ACGME pays increased lip service to physician wellness

Because actually changing how young doctors are trained or medicine is practiced is a big hairy potentially expensive and undoubtedly difficult problem, the ACGME has opted to abandon doubling down on actual rules governing work hours and instead focused on broad and largely unenforceable mandates on “wellness.” You can read the track changes version of the new ACGME Common Program Requirements here.

I’ve attempted to translate key portions of Wellness section for clarity:

In the current health care environment, residents and faculty members are at increased risk for burnout and depression. Psychological, emotional, and physical well-being are critical in the development of the competent, caring, and resilient physician. Self-care is an important component of professionalism; it is also a skill that must be learned and nurtured in the context of other aspects of residency training. Programs, in partnership with their Sponsoring Institutions, have the same responsibility to address well-being as they do to evaluate other aspects of resident competence.

Guys, be nice.

This responsibility must include:

a) efforts to enhance the meaning that each resident finds in the experience of being a physician, including protecting time with patients, minimizing non-physician obligations, providing administrative support, promoting progressive autonomy and flexibility, and enhancing professional relationships; b) attention to scheduling, work intensity, and work compression that impacts resident well-being; c) evaluating workplace safety data and addressing the safety of residents and faculty members;

Please attend to the degree of suffering you impose on trainees. There are no guidelines to help you determine what that might entail, so please use your best judgment. We trust you.

d) policies and programs that encourage optimal resident and faculty member well-being; and, d)(1) Residents must be given the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours.

You must let doctors see other doctors for personal reasons. You can make them use vacation days. You can also remind them that they’ll be letting their peers down who will now have to cover twice the work.

The program, in partnership with its Sponsoring Institution, must educate faculty members and residents in identification of the symptoms of burnout, depression, and substance abuse, including means to assist those who experience these conditions. Residents and faculty members must also be educated to recognize those symptoms in themselves and how to seek appropriate care.

Please single out residents who look especially miserable.

There are circumstances in which residents may be unable to attend work, including but not limited to fatigue, illness, and family emergencies. Each program must have policies and procedures in place that ensure coverage of patient care in the event that a resident may be unable to perform their patient care responsibilities. These policies must be implemented without fear of negative consequences for the resident who is unable to provide the clinical work.

HAHAHAHHAHAHAHA

Also, please remember burnout is a problem with an individual trainee and not indicative of a systemic failure.

Clinical and educational work hours must be limited to no more than 80 hours per week, averaged over a four-week period, inclusive of all in-house call clinical and educational activities, clinical work done from home, and all moonlighting.

Please make sure your residents understand that they do not document work more than 80 hours per week.

Residents should have eight hours off between scheduled clinical work and education periods. There may be circumstances when residents choose to stay to care for their patients or return to the hospital with fewer than eight hours free of clinical experience and education.

We used to say 10, but 8 is easier to comply with so we changed it back. Also, it’s okay to help residents choose to stay when particularly useful. In fact, we’re continually surprised at how selfless residents are, particularly in general surgery.

Clinical and educational work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments.

When we say 24, we mean 28. Just don’t put it on the official schedule like that.

In unusual rare circumstances, after handing off all other responsibilities, a resident, on their own initiative, may elect to remain beyond their scheduled period of duty or return to the clinical site…

Physician, heal thyself (during brief bathroom breaks).

These additional hours of care or education will be counted toward the 80-hour weekly limit.

Please make sure your residents are honest. Really. Even though residents breaking duty hours is always due to a resident’s inefficiencies and not related to over-reliance on cheap labor by your healthcare system, we still want to know.

The program director must review each submission of additional service, and track both individual resident and program-wide episodes of additional duty.

This was too tedious, sorry about that.

A Review Committee may grant rotation-specific exceptions for up to 10 percent or a maximum of 88 clinical and educational work hours to individual programs based on a sound educational rationale.

Don’t forget to mentally tack on the uncounted additional 10% for up to 97 hours per week.

 

Incoming interns, I hope this was helpful to make sense of the new changes.

 

 

16 hours is a nice start to the shift

Changes to the 2017 ACGME program requirements:

Maximum Duty Clinical Work and Education Period Length

Duty periods of PGY-1 residents must not exceed 16 hours in duration.
Duty periods of PGY-2 residents and above may be 547 scheduled to a maximum of 24 hours of continuous duty in the hospital.
Clinical and educational work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments.

The first chapter in the experiment in trying to make residents lives better is coming to a close. The 16-hour rule is going away. That’s because:

The requirements were revised to reflect that residency/fellowship education must occur in a learning and working environment that fosters excellence in the safety and quality of patient care. With that priority as their foundation, highlights of the changes include:

— greater emphasis on patient safety and quality improvement
— a dedicated section addressing the critical importance of physician well-being to graduate medical education and patient care
— more explicit requirements regarding team-based care a framework for clinical and educational work hours that allow for flexibility with a maximum toward the ultimate goals of physician education and patient care

Now, the 16-hour rule has always been controversial. As I’ve discussed before, its implementation within the current training paradigm of high work density shifts and a long (80+) workweek leaves a lot to be desired. There’s no doubt, for example, that interns doing less work on some services automatically leads to upper levels doing more. Likewise, because of the coveted post-call day off, it is for many services better to work a few long shifts than a bunch of shorter ones. I would argue that all things being equal, working a short shift would be nicer than working a long shift. The problem is that all things are not equal, and working a long shift and then coming right back to work the next morning sucks.

This change is supposedly evidence-based on the back of the FIRST trial. If you haven’t heard of it, I discussed it here. Frankly, believing that the take home message of the FIRST trial is that working longer hours is better is a very generous reading of its data.

As a general rule, an arbitrary shift length limitation by itself can do almost nothing to combat physician burnout or its effects on patient safety, because those effects are predominately related to chronic fatigue, which comes from indefinitely working an unsustainable schedule and juggling too many patient care tasks at once while often being treated like a subhuman. A shift length of 16 hours at a time just means that it partially prevents a very particular variant of acute fatigue, during which inexperienced interns might be more susceptible to doing stupid things. And that assumes you can get home, eat, get a good amount of sleep, and make it back during that 8-10 hour break.

But the idea that abdicating the reins and momentum on top-down measures to control resident work-hours is concordant with both “a greater emphasis on patient safety” and “the critical importance of physician well-being” is sadly only true in the parallel universe the ACGME occupies. Even the FIRST trial showed that “Residents working longer shifts indicated that their educational experience improved, but at the expense of time with friends and family, extracurricular activities, rest, and health.”

Of course, between working 16 hours for 80 hours or 24 hour shifts up to 60 hours, which would you choose? A long shift can be a good shift, but it’s hard to have a work life balance or avoid “work compression” if you’re always at work.

The 16-hour rule only made sense in a world where as a country we’ve decided to take a proactive centralized approach to ensuring doctors are trained in a way that is compatible with the values we want, not just the self-destructive values we’ve had.

16-hours for an individual shift without addressing 1) how much work must get done per shift and 2) how many hours are worked over time is meaningless. As a component of a sustainable training regiment, it may have actually had a chance to improve patient care. Certainly, the public thinks so. But in a world where 80 hours is the ideal but unforced limit, we’re not there yet.

I think there are valid arguments that an arbitrary universal shift max that short may be unproductive and that it is possible to mitigate some fatigue effects during a longer shift in the appropriate work environment. Certainly scrubbing out of a surgery at the critical moment because you hit a limit is probably stupid. But so is working 80 hours a week for months or years at a time. So is having a job where you’re forbidden from using your vacation or are shunned for getting sick.

We’re in trouble when residents don’t tell the truth about how long they work, how hard they work, or how independently they work for fear of censure or—worse—getting their program in trouble. But that’s how basically every program where residents truly suffer works.

 

 

 

 

Explanations for the 2017 Official Step 1 Practice Questions

The NBME has released the new 2017 USMLE “Step 1 Sample Items” last month, which are identical to the set released in 2016.

Last year they finally updated the software version to be browser-based instead of a downloadable Windows application, so now you can do the interactive version like the real deal regardless of your computing preferences. It also appears that the online order is now the same as the PDF (with the addition of a few multimedia questions at the very end).

Multimedia question explanations for in Block 3 (please be aware you frequently do not need the multimedia information to accurately answer multimedia questions correctly):

  1. E – I’m going to point out that a normal healthy kid with no cardiac history or symptoms and no family history of sudden cardiac death for a pre-sports physical is probably going to have a benign exam no matter what you think you hear.
  2. E – Classic Moro reflex, entirely expected and normal until it disappears around age 4 months.
  3. E – Pill-rolling resting tremor of Parkinson’s disease secondary to loss of dopamine neurons in the substantia nigra.

You can see my otherwise complete explanations for this and last year’s set here. Your best bet for score correlations is probably here.

You may also enjoy some other entries in the USMLE Step 1 series:
How to approach the USMLE Step 1
How to approach NBME/USMLE questions
How I read NBME/USMLE Questions
Free USMLE Step 1 Questions

Articles before Acronyms

Recent pet peeve, of which many healthcare writers and physicians are guilty: using the incorrect article before an acronym.

Everyone knows that you use “a” before a consonant and “an” before a vowel. What people may not realize is that it’s not the spelling that matters of the following word but its pronunciation. The actual rule is to use “a” before a consonant sound and “an” before a vowel sound.

Correct:
A MICU admission
A HIPPA violation

Also correct:
An MRI
An HIV patient

I know it may look funny, and your word processor may punish you with a colored underline, and Clippy may scoff at you from his digital paper clip grave, but thems the rules.

Residents & The Match: Overworked, Underpaid

The Atlantic has a nice brief history of the NRMP Match and an argument for it as a causal factor as to why being a resident is generally terrible. And, in case you didn’t know, the public also wishes you weren’t working so hard:

Medicine enjoys the status of being the most prestigious profession in America, yet the rigor of medical training remains unduly excessive. The American public overwhelmingly supports restrictions on residents’ working hours. A recent poll conducted by an independent public-opinion survey firm found that nearly 90 percent of Americans believe residents’ shifts should be 16 hours or less, and over 80 percent of those surveyed said that they would request a new doctor if they knew their physician was on the tail end of a 24-hour shift.

The Atlantic has been posting a lot of doctor stories recently with the current Republican-ACA collision. One thing Ryan Park’s argument is missing, though, is the fact that the hospitals only sort’ve determine the salaries of their residents. The more than $100k cost of a resident’s salary plus their “training” comes from CMS. Yes, the government, which also sets the number of spots they’re willing to fund. If a hospital were to suddenly improve salaries and benefits, they would lose the “free-ness” of the labor. If they hire more people than are funded (i.e. over the cap) to get the work done, they’re even more in the red. The government subsidizes the cost of training doctors, but as a practical matter, the government is largely subsidizing academic medicine, as well as teaching and county hospitals nationwide. The vast majority of these hospitals aren’t really footing the bill, and their budgets rely on having residents on hand for predictable periods of time churning through the night.

Park includes a reference about how resident training preferences may be a contributing factor to suppressing salaries:

In ranking programs, as Signer of the NRMP points out, most medical students are mainly concerned with prestige and the quality of training, not money. One 2015 study showed, for example, that even without the match, residents would still earn far less than their true market value—which is estimated to be about double what they presently earn—because they, in effect, accept a pay cut for high-quality medical training and a prestigious residency placement.

But of course! The salaries are all terrible. That reference does make that conclusion, but we know better because resident pay is so homogenous (again, paid by CMS with regional COLA). If a terrible program pays a few thousand more per year than a great program, of course no is going to care. Educational factors clearly trump trivial salary differences. If cost were the only factor in all people’s choices, no one would choose to attend private schools. But if a decent nonmalignant program paid twice as much (i.e. a PA salary) as a prestigious misery-factory? It wouldn’t sway everyone, but I have no doubt it would absolutely have a big impact, just like how a lot of very talented people only consider attending their state medical school.

The US has an abundance of patient care to carry out and a growing shortage of doctors, but we’ve both resisted real increases in resident numbers and prevented substantial changes in the training paradigm. In a world where the same Medicare coffers will pay for drugs that cost more than a resident salary while advance practice nurses have lobbied for greater and greater autonomy, the ACGME’s focus on “milestones” and the length of training has serious unintended consequences.

Imagine for a moment that internal medicine, family medicine, and pediatrics were two-year residencies. Without massive budget changes, suddenly we’d be training 50% more generalists per year AND the return on the time/money investment of becoming an internist would improve substantially (likely luring higher performing students). Would there be major negative consequences in the quality of those graduating residents? How long would they last? If so, could they be mitigated by changes in medical school or residency training? Have we even tried? Have we even considered it in the past 40 years?