Sunday, August 2, 2009

A new breed of doctors

A patient complains to her anesthesiologist about her anesthesia bill. "Doctor, I can't believe you charge me this much money to put me to sleep." The anesthesiologist replies, "No madam. Putting you to sleep is free. This fee is for waking you up."

While talking with my colleagues, a complaint was voiced that medical, and anesthesia, residents sure have it good compared to when we were in training. While we had to walk six miles to work in hip deep snow and crafted Ambu bags out of the bladders of sacrificial virgin lambs, the current residents' hours are strictly capped at eighty hours per week. And the talk was of even stricter work rules next year. Their work week will be capped at 65 hours a week, with no 24 hour shifts and a required 10 hours of rest between shifts. When a resident's work day is finished, he or she must leave immediately by pulling his car out of the parking lot, swiping his ID card at the gate to signify he is no longer at work. Study at the hospital library after work? No can do. Postop checks? Not if it will violate the work hours limit.

But it is the clinical skills that will suffer the most. The 65 hour work week includes classroom time. So actual OR time will be much less. While the resident will put at least one patient to sleep during the day, he may not be around for the end of the case, the critical time when major decisions are made about extubation criteria, hemodynamic stability with awakening, need for intensive care postoperatively, and PACU complications. And of course the longer the case, the more critical the postoperative period, and the less likely the anesthesia resident will be present to make the important decisions. The residents will have the intellectual knowledge to pass the board examinations, but they will be lacking in the art of anesthesia, the little intangibles that are not taught in books but every anesthesiologist has learned in a successful practice.

These new anesthesiologists may actually be perfect for the future of medicine as envisioned by our politicians. With reimbursement threatening to be lowered even more and millions more patients flooding the health system, all physicians may eventually be forced into salaried positions. At that point, there is no reason to work past your scheduled shift. The evening shift will take over, even if it is in the middle of a case. There is no incentive to work any longer and every incentive to leave. The new residencies are the perfect training grounds for what's coming to the practice of medicine.

1 comment:

  1. Years ago when I was a resident rep on the Residency Training Position, a proposal came up to restrict maximum resident call from 1 in 3 to 1 in 4. Several Department Chiefs including my chief (and we already did less than 1 in 4) reacted as if this would be the end of medicine as we new it.

    Now (at least in Canada) residents do 1 in 4 or less and some of them even get to go home at noon the day after.

    Has the quality of the finished product suffered? Probably not.

    In Canada at least, surgery residents put in more hours during their residency than anaesthesia residents. If your life depended on care from a newly qualified anaesthesilogist or a newly qualified surgeon who would you pick?