would.
Also, he's clearly Dr. House; Ctrl-F "Leaving much"
