I recently unearthed the following short piece, which I had written in the wake of residency work hours changes over the last two years and ultimately never published. The work hours changes had tightened regulations on how long physicians-in-training could legally work in hospitals in the United States. I turned back to this piece after attending a meeting among staff at a community health center in Boston where I serve one half-day a week as a resident physician. My Nyaya colleague Ryan Schwarz (who is in the same position as myself) and I found it remarkable that the physician to non-physician provider ratio is 2:1, whereas at Bayalpata Hospital this ratio is approximately 1:10. Much of the discussion at the clinic focused on how to better involve non-physician providers—“task shift” is the buzz-word—but both Ryan and I were struck by how this fundamentally inefficient human resources structure was hampering the functioning of the clinic. This odd inefficiency—too many doctors vis-à-vis other non-doctor providers—is a cruel joke to our colleagues at Bayalpata Hospital who have to spend an inordinate amount of energy recruiting doctors in order to maintain even a 1:10 doctor to non-doctor provider ratio. Doctors in Nepal just have so many greener pastures than our humble hospital in Achham. By necessity, we must constantly innovate to figure out how to incorporate non-physicians into roles in the United States that physicians often fill; “task shifting” is not a human resource strategy but a human resource necessity. Yet in so doing, I do think that our work in Achham has much to offer places like my health center in the United States. This is one of many examples of how the experiences of resource-limited settings have much to offer here, since teams involved in global health delivery, such as Nyaya Health, have so frequently had to search for innovative solutions in the face of constant human resources crises. The below touches on legal changes specific to the American education system, but I do believe the issues both inform, and can be informed by, efforts in places such as Achham, Nepal.
New Residency Work Hours: Time for Training Leaders in Medicine
Ever since the Flexner Report compelled American medical education to integrate the training of doctors with scientific inquiry, scholarship, and the university [1], a key component of residency training has been to foster doctors who will innovate and advance the practice of medicine. Although not a stated goal of the expanded work hour regulations, the recent ACGME recommendations [2] provide a critical moment to return to these roots. While debate over residency work hours has appropriately centered on issues involving rigor of residency education, patient safety, and transitions of care, a central question persists: how residency work hours will impact the training of leaders in medicine. The impact can be beneficial, but significant work lies ahead.
The need for doctors to serve as managers, scientists, and leaders has never been more important, given the explosion of medical technology and large complexities within the healthcare system. The forms of leadership that our current residents take will be varied. They may expand access to healthcare in a rural town by more effectively using nurse practitioners in a private primary care practice. They may sit on boards of public health, or lead large non-profit organizations, or drive quality improvement in public urban hospitals, or write policy that changes the care environment. They may innovate in biomedicine or basic science or clinical epidemiology. They may write popular press articles and books that communicate new ideas about health to the public. Central to being a member of the medical profession in the modern era should be about injecting our society and our health institutions with creative energy. Over-worked residents whose worlds become defined by narrow roles in the hospital do not leave postgraduate training programs well-prepared for these roles. Furthermore, current residency training fosters an ethic that being a doctor is about simply putting in time rather than about being an effective leader and innovator.
Achieving sufficient operation volume, experience with diagnostic complexities, and challenging management decisions while maintaining attention to work hours necessitates that programs re-think the role of the resident. Training should focus on managing complexity. For example, clinic patients that are not of sufficient complexity should not be primarily seen by residents and should not count in accreditation numbers. On the inpatient wards, much of the coordination and discharge planning that are done by residents should be delegated to administrative personnel and mid-level providers. Inpatient rotations should be assessed by the level of complex management decisions that residents themselves are responsible for. Short-term single-day, weekend, or afternoon coverage (“day float”) of inpatient wards, i.e. work in which the covering resident is not involved in critical decision-making, longitudinal care, and morning rounds, should not be covered by residents, since there is little educational value and much time lost in such work.
These changes may mean that residency programs become longer even as they become more focused on research, innovation, and managing complexity. The ACGME should consider “Leadership” as a seventh core competency [3]. Evaluation metrics should be developed to assess residents’ success as leaders. Are they capable of making independent, autonomous decisions on patient care questions of clinical, social, ethical, or biomedical complexity? Are they demonstrating innovation in aspects of biomedical, policy, clinical, or healthcare management work? Adopting standard metrics for these will not be easy, and holding residency programs accountable for the leadership skills of their residents, but this is central to ensuring that our healthcare system has effective managers and innovators at the helm.
The central challenge is to identify ways to staff much of the critical work that residents are currently compelled to perform. Fundamentally, we need an infusion of well-trained mid-level providers who can manage much of basic clinical care, counseling, and patient-follow-up, and we are going to have to be willing to pay for it. Changes in the regulatory environment to further capacitate these providers will be necessary [4]. Routine, less complex elements of health care delivery should be delegated to those with the proper training to administer those tasks. We are already seeing this with the growth of nurse practitioners on the wards and in clinics [5,6]. Further expansion of the role of mid-level providers will cost teaching hospitals money (since they are more expensive than residents), but will, in the long-run, make for a healthier, leaner, and more dynamic healthcare system. For its part, the federal government should be more willing to subsidize hospitals to train leaders and complexity managers than to subsidize basic hospital operations that should be managed by mid-level practitioners. In fact, in the long-run, we cannot afford not to make this investment.
Ultimately these changes may mean that, as in Flexner’s day when the Report led to the closure of dozens of unqualified medical schools, residency programs need to become smaller even as training programs for mid-level providers vastly expand. To meet the needs of our patients, the demands of healthcare reform, and the integrity of our profession, we may not need more doctors. Rather, we need a cadre of physician-leaders who are ready to drive the push for newer technologies and expanded access to better healthcare services. We need smarter, more creative, more balanced leaders in medicine. The new work hour regulations are a welcome call to action to inject an emphasis on managing complexity, on innovation and on leadership into graduate medical education.
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Duncan Maru, MD, PhD is a co-founder of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program and fellow in Global Health Equity at Brigham and Women’s Hospital and Children’s Hospital of Boston.
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