Multiple Trends Forcing New Look at Residency

Smith contrasted an older model of apprenticeship training, under which residents typically worked extraordinary hours but were schooled in professional commitment to patients, with the task-driven environment of today's teaching centers in which residents in some specialties have little time at all for direct patient care.

“In the old model of surgery, when you went to the ER to evaluate a patient, you had a master clinician who could examine the abdomen better than any CAT scan, you made a judgment about surgery, you got the patient ready for it, and took care of post-op care,” he said. “When the patient was doing push-ups in his room three weeks later, he went home.”

Today, he said, it is not uncommon for surgery residents to see a patient for the first time 90 minutes before the operation without having participated in any of the presurgical deliberations, the resident observes the surgery with a video camera, the patient leaves the hospital 24 hours later, and all the postoperative complications are handled by the surgeon.

“It should be no surprise why every fifth-year surgical resident says [he or she does] not feel competent to do surgery,” he said. “This is why everyone wants to do a fellowship.”

Moreover, the patient-safety movement and fear of litigation have caused institutions to be reluctant to let trainees do clinical procedures they were expected to do a generation ago. “We have become obsessed with safety,” he said. “We have senior obstetric residents who have never done an unsupervised delivery.

“The safety movement is in danger of turning residency training into a spectator sport.”

Pressed to say how he would integrate professionalism with the new demand for competency, Smith said training directors need greater flexibility to exercise their own judgment and be creative while still ensuring that residents meet requirements.

“I would not destroy the competency movement, but I would give people enormous freedom,” he said. “I trust residency directors, and I would give them the freedom to use creative systems of teaching and measuring and ask them to articulate them in ways that are not rigid.

“The competency movement is an intellectually honest attempt to say what the components are that make up the competent physician,” Smith said. “But I think we came up with mechanistic solutions that perhaps degraded it into” a system of check boxes.

He emphasized that in the frenetic effort to meet requirements and accomplish tasks, what has gone missing from training is time—time for residents to think, reflect on the patients they care for, and form collegial bonds with their fellow residents.

“If I were a hospital administrator, the argument I might listen to is that residency programs with time to reflect are likely to produce doctors who render patients much more satisfied with their care,” he said.

And how will training directors teach professionalism and“ ownership” of a patient while still honoring residents' desire for a balanced family life?

“It may be that hours aren't the stumbling block, but some modicum of control and predictability,” Smith said. “One of the solutions is to say to residents as a group, 'Some days patients do unpredictable things, and our image is that if you own that patient, you are going to try to seek closure to those crises. But we also understand that some days that 3-year-old is coming out of day care like it or not at 5:30 and [you have] got to have time to go off. As a group you should protect each other and transfer care and ownership. If as a group you take on that flexible model of ownership of the patient, we are all going to be happier.' ”

“I think neither side has gotten to that dialogue,” he said.▪