Unintended Consequences
Besides ensuring excellent medical treatment for patients, the ACGME work rules were intended to keep residents alert so that they could fully engage in the work and education needed to become fine physicians. The rules, however, are backfiring. Residents no longer are able to observe the timing of a patient's response to an intervention; they can't follow the tempo of a fever or the bloom-and-fade cycles of a rash even when, as responsible physicians would, they sincerely want to. Their heads are crammed with the facts they've learned during medical school, but they can't see firsthand the course of a birth or a gall bladder attack or the phases of recovery from a surgical procedure and then integrate those facts into informed decision making. Instead of producing physicians with high professional standards who see their patients through to the end (of labor, of an operation, of an illness, of a life), the current system is creating a legion of shift-worker physicians who leave when the clock strikes a certain hour rather than when the job has been completed.
In evaluating their training programs, residents often ask for increased autonomy. They realize that in the future they'll be solely responsible for the care of their patients, and they worry that without a certain amount of autonomy during their training, they won't be adequately prepared for independent decision making. Yet with their current here-today-and-gone-tomorrow schedules, they can't be given increased autonomy—they won't be around for the next step or haven't been around for the last step. They don't have the big picture.
The children's hospital where I work contains what I consider the world's most precious treasure: children who are the future of our society. The other great treasure in my hospital is the young physicians of tomorrow who will carry forward our medical values, traditions, and practices. The reason that the doctors at my children's hospital are disappearing or aren't there when they're needed is, simply, inadequate resources to compensate for the restrictions of the new work rules and the resulting workforce reduction.
It's always about the money. In terms of the new ACGME regulations and providing medical care for children, we (meaning our society) can't seem to figure out the money part.Yes,to some extent, we might be able to work"smarter" with new technologies and information systems. Yes, we need to figure out how to streamline communication among the many team members. Indeed, we need resources to create real teams.
As we consider how to allocate medical and educational dollars, the question becomes, What's more important than healthy children and well-educated physicians? We know the answer: Nothing. But when the next question is, What are we doing to meet the challenge of having enough doctors for enough hours in all of our hospitals, we also know that answer: Nothing.
Health Affairs. 2008;27(3):850-854. © 2008 Project HOPE
Cite this: The Disappearing Doctors - Medscape - May 01, 2008.
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