A BRIEF HISTORY OF GME From Apprenticeship to
A BRIEF HISTORY OF GME From Apprenticeship to the 80 -Hour Workweek LT Mickey Skaret, MD PGY-3, Medicine 15 Sept 2017
Disclosures • I have no financial, personal, or professional conflicts of interest to disclose. • The views expressed in this presentation do not reflect the official policies of the Defense Health Agency, the Department of Defense, or the U. S. Government.
Objectives • To review the humble beginnings of graduate medical education (GME) in the U. S. • To outline the central themes of GME, past and present • To discuss the balance between quality of education and patient safety in the past century • To explore the issue of the clinical learning environment (duty hours) • To ponder the road ahead for GME
Before GME 1700 s to early 1800 s • Apprentices and preceptors • Highly variable learning environment
Before GME Early 1800 s • Numerous proprietary medical schools: an improvement? • Required 3 yrs of apprenticeship • Entirely didactic • Two terms of lectures • Summer classes on clinical skills (optional)
The First Residencies • Pre Civil War: Residency programs in major east coast cities began opening • By 1873: 178 hospitals offered a total of 309 positions • Boston City Hospital • “Old Blockley” (Phila. Gen. Hospital) • Bellevue Hospital • Mass. General Hospital • Early residency based on indentured servitude The Gross Clinic, T. Eakins, 1875
Life as a 19 th Century House Officer “[House officers] shall attend to patients on their admission, and give the necessary directions for their comfort…and shall make a daily evening visit to each patient. ” – Boston City Hospital, 1866 • Performed a variety of menial tasks • Lived in the hospital; prohibited from marriage • Very little autonomy; expected to be subservient “Subordination, Capacity for Labor, Conduct” – Requirements of house pupils at MGH, 1874
Specialization & European Education Mid 1800 s: Trend toward medical specialization “It is no longer possible for any one man to grasp and retain a knowledge of all the branches of medical science” - John Shaw Billings, 1878 • Specialization required training in Europe Late 1800 s: Clinical Science • The European standard • Scientific method + clinical research higher quality medical education • Demand for clinical science in the U. S.
The First Modern Residencies 1876 • Johns Hopkins University opens, America’s 1 st research university 1889 • Johns Hopkins Hospital & residency programs open 1893 • Medical school opens at Johns Hopkins The Johns Hopkins Hospital, 1889
The Birth of Modern GME at JHU • GME built in from day 1 • Three Residency Programs • Medicine (Sir William Osler) • Surgery (William Halstead) • Gynecology (Howard Kelly) • Novel ideas for American GME • Residents given full responsibility for patients • Culture of inquiry and investigation • Residents as teachers • Extended duration of training (2 years) The Four Doctors, J. S. Sargent, 1906
The Spread of Modern GME • “Teach the Teachers” • Early goal to create thought leaders in GME who would direct their own residency programs • Halstead’s 17 chief residents 11 new program directors • Through the 1930 s • Reputation of residency training as the gold standard for excellence in medicine • Fewer and fewer American physicians seeking out training in Europe
Early Principles of GME The residency-trained physician must… • Understand the scientific method to keep pace with the progress of knowledge • Think critically and acquire/assimilate new knowledge • Possess sound clinical judgment • Practice with the skill to handle inherent uncertainty & risk
Early Principles of GME To accomplish these goals… • One must be allowed to take on increasing responsibility, under supervision from immediate superiors • There should be no substitute for learning at the bedside “One case carefully studied and recorded is worth many cases observed superficially. ” - Francis W. Peabody, chief of medicine, Boston City Hosp. • One must put the patient’s welfare above all else
Education vs Service 1920 s – 1940 s • GME became indispensable to healthcare in the U. S. • Residents as students or workers? • Ordering blood tests? Educational • Drawing blood? Less educational • Running to the lab? Not educational 1965: Medicare • Increased number of insured patients more work for residents • Increased pay for residents & funding for facilities, but no funding for ancillary staff to take over menial tasks
Quality, Safety, and Supervision 1950 s – 1960 s • Teaching hospitals were presumed to deliver the best care • Thought leaders attracted to academic centers • Trainees required to stay up to date on the literature • Of course, errors did occur • Usually linked to individual resident’s mistake (no focus on systemic errors) • Resident as “second victim” “forgive & remember”
Quality, Safety, and Supervision 1960 s – 1970 s: Early Investigation into Errors • Proposed cause: inadequate supervision >> fatigue • Osler Medical Service at Johns Hopkins: • 50 -60% of patients managed without faculty oversight • “Encourages individual growth & scholarship in medical practice” • Faculty assistance available (in theory) • “The Hidden Curriculum” • Idea that residents would be labeled as weak/indecisive for calling for help
The Duty Hours Question Mid 20 th Century • 36 hour call for interns & residents, every other night = 100 hrs/week 1975 • Residents in NYC go on strike, calling for fewer hours • Hospitals agree to reduce call to every 3 rd night 1981 • Accreditation Council for Graduate Medical Education is founded; no change in duty hours
1984: “A Case That Shook Medicine” Libby Zion, an 18 y/o F college freshman with PMH of depression (on phenelzine, an MAOI) • Pt presents to the ED with “flu-like” symptoms, fever to 103. 5°F, and myoclonic jerks • Admitted for hydration & observation, diagnosis: “viral syndrome with hysterical features” • Given meperidine to control shaking
1984: “A Case That Shook Medicine” Later that night… • PGY 2 has gone to the on-call room • PGY 1 gives haloperidol for worsening agitation • By 06: 30, temp is 107°F • Cardiac arrest unsuccessful resuscitation • Posthumous dx of serotonin syndrome
Libby Zion: Root Cause Analysis
Libby Zion: The Aftermath 1984 -1985 • Libby’s father, prominent columnist media outrage 1986 • Grand jury considers murder charges for housestaff • Expert panel, headed by Dr. Bertrand Bell, to examine training/supervision of housestaff in NY 1987 • Bell Commission: 80 -hour workweek with shifts < 24 hours 1990 • ACGME sets 80 -hour limit for IM, Derm, Ophtho, Prev Med • Limits call to every 3 rd night with 1 day off in 7
More Duty Hour Restrictions 2001 • Political debate and negative press • Petition from advocacy groups requests that OSHA regulate duty hours; federal legislation proposed 2003 • ACGME announces duty-hour requirements for all specialties • 80 -hour workweek with 1 day off in 7 • Shifts < 24 hours (with 6 add’l hours for education/handoffs) 2011 • ACGME restricts PGY 1 shifts to < 16 hours
Playing Devil’s Advocate… • Regarding the 80 -hour workweek: “[It is] a number with some general acceptance, without much scientific underpinning. ” - Dr. Paul Friedmann, co-chair, ACGME Work Group on Resident Duty Hours and the Learning Environment • Thought leaders have argued that duty hour limits were made in response to political pressure, not based on scientific evidence of benefit
Outcomes of Duty Hour Limitations Before ACGME regulations (2003) Conflicting evidence under NY State limitations • Increased errors for surgical patients • Delayed test ordering and more complications for medical patients • Residents reported conflicts between compliance with duty hours and obligations to patients/colleagues
Outcomes of Duty Hour Limitations After ACGME regs (2003/2011) • Pt Outcomes: • Two large studies showed no difference • Actual Hours Worked: • Decrease in hours from ~85/wk to ~65/wk (for IM residents) • However, several studies showed residents working >> 80 hours • A few showed that residents perceived an increased clinical demands/workload/stress and reduced participation in didactics • Academic Performance: • Data is scarce
Perceptions of Duty Hours • Survey of 2323 interns from 51 programs (14 institutions) • Data collected pre- and post-16 -hour shift limit for interns • Despite decrease in duty hours, no significant changes in hours slept, depressive symptoms, or well-being score • Increase in fear of making serious errors • Work compression: fewer hours for the same work
The FIRST Trial • The first and only RCT for duty hours • Surgery residency programs randomized to standard ACGME duty hour policy vs. “flexible policy” (waived rules on max shift length and time off between shifts) • Primary Outcome: 30 -day rate of death/serious complication
The FIRST Trial Results: • No difference in death/serious complication or in secondary post-op outcomes • No significant difference in self-reported quality of education, well-being, or perception of patient safety • Residents in flexible policy programs less likely to leave during an operation or handoff active patient issues
This Year’s Changes 2017 • New ACGME requirement as of 01 JUL 2017: • PGY 1 s can now work 24 hour shifts • Renewed emphasis on 80 -hour workweek, patient safety, and supervision “At the heart of the new requirements is the philosophy that residency education must occur in a learning and working environment that fosters excellence in the safety and quality of care delivered to patients both today and in the future. ” - Thomas J. Nasca, MD (CEO, ACGME)
Coming Soon! The Individualized Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (i. COMPARE) Study • Similar design to FIRST trial, but with IM interns • Programs randomized to max shifts of 16 hrs vs. flexible schedule, allowing up to 30 hr shifts • Finished data collection in June 2016
The Bottom Line • GME in the U. S. has come a long way • The central themes of GME (e. g. the necessity of taking responsibility for patient care and the primacy of patients’ welfare) are deeply rooted in our culture • In the past century, the scales have tipped both ways with respect to the balance of education and service • The ideal clinical learning environment to maximize learning, resident wellness, and patient safety is not clear
The Road Ahead • The answer to the duty hours question requires further research with highly powered, randomized studies • Optimizing the clinical learning environment will require a more holistic approach • Improving systems to offload menial/redundant tasks from residents will allow for more focus on better care • Inadequate supervision and the “hidden curriculum” likely produce more sentinel events than resident fatigue, so programs to address these should be supported
Acknowledgements • Sarah Cantrell, MLIS • CPT Sarah Ordway • LT Tom Mellor • Sydnee Mc. Elroy, MD & Justin Mc. Elroy • Sawbones: A Marital Tour of Misguided Medicine
QUESTIONS?
References 1. Nasca, T. , Memo. 2017, ACGME: ACGMECommon. org. 2. Asch, D. A. , K. Y. Bilimoria, and S. V. Desai, Resident Duty Hours and Medical Education Policy - Raising the Evidence Bar. N Engl J Med, 2017. 376(18): p. 1704 -1706. 3. Alvin, M. D. , i. COMPARE: An Intern's Perspective. J Grad Med Educ, 2017. 9(2): p. 261 -262. 4. Rosenbaum, L. , Leaping without Looking--Duty Hours, Autonomy, and the Risks of Research and Practice. N Engl J Med, 2016. 374(8): p. 701 -3. 5. Philibert, I. , What Is Known: Examining the Empirical Literature in Resident Work Hours Using 30 Influential Articles. J Grad Med Educ, 2016. 8(5): p. 795 -805. 6. Bilimoria, K. Y. , et al. , National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. N Engl J Med, 2016. 374(8): p. 713 -27. 7. Ludmerer, K. M. , Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. 2015, New York, NY: Oxford University Press. 8. Sorensen, M. J. , Let's Heal Ourselves. Journal of Graduate Medical Education, 2014. 6(3): p. 449450. 9. Sen, S. , et al. , Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. JAMA Intern Med, 2013. 173(8): p. 657 -62; discussion 663. 10. Rosenbaum, L. and D. Lamas, Residents' duty hours--toward an empirical narrative. N Engl J Med, 2012. 367(21): p. 2044 -9. 11. Lerner, B. H. , A Case That Shook Medicine, in The Washington Post. 2006. 12. Steinbrook, R. , The debate over residents' work hours. N Engl J Med, 2002. 347(16): p. 1296 -302.
References Images • https: //upload. wikimedia. org/wikipedia/commons/thumb/0/02/John_Redman_b 1722. jpg/440 px. John_Redman_b 1722. jpg • https: //en. wikipedia. org/wiki/Geneva_Medical_College#/media/File: Geneva_medical_college. jpg • http: //practicing-medicine. thenewatlantis. com/2014/03/residents-and-rounds. html • http: //memolition. com/2015/05/22/doctors-post-pics-defending-med-residents-caught-sleeping/ • https: //www. worldmapsonline. com/images/giclee/satellite_image_maps/europe_physical_giclee_lg. j pg • http: //academicdepartments. musc. edu/gme/acgme/ • http: //imgur. com/gallery/Nwyb. V 9 O • http: //www. paintingmania. com/professors-welch-halsted-osler-kelly-four-doctors-171_14565. html • http: //media. istockphoto. com/photos/asian-college-student-pictureid 138017387? k=6&m=138017387&s=612 x 612&w=0&h=DJJT 2 ap 7 Zkcb. ISRihl. Ay. MM 6 DUu. CNC 4 Iy. ORWfbe. Mp. Gw • https: //i. pinimg. com/736 x/99/bd/09/99 bd 09 c 449 de 3 d 71 cff 2 b 4478 fc 8 a 392 --work-clothesworkwear. jpg • https: //racqliving. com. au/wp-content/uploads/2015/11/Feb-March-Road-Ahead-header. jpg
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