“The most essential part of a student’s instruction is obtained…not in the lecture-room, but at the bedside. Nothing seen there is lost…its unforeseen occurrences stamp themselves indelibly in the memory.” Oliver Wendell Holmes
The Accreditation Council on Graduate Medical Education (AGCME) recently limited the work hour requirements for interns and residents in residency programs as of July 2011. The most recent modifications limit doctors-in-training to an 80-hour work week. First year residents (interns) can serve no shift longer than 16 hours while all other trainees can work up to 24 hours continuously in direct patient care with an additional 4 hours for patient care transition allowed.
Even though work hours are now limited, the duration of residency training has remained the same. Some believe – especially those who trained either in the era before duty hour limits or those under the first iteration of limits instituted in 2003 – that by limiting duty hours while not extending the length of residency programs, residency programs may produce poorly trained new physicians. This study explores the possible deficiency in training by comparing the quality of diabetes care provided in residency clinics with the quality of diabetes care provided by practicing physicians. The quality of diabetes care was chosen for evaluation because there exist widely agreed-upon quality metrics. The Diabetes Practice Improvement Modules (DPIM) of the American Board of Internal Medicine (ABIM) are already being used as an assessment tool for ABIM.
Data were collected from sixty-seven clinic sites in thirty-seven residency programs and 703 practicing general internists in various settings. Baseline data collection for the DPIM occurred from 2005–2010. There were 2,493 chart reviews from residency clinics and 13,777 chart reviews from practicing physician clinics for patients with type 2 diabetes ranging in age 18-75 and who received care from their respective clinic or physician for at least twelve months. Statistical analysis with t-tests determined whether there were significant differences between the two groups regarding selected patient characteristics.
When compared with patients of practicing community physicians, patients seen in residency clinics were younger, had lower self-ratings of overall health, more likely to be current smokers and have long-term complications of diabetes mellitus.
Residency clinic patients were less likely to have process measures completed compared to practicing community physicians’ patients. These recommended measures included: retinal exams (43.8 versus 62.8 percent, p<0.01), foot exams (43.3 versus 69.1 percent, p<0.01), and smoking assessment and therapy (86.7 versus 96.6 percent, p<0.01).
Residency clinic patients also had worse intermediate outcomes compared to their community counterparts: poor HbA1c control (24.9 versus 13.3 percent, p<0.01), poor blood pressure control (40.9 versus 26.5 percent, p<0.01), and poor LDL control (26.5 versus 22.0 percent, p<0.05).
The recent change in the United States’ postgraduate medical education system has been both a blessing and curse for future physicians in-training. Limiting work hours for interns and residents was definitely needed based on anecdotal evidence and numerous studies that identified medical errors and psychological stress associated with sleep deprivation.
The concern, however, is the limited amount of time that interns and residents have in supervised direct patient care. Medicine traditionally has been taught both by didactic (classroom) learning as well as (hands-on) apprenticeship. However, time limitations placed on the newest crop of residents threatens to dismantle the importance placed on apprenticeship. Eventually, the ACGME may need to reconsider extending the length of residency training programs to ensure that future physicians in-training are well equipped to handle this ever-changing and demanding medical field.
Tyree Winters, DO
Read an inspiring post about how Dr. Winters chose to become a doctor of osteopathic medicine and how his is giving back to his community.
Editor’s note: As the population of patients cared for in residency clinics appear to have worse health from the start, it is not surprising that intermediate outcomes were worse. However, the poor performance on process measures in our nation’s supposedly great academic institutions points to unacceptable execution.