By Sefira Bell-Masterson, Dr. Lakshman Swamy and Dr. Christopher Worsham
A few things in medical education have changed in the past 100 years.
A century ago, for instance, resident physicians-in-training literally lived on hospital premises.
They received room and board but no other compensation. They routinely performed any task related to patient care, ranging from transporting patients to the operating room to performing their surgeries.
Clearly, things have changed. But what hasn’t changed is how medical residents are used for any task that needs to be done during a patient’s hospital stay.
Today, residents are expected to learn medicine, care for patients, and improve our health care system — often in addition to teaching and research. All this needs to be done within a limited number of nationally regulated duty hours, now the subject of an ongoing and increasingly controversial conversation in the medical community since restrictions were put in place in 2003 and 2011.
Over the past decade, there has been much debate about the benefits and drawbacks of duty hour restrictions, yet prior research into this topic has shown mixed results. Earlier this month, however, researchers published results of a first-of-its-kind randomized trial (the FIRST Trial) of 117 surgical residency programs across the country. The study’s authors concluded that there was no difference for patients or their doctors’ satisfaction whether residents worked under current duty hour restrictions or under more flexible rules. Results of a similar trial performed on medical residents (the iCOMPARETrial) are expected later this year.
As residents ourselves, we believe the duty hours conversation has missed a major point: Though our hours are being limited, what we actually do during these hours is not.
There has been a great focus on the number of hours worked, but silence about the actual work done.
Erica, a resident in obstetrics and gynecology in Delaware, routinely runs her own lab tests in the office. Karl, a pediatrics resident in New York, often spends valuable time in the room with a child and her parents laboriously copying information from her medical record to fill out school forms.
Adil Yunis, an internal medicine resident in Boston, will spend 30 minutes on the phone trying to get a cardiology appointment for his patient who just had a heart attack.
These tasks (all real, but with two last names withheld ) are examples of what many residents call “scut.”
“Scut” is medical slang for the non-clinical yet essential tasks that do not require a doctor’s degree or expertise. Though it varies in different hospitals, this work includes, but is not limited to: transporting patients, coordinating hospital discharge, drawing blood samples, scheduling appointments, obtaining health records, sending faxes, filling out forms, and entering computer data.
Our patients’ lives rely on this work, and in no way are we implying that it is unimportant. But as a patient, would you prefer that your doctor spent her limited time in residency building her clinical skills, or on the phone making appointments?
When scut is forced onto an already-busy resident, it is detrimental to his or her training, as it cuts directly into time that could otherwise be spent on face-to-face care, education or system improvement. But as long as the work is done, hospital operations move forward, leaving no obvious need for administration to invest in system change.
Sadly, many residents accept these systematic problems as inevitable.
Fortunately, residents at our hospital are not resigned to this. Our predecessors in 1915 formed the country’s first resident union to have a voice in their own training. They used that voice to advocate for their patients and themselves, and we are proud to continue this tradition 100 years later.
We work directly with our hospital administration to improve our system and remove barriers to productive learning and care. By keeping an open dialogue between front-line residents and the administration, our hospital can better adapt to the continuously changing world of modern medicine to best serve our residents, our institution and, most important, our patients.
What if Adil, the resident making his patient’s appointment, had a way to quickly schedule appointments through an automated computer system? Could he then spend more time at his patient’s bedside answering her questions prior to discharge?
In fact, Adil is doing exactly that. As part of a collaboration between the hospital and our union, he is working directly with executives to build automated appointment scheduling into the electronic health record.
Ongoing collaboration like this is improving the health care system, the quality of residency training and patient care by combining residents’ front-line expertise with the full resources of the hospital C-suite.
This spring, the Accreditation Council for Graduate Medical Education (ACGME, the regulatory body for American residency programs) will hear testimony on duty hour regulations. In light of the new research, debate will likely include a call from some to change current regulations. Indeed, we should revisit current regulations and set the most appropriate limits on how many hours residents can work. This discussion, however, must focus not only on the number of hours we work but also on what we are doing with those hours.
With its oversight, the ACGME can help facilitate this type of collaboration between residents, unionized or not, and teaching hospital executives across the country. If we cannot find ways to collaborate, broader policy solutions such as federal funding reform may be the only way to ensure that our residents are best prepared to take care of America.
Ultimately, the question is simple: Would America prefer its future doctors to train at the bedside, or at the fax machine?
Lakshman Swamy, M.D. and Christopher Worsham, M.D. are resident physicians in internal medicine at Boston Medical Center. Sefira Bell-Masterson is the regional director of the Committee of Interns and Residents, the physician’s union that represents the residents and fellows at Boston Medical Center.