Tuesday, April 13, 2010

Watch Me!

In the March issue of the Journal of Graduate Medical Education there is a paper entitled "How Residents View Their Clinical Supervision: A Reanalysis of Classic National Survey Data". This paper presents the results of a 1999 survey of 3,604 PGY 2 and PGY 3 residents. (The "PGY" refers to "post-graduate year", in other words how far along the physician is in her training after medical school.) The residents in this survey represented a random sample of 14% percent of all physicians in training, and almost two-thirds of the residents responded to the survey.

The good news is that the majority of the residents felt they had adequate supervision during their training.

Unfortunately, about a quarter of the residents reported that they had seen patients without adequate supervision at least once a week. Five percent said this occurred almost daily. Residents in opththalmology, neurology, neurosurgery and psychiatry were more likely to report inadequate supervision, while residents in pathology and dermatology were least likely to experience this.

Poorly supervised residents reported many other problems with their training programs, all of which could affect patient safety. Residents without adequate supervision also reported increased use of alcohol, significant weight change, or use of medications either to stay awake, to help them sleep, or to help them cope with the residency. They were also more likely to report higher ratings of self-assessed stress, sleep deprivation, total weekly work hours, and having worked while in an impaired condition. They were also more likely to report that they personally had been belittled and humiliated, or physically assaulted while working. In spite of all this, there was no correlation between sleep-related medical errors and being named in a malpractice suit.

Recently the Institute of Medicine issued a report with recommendations to reform graduate medical education. The report emphasized the connection between a healthy working (or training) environment and safe patient care. Surprisingly, medical organizations have not widely welcomed this. Certain specialty organizations are concerned that duty hour reform may deprive residents of valuable training experience and that the financial burden of duty hour reform will drive up the cost of health care. What this survey highlights is the fact that failure to adequately supervise residents and to provide humane working conditions creates a risk for the young physician as well as the patient.


Lockup Doc said...

Interesting topic. I've always wondered how common this issue is for psychiatric residents in different training programs.

This was always a concern among my fellow residents when we were in residency. There was one year during which we did most of the primary on-call (for what seemed like the entire world!). It was really an unrealistic responsibility.

One resident (PG-2/second year resident) was responsible for covering the university hosptial inpatient unit, the univ hosp ER, any urgent hospital consults, the VA Urgent Care (the ER equivalent there), the VA inpatient psychiatric unit, the VA outpatient practices, the entire university outpatient psychiatric clinic, and the patients from an HMO in town that had an agreement with the U.

What this meant is that at 11PM, one resident would not uncommonly be in the university ER with anywhere from 1-3 patients to see (some of whom may have needed admission) while an outpatient from the university clinic would be calling and threatening suicide. In the meantime, someone would have arrived in the VA urgent care after driving 150 miles--arriving with suitcase in hand. Some of the faculty members' patients would be calling with problems. The police would be bringing someone in who was psychotic and agitated. And so on. Yes, a faculty member could be called at home, but the bottom line is that one person was responsible for doing all of this. All at once. Trying to interview patients with the beeper constantly going off.

For one relatively inexperienced doctor-in-training, that just doesn't make sense. It's hard to be compassionate or do a good job in that situation.

tracy said...

i found the info page on the then PGY-4 Psychiatric Resident i was in therapy with for, unfortunately only 10 months, and he commented on the excellent and varied supervision his class had. Either he was an excellent and natural therapist (which i think is true!) or all of the supervision helped. Whatever, he was wonderful and i miss him deeply.
Shout out to Dr. C K !

Ivory said...

Certain specialty organizations are concerned that duty hour reform may deprive residents of valuable training experience and that the financial burden of duty hour reform will drive up the cost of health care.

They are right - it probably will make things more expensive. But medicine is sort of a ponzi scheme now, relying on the cheap labor of underpaid folks to support large faculty salaries that may or may not have anything to do with billing for clinical work. It would make sense to increase resident pay and normalize their work when, realistically, they are paid less now then they were in the 70's and their jobs are more complex.