Insights on Residency Training

A sign of the times?

Recently, our residency program had the excellent fortune of hosting Dr. Bob Wachter as a visiting speaker. Dr. Wachter is considered a pioneer in the hospitalist movement and has built his career around inpatient quality and safety. During lunch with Dr. Wachter, some of our residents, and hospitalist faculty, we discussed the topic of resident autonomy in the hospital. In the glory days of residency, I imagine that house officers experienced autonomy in its truest sense of the word: self-rule and utter independence. At least that’s the impression I have from Stephen Bergman’s (a.k.a Samuel Shem’s) House of God … a Lord of the Flies–like island inhabited by unsupervised and uninhibited junior physicians.

We all know that the 21st century’s inpatient environment leaves less room for such resident independence — and shenanigans, for that matter. Through regulatory and advisory bodies, patient advocacy groups, and our own recognition, we are now rightly focusing on other domains of hospital care. The main priority is not to “just let the doctors take care of patients how they want.” With this sea change, resident autonomy has evolved accordingly — both in practice and as a concept.

In case you haven’t heard, the quality and safety era is here to stay. Because true autonomy and “learning by doing” can potentially stand squarely at odds with quality metrics and the safest possible outcomes, I have to wonder:

• Will resident autonomy disappear completely in the future?
• How has autonomy changed already?
• And how will trainees learn to practice independently with all of this change?

Anyone that works in graduate medical education knows that duty-hour reform fundamentally shook the resident learning experience and thus affected autonomy. Since the additional 2011 duty hours changes were enacted, teamwork has become the name of the game. Residents routinely are forced to pass off decisions or depart before the implications of their decisions materialize. Attending physicians now seemingly shoulder more of the clinical workload, too, when residents’ shifts are truncated by a requirement to leave the hospital.

There is also probably universal agreement that the imperatives to reduce hospital length of stay and to facilitate safe discharges affect resident independence. As an attending, I know the pressures that the hospital is under, and I often feel compelled to be very directive about making prompt discharge a reality.

I doubt that residents would feel that either of these changes has eliminated their autonomy completely. Often in medicine, there is no single correct way to achieve an end. For this reason, residents can still safely be given leeway in many clinical decisions. There is still some art in what we do, and autonomy lives to see another day. But there are looming changes on the horizon that might threaten resident autonomy even more. Those that spend time in the hospital training environment recognize that all participants in inpatient care will increasingly be measured by how well they do their jobs. It is hard to conceive of a system in which residents and the attendings that supervise their care will be spared from aggressive quality improvement.

The stakes are simply too high nowadays. Health care is expensive and still unacceptably unsafe and unhelpful. With mounting pressures to provide higher value care, residents’ decisions are likely to undergo more scrutiny. Why is Resident A ordering more CT scans than Resident B? Why are Resident C’s patients staying in the hospital 2 days longer than Resident D’s? In my own experience as a chief resident, I know that residents still want autonomy. Heck, autonomy was my top priority in evaluating residency programs myself. As I have interviewed and met a number of applicants to our program during this residency match season, I sense that soon-to-be trainees are also putting autonomy high on their list of values. I like to tout my program’s emphasis on autonomy. I try to foster resident growth while attending on service by relaxing the reigns. I know the term autonomy doesn’t mean what it once did. Yet I do have hope that we can still give residents the leeway to “learn by doing” while preserving the health of the patients we serve and the financial stability of our healthcare system and our country.