residency training in the united states: past, present, future society of university...

Residency Training in the United States:

Past, Present, Future

Society of University Otolaryngologists

November 14, 2015

Kenneth M. Ludmerer, M.D.

No Financial Disclosures

Financial Disclosures

To understand:

1. The evolution of the American residency system

2. Current challenges and opportunities in residency training

3. Potential solutions and future direction

Learning Objectives

1. Creation: Johns Hopkins Hospital, 1889

2. Roots:– Apprenticeship tradition– Teutonic inspiration

3. Academic emphasis: residents of JHH = research fellows at JHU

Origin of Residency

1. The diaspora from John Hopkins

2. Objectives: academic leaders first, specialists second

3. For some, not all

4. Alternative paths

Spread of Residency, World War I to World War II

1. Educational principles­ Assumption of responsibility­ Explore problems in depth (reflective learning)

2. Moral dimension– Unswerving commitment to solving the patient’s

problem– Thoroughness and scrupulous attention to detail

The American Residency

1. Charity care

2. High professional authority; quiet consumer voice

3. Attitudes toward work and personal fulfillment

Cultural Influences

“What about the wife and babies if you have them? Leave them! Heavy are the responsibilities to yourself, to the profession and to the public. Your wife will be glad to bear her share of the sacrifices you make.”

Sir William Osler

1. The presence of time2. The presence of ward patients3. Intellectual excitement – atmosphere of

discovery4. Close personal relations with senior faculty,

junior faculty, hospital administration, and each other

5. Absence of commercialism at academic medical centers

The Learning Environment

1. Hard work

2. Paternalistic

3. Rich learning environment

4. Presence of faculty

5. Exhilaration – sense of being engaged in doing “good work”

The Life of a Resident

“I am remembering the internship through a haze of time cluttered by all sorts of memories of other jobs, but I haven’t got it wrong nor am I romanticizing the experience. It was simply the best of times.”

Lewis Thomas

Conditions of work are what matter,

not work hours alone

1. Excessive work load (“scut work”)

2. Graduate Medical Education (1940) and all subsequent reports

3. Problem persists because hospitals benefit

“Education vs. Service”

1. Establishment of Boards

2. Abolition of alternative paths

3. A reforming profession – change from within

Triumph of Residency

1. The triumph of specialization2. The democratization of residency3. Declining research emphasis. Produce practitioners, not

investigators4. End of era of paternalism5. Decline in sense of family6. Learning environment remains strong: time, autonomy, scholarly

atmosphere, service values permeate academic medical centers, patient-centered care

1945-1970

1. Safety- Sicker patients- Greater consequences of error- Inadequate supervision

2. Disappearance of faculty

3. Continuation of sleep deprivation and heavy workloads

Cracks in System

1. Memoirs; House of God; studies, observations, house staff unions

2. Causes: excessive workloads, sense of marginalization

3. Root problems not addressed

1970s: Discovery of Burnout

1. July 1, 1984 – DRGs (diagnosis related groups)

2. Learning environment erodes:– Too many patients to be thorough or to

engage in reflection. Transformation of “scut”– “Eurekapenia”– Commercialization of academic medical center

3. Decline of patient-centered care

The Era of Throughput – 1980s to Present

1. 1984 – Libby Zion case

2. 1990s – Highly publicized medical errors

3. 1999 – IOM’s To Err is Human

4. Concern was patient safety

The Era of Work Hour Regulations – 1984 to Present

1. External forces

2. Consumerism

3. Loss of trust in physicians

Context of Work Hour Regulations

1. 2003 -- ACGME establishes work hours regulations

2. 2008 -- IOM report

3. 2011 -- ACGME issues revised rules

Work Hours Chronology

1. Safety: no impact

2. Learning: decline of educational value of residency. Shift from professional education toward vocational training.

3. Work compression. Demoralization of house staff and far less joy in work. Residents cry out: “Let Me Heal”.

4. Further decline of patient-centered care

Consequences

1. Back to basics: conditions, not hours, of work are what matter.

2. Eliminate the “+4”

3. Back to Johns Hopkins: the Aliki Initiative

4. Lesson: real improvement in residency education is costly.- 2009 IOM report on GME - $1.7 billion/year

5. Finding the funds: IOM report (July 2014), recapturing IME.

Solutions

1. The dilemma of autonomy

2. Needs of present vs. future patients

3. Continuity of care vs. rest

4. Work-Life balances

5. Who are the patients?

Perpetual Tensions

1. Caring vs. commercialism in our health care delivery system

2. Our opportunity: parsimonious care improves quality and lowers cost.

The Future