In my view: The trouble with the future is that it just ain't what it used to be!

Posted Apr 14, 2009

Donald Girard, MD, J.S. Reinschmidt Professor of Medical Education, Professor of Medicine and Associate Dean, GME and CME, offers his view on the new IOM recommendations for revised duty hours and workloads for medical residents.

The educational model used nationally to teach Graduate Medical Education (GME) was in large part set down by William Osler in the last part of the 19th century in Baltimore at Johns Hopkins Hospital. Is it time to step back and ask ourselves: should we keep trying to fix this model in bits and pieces or is it time to consider a new model better adapted to modern medicine? This question was raised anew for me recently when the Institute of Medicine (IOM) made a number of new recommendations after huddling with their membership – a group conspicuously devoid of physicians from the trenches of teaching hospitals.

Since 2003, residents have been required to adhere to a requirement that they not work more than 80 hours per week (averaged over four weeks). There are a number of corollaries to the requirements but that is the central one. The new IOM recommendations include changes in resident supervision, improved methods for transition of care, increased responsibility of the sponsoring institution to “sign off” on the fulfillment of requirements and, notably, more restrictions on the work routines of the residents.

At the 2009 annual Accreditation Council of Graduate Medical Education (ACGME) meeting in Grapevine Texas, Dr. Nasca, the head of ACGME, and his colleagues reported on the latest iteration of concerns about resident fatigue as it relates to patient safety. While the tenor of the presentation was collegial, there was unspoken but clear concern that these recommendations were not suggestions but mandates. Dr. Nasca concluded his remarks with a quote from Yogi Berra: “When you come to the fork in the road, take it.”

I have to admit I did not grasp the relevance of the quote. I rose to the microphone and introduced myself. And I began my brief comment with another famous and arguably more appropriate Yogi Berra quote: “The trouble with the future is that it just ain’t what it used to be.”

I continued that I had served my internship now forty years ago. During that year, I was on call half the time every other night and half the time every third night. I reported to the audience that I had no beeper, there was no ICU, that patients stayed in hospital for weeks at a time as we coursed the outcomes of their illnesses. And I still remember that there was so much we could not do.

Fast forward those forty years to find that patients are now divided into two quite circumscribed groups: the ambulatory ones and those hospitalized. And among the latter, those in the wards or intensive care units are increasingly the same, horrifically ill. And the chapters of care are nearly endless. No patient can die in the hospital without having endless, technically-sophisticated procedures. In fact, the remarkable technological advances of these years quite certainly resulted in the establishment of “end of life care” and Hospice programs.

And yet our training programs continue to pave the residents’ curricula with the well-worn methods of Osler who established his experiences as the basis for “house officers and resident physicians.” Our current training programs have been modeled on experiences from decades and decades ago.

I concluded by thanking our leaders for their thoughtful presentations but returned to Yogi Berra’s warning: indeed the future just ain’t what it used to be and perhaps we should look closely at how we train our new generations of physicians.

Perhaps it is time to consider a brand new modern model for training as we pass the tenth year of the 21st century – and to reconsider this incremental "improvement" process that simply continues to pound a square peg into around hole; in other words, an educational model based on the clinical conditions of the 19th century.

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