Education Fuels New System on Inpatient Wards
An innovative system designed to work in tandem with the recent Accreditation Council for Graduate Medical Education (ACGME) 16 work hour restrictions has changed how faculty, interns and residents and care for people on inpatient wards. The new ward structure was developed by residents and program directors and tested as a pilot program at the Veterans Administration before going into full operation last June. Ronald Witteles, MD,
Ronald Witteles, MD, Internal Medicine Residency Program Director
Newmakers in Medicine: What has improved under the new system?
Ronald Witteles: Patient flow has been far better, and trainees are better able to do proper rounds, get to the bedside with faculty, and attend conferences. The new system – in which residents have fewer admissions per day but admit patients on more days – is far more sensible. On the ground level, residents more than anyone, understand what works and doesn’t and we wanted this new system to be driven solely by educational concerns. At monthly meetings with the residents (called Committee on Residency Reform), program directors, chief residents and residents discuss any and all aspects of the program. It’s a perfect ongoing mechanism to get feedback and enables us to make changes in real time.
The new 16-work hour restrictions provided the push and political capital to make changes that were a long time coming.
NIM: How do you balance supervision, autonomy, and opportunities for independent decision-making?
RW: One of the factors that distinguish American medical education is that trainees can make real-time decisions rather than just carrying out a plan dictated from above. Clearly there is an important balance to strike, ensuring that trainees have the proper independence, but also the proper level of supervision. Our attempt is to have a process with graded responsibility based on only having residents in positions to make the decisions that they are ready to make. The specifics have to be designed for the unique characteristics of each rotation, and the balance is a tremendously important one to get right because you can easily lean too much one way or the other. We have established guidelines for what needs to be discussed and who needs to be seen by a more senior person in real time. Beyond that, there is of course someone available at all times for a resident to go to for any question or to see a patient if necessary.
NIM: Do work hour restrictions help prevent medical errors?
RW: I think the only honest way to answer that is, “We don’t know.” It is still not clear whether the 2003 change lowered medical errors. The fundamental trade is having more awake physicians on one hand, but more handoffs on the other. Since the same doctor is no longer with patient the whole way through, there needs to be formal training and a skill set for how to do an effective transition of care, which has increasingly become a focus of our educational efforts. No matter how well that transition of care is done there is always going to be some extra chance of error. Obviously the more tired somebody is there is also the extra chance of error and so it is a balance of those two factors.
In addition, what is the long term impact of having less training? If you decrease the total number of hours that an individual is trained in internal medicine or surgery, what is the effect, not just for errors as they go through training but for when they go out and practice independently? Are physicians being as well trained now as before? It’s an ongoing debate with no definitive evidence one way or the other.
At the end of the day, however, the question of whether the new work-hour rules are good is the wrong question to ask. We don’t get to decide if we want to comply with them – they are mandated by ACGME, and we are bound to follow them. The question we are therefore left with is how we can best build an educational system within the rules, and we believe that the new system has been extremely successful in achieving that aim.