Thursday, December 06, 2007

Counterintuitive

Counterintuitive: coun·ter·in·tu·i·tive (koun'tər-ĭn-tōō'ĭ-tĭv, -tyōō'-) adj. Contrary to what intuition or common sense would indicate

For some time now, the Powers That Be® have been stating that in the brave new world of the 80-hour residency work week we would have better rested, more motivated residents willing to tackle the challenges of training with vigor, good humor, and as much or more dedication as their predecessors. And for just as long, curmudgeonly surgeons such as myself have called BS on that idea, feeling that it takes a whole lot more than counting hours in training to make a complete surgeon -- or physician of any stripe -- concerned that the residency training system would eventually turn out fewer numbers of adequately trained surgeons. However, the Powers That Be® have more clout than simple surgeons such as myself, and have made persuasive arguments that the 80-hour work week would increase the number of students willing to go into general surgery in particular.

Do they have any data to back that up? Well, not quite. And, just because I like to throw cold water on social engineering masquerading as good medical policy, I'd like to share a little data with you that might come as a surprise.

In this month's American Journal of Surgery there is an interesting article entitled General surgery resident attrition and the 80-hour workweek. The authors sent a simple, seven question survey to all 252 ACGME accredited general surgery training program directors, and received responses from 124. Basically, the survey asked about attrition rates for categorical general surgery residents (those who entered the training program intent upon completing a 5-6 year course of training in general surgery) over a 4 year period starting just prior to the 2003 institution of the 80-hour rule. Now, it would seem intuitive to expect that attrition rates would go down, or at a minimum stay stable, following the implementation of the 80 hour rule. Of course, theories based upon intuition need to be tested and validated --- what was found was the opposite (from the abstract):
One hundred twenty-four of 252 programs (49%) responded, reporting a loss of 338 categorical residents. The total attrition rate increased from .6 residents lost/program/y to .8 residents/program/y (P = .0013). Lifestyle concerns were the most commonly reported reason for residents leaving during surgical training. The majority (56%) of those who left surgery entered other fields of medicine (ie, Anesthesia and Family Medicine most commonly).
Makes you go "Hmmm," doesn't it? Training programs, and their governing bodies, have gone out of their way to make general surgery training "easier," less time-consuming, and supposedly more attractive as a result, and what happens? Fewer residents complete surgical training!

This study begs the question "why?" Fear not -- as unusual as it is for me to offer an opinion, let me make a few observations. First of all, making an educational experience less rigorous does not necessarily make it more attractive. I subscribe to the idea that things worth having are worth working hard to get --- like SWIMBO, for example. Secondly, when surgery residency is advertised as "fun, and now easier!" it does not necessarily attract the type of applicant willing to put in the hard work it takes to end up as a practicing surgeon. After all, if "anyone can do it" is a good way to advertise for applicants, why isn't that posted on a sign at the base of Mt. Everest?

Last of all, we should all recognize that this happens because of the Law of Unintended Consequences --- whenever we make policy decisions with a social engineering intent, rather than based upon rational thinking, what we end up with rarely resembles a desired outcome.
And, since we all know there is no going back, the best we can hope for is a little more rational thinking in the next few years to ensure that good surgical resident training is preserved as much as possible.