Make It Count
Ok, NOW I’m going to talk about Pauline Chen’s latest entry in the health section of the New York Times. Here’s the link:
When I talk to my banker brother-in-law about work, I have no idea what he’s talking about and he has no idea what I’m talking about. When the average person reads about resident’s work-loads, I’m not sure he/she knows what that means. It’s not going from patient to patient laying on hands and doing therapeutic communication and intervention. That would be awesome. It’s not going from OR to OR doing case after surgical case. That would be awesome too. It’s spent doing paperwork. Let me give you an example: if a surgical resident gets called to consult on a patient in the ER, that means an ER doctor thought the patient might have a surgical problem. The resident goes down to the ER and examines the patient. So far so good. Now he leaves the room and walks to a computer, where he then types in his note about what he saw, including history, physical, medications, vitals, past surgical history, etc. etc., most of which has already been documented somewhere by somebody else. Then he calls his attending (the senior doctor, his boss) to discuss the patient. The he goes back to the computer and orders whatever tests the attending thinks he should order. Then he has to admit the patient to his service, which requires going to a different program on the computer and entering “admission orders”, which include important things like imaging studies and otherwise involve checking a lot of “standard order” boxes. The he opens a different program on the computer and re-enters everything he just did in the record that the surgical team is using to keep track of everyone, because this resident is leaving in 8 hours and the next one has to know what he was thinking. How much of that was patient care and/or learning? 20%?
When I was a senior anesthesia resident I did a rotation called “advanced” which presumably meant I’d get assigned to “advanced” cases, i.e., the difficult cases. More often than not I ended up doing foot cases or cataracts. Because the hospital needed a warm body to staff that room. No learning was going on, despite people who claim that “you can learn something from every case”. BS. Whole days would be occupied this way.
I think the duty hour issue and the work load issue are two separate problems. The hours problem is system-wide and includes all health care workers to some degree or another. The work load of residents is unique and has to change. Residents are, but should not be, slaves to their departments. Residents should not be used to do paperwork and staff rooms. That advanced month should have been spent in bypass surgeries, liver transplants, pulmonary cases, lung resections, things that I could have learned from. That surgical resident should have been able to see 5 patients and discuss them with his attending in the time he had to spend on the computer, and learned a lot more.
Residents don’t need to work more hours or see more patients. They need to work more MEANINGFUL hours and see more EDUCATIONAL patients and diseases. This will never happen in our current system because medicare pays for residents; it’s not going to pay for NPs or PAs or any other extender. Hospitals won’t pay for what they can get for free.