Saturday, July 26, 2008

The Aggravated Education

Sometimes, I start to feel my age, deep down in my bones. This morning, I'm feeling it way down in my psyche --- I feel like the most curmudgeonly and crusty old fart alive today. Mais pourqois monsieur le DocSurg? Because of the idiocy of stuff like this.

War games? Fake situations? What, are there not enough real sick people to care for? The opening paragraph is telling:

With the advent of work-hour restrictions, many training programs are struggling to evaluate the education and competence of trainees in more exacting ways. The traditional role of the "house officer" consisted of extended hours in the hospital and minimal cross-coverage. This system has since evolved into shift work (i.e., night float) where residents are caring for larger numbers of patients whom they may not be familiar with. In this new environment, the ability of the clinician to rapidly assess and intervene in a situation, with little previous knowledge, is becoming more important. Additionally, the ability of junior clinicians to recognize the need for help is imperative.
I'd like to offer a little re-write, to reflect the motives and reasons behind this kind of garbage:
With the advent of work-hour restrictions Since the idiots in charge decided that we had to limit surgeons in training to an artificial limit of 80 hours per week, many training programs are struggling to evaluate the education and competence of trainees in more exacting ways figure out how to cram as much knowledge that time permits into their trainees in order to give them some degree of clinical competence. The traditional role of the "house officer" consisted of extended hours in the hospital and minimal cross-coverage, i.e., extended hours in the hospital caring for their patients, and cross-coverage was minimal; this ensured both that the trainee received a lot of clinical experience and that patients had someone available that was familiar with their problems. This system has since evolved into shift work (i.e., night float) where residents are caring for larger numbers of patients whom they may not be familiar with covering patients that they have never seen, never operated on, and do not know. In this new environment terrible system foisted upon us by attorneys and so-called education experts, the ability of the clinician to rapidly assess and intervene in a situation, with little previous knowledge, is becoming more important dangerous, because now have a whole host of well-meaning residents who may be wholly unprepared to care for a patient they barely know. Additionally, the ability of junior clinicians to recognize the need for help is imperative because the junior residents are getting so little training, the senior residents and attendings will need to be readily available to take up the slack (without an artificial 80 hour work week restriction).
These residents don't need "war games" to prepare them for emergencies. What they need is time on the wards, caring for their own patients, sometimes being called back in to assess their fresh postop patient to see if they need to return to the OR....and then being the one in the OR with the patient. It's pretty hard to be a surgeon without taking an "ownership" stake in the outcome of your patients. I fear that the "professional educators" are pushing medical education over a cliff, from where it may never recover.

Maybe we should ask one of these "educrats" a few questions.......


Hi there, I'm Nancy Nanny, MD, RN, BSN, MS, PhD, director of resident education at Western Elbonia State University (the "College of Knowledge") {W.E.S.U.C.K.} Medical School. You can call me Dr. Nancy!







I'm Aggravated DocSurg. You can call me Aggravated. Really aggravated.











Well, now, what seems to be the problem?










Well, Nancy, ...











(cough) Doctor Nancy...






Yeah, Dr. Nancy. I think you are taking surgery residency education in a direction it was never intended to go. If residents are restricted from seeing patients the night after they were on call, how are they going to know if they made the right clinical decisions?








Those poor, tired dears! How are they going to read if they have to work the day after call? How are they going to prepare for the ABSITE? We can't have them perform poorly on standardized tests, now can we?!









Read? They can read when they get home; that's why God invented coffee. And what about the idea of continuity of care? How are they going to learn the responsibility of caring for patients they have operated upon?





Oh, Aggravated, you are a such a card! Continuity of care? That's an obsolete notion foisted upon us by the old bourgeois medical hierarchy which has no place in modern medical training. We work as a team to provide the ultimate patient care workplace. Concepts such as patient ownership, "captain of the ship," and the like have no place in today's brave new world of resident training.




Er, OK. I'd say that your residents are in for a rude awakening when they get into the real world, where the ultimate responsibility for patient care rests with them. Their malpractice carrier will, I'm sure, let them in on that little secret.

You mentioned the ABSITE. Since we are supposed to be making our clinical decisions on "evidence-based medicine," can you tell me how well the ABSITE scores predict residents' ability to care for patients?






(cough)......(cough)









Alrighty then. Let's try another subject. Has the 80 hour work week provided a better clinical learning experience for surgery residents?






Oh, my, yes! Residents are happy with the changes.







Um, Dr. Nancy, with all due respect, you didn't answer my question; any sane person would be "happy" doing less work. Let me give you a little information.

Since the advent of the residency work hour restriction, surgery residents are performing about the same total number of cases in training, but one study demonstrated a 40% decrease in technically advanced procedures with a 44% increase in basic procedures. The study also demonstrated a 54% decrease in the operative volume as first assistant. Operative continuity of care by residents decreased from 60% to 26% of cases. Other studies have found similar issues. And as for decreasing error rates.....sorry, not so much.



But they're happy! And they have time outside the hospital!











Since when did happiness and time outside the hospital equate to quality patient care? I may be an old fart, but there was a time in my training when I was made happy by learning how to take better care of my patients.






But you are missing the point! We must ensure that our young trainees receive training in the Core Competencies mandated by the all-seeing, all-knowing ACGME:
  • Medical Knowledge
  • Patient Care
  • Practice Based Learning Improvement
  • Systems Based Practice
  • Professionalism
  • Interpersonal and Communication Skills


Male bovine droppings! "Practice Based Learning Environment?" "Systems Based Practice!!??" You're making that shit up!











(cough)








Let me guess. The data to support this tripe is......?












Zippo. Nada. Zilch. The big goose egg. A little bit is better than nada? Uh-uh, not here, buster.










But you insist that residency programs follow this because......










Actually, because we can!








I think I'm going to be sick. Actually, strike that. I hope I don't get sick, especially as I get older, because we may be inundated with poorly trained physicians who need a whole lotta on the job training after they have completed their training.

Well, fortunately I'm done with all of that. The educrats can't get to me now.



Oh, you clueless little man. You. Have. No. Idea.

Here's what we have planned for you!










(cough)

Uh, you're shitting me joking, right?








(cough) (smile)









It's not a martini, but it'll have to do.