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    What Kind of Doctors Are We Training for the Future?

    Medical training is one of the most difficult times a new doctor has to endure in their quest to become a licensed and board certified physician or surgeon. Medical residencies traditionally require lengthy hours of their trainees. The American public and the medical education establishment increasingly recognized that such long hours were counter-productive, since sleep deprivation increases rates of medical errors.

    In 2003, the Accreditation Council for Graduate Medical Education (ACGME — the society that accredits training programs) addressed the current residency training and duty hour requirements. The elements highlighted include patient safety, resident wellness, and the resident training experience.

    After lengthy debates among various medical societies, in 2007, regulations capped the work-week at 80 hours for medical residents in training. The ACGME also mandated that overnight call frequency to no more than one overnight every third day, 30-hour maximum straight shift, and 10 hours off between shifts. While these limits are voluntary, adherence has been mandated for the purposes of accreditation of the residency.

    First-year residents, also called interns, must pull shifts no longer than 16 hours straight, due to new work standards that took effect on July 1. A group of patient safety advocates say more must be done to protect all residents from sleep deprivation, fatigue, and the medical errors that often follow a longer work week.

    As it stands, beyond their first year, residents can be scheduled for up to 24 straight hours, and they can stay on an additional four hours for the sake of a proper patient hand-off, according to the ACGME.  Under the previous ACGME standards, 24 hours was the maximum shift for all residents, and six hours was the most they could tack on. Many experts think these new regulations do not go far enough.

    I want to talk about the reality of medical training that many of these “experts,” who have never taken care of a patient, fail to understand. Since I am a board certified in both general surgery and cardiothoracic surgery, I will discuss training from my perspective as a surgeon.

    After four years of medical school and nine more years of surgical training after that, I went into private practice as a heart surgeon in 1999. I did my general surgery training at Los Angeles County-USC Medical Center, which is probably the busiest hospital in the US. I performed over 1300 cases as the primary surgeon in four years and often spent 130 hours a week at the hospital. I did my heart surgery training at University of Miami-Jackson Memorial Hospital, which also is one of the busiest hospitals in the United States.

    Today, the graduating residents from the same general surgery program I trained at finish with around half the number of cases that I performed in the same time frame of training.  I am not some macho or egotistical surgeon, which is often the stereotype that is unfairly placed on surgeons.  In fact, I do value my life outside of the hospital.

    There are reasons that surgical training is so long and difficult. The first reason is to weed out those doctors that just can’t perform under such extreme conditions.  The second reason is that in order to develop the proper skills, there needs to be a graded approach in order to be able to operate and care for patients independently.  Today, in most residency programs, many residents only do a portion of the case, because the attending surgeon does the rest.  After graduation, how are these surgeons going to face a sick patient “alone” if they haven’t done it during their residency with great frequency?

    Unfortunately, many times training is done under exhausting conditions.  And like in any profession, mistakes are made.  I can assure you fatigue is not one of the main reasons.  I feel that it is the lack of experience in being able to handle many sick patients and the failure to learn to do complicated operations independently.

    With a shortened work week, now at 70 hours, there can be no accountability on the part of residents, since as soon as the “going gets tough,” they’re allowed to go home.  In the real world sick patients are not on a 9 to 5 schedule.  Does anybody ever think why it takes so long to become a navy fighter pilot?  Do you ever think that mistakes are made due to pilot fatigue?  The answer to the last question should be obvious, but the grueling, repetitive training minimizes this, as it does in surgical training.

    So what kind of doctors are we training for the future? The answer is a group of individuals who don’t know how to work under difficult conditions, have no commitment to patient care, and basically cannot perform the necessary operations independently at the end of their residency.  Operating on simulators is not the same as operating on the human body.  There is no way to simulate five gun shot wounds coming into Los Angeles County – USC Emergency Room at one time and being able to independently decide how to triage the patients.  There is also no way to simulate having spent two days on-call with limited sleep and having to do a heart transplant.  Unfortunately, heart donors don’t necessarily die during the day. And unless we prepare our future doctors for a most difficult career, the future of medicine, as we currently know it, is doomed for failure.

    Doctors already rely on too much testing to make a diagnosis, which increases the cost of health care.  The art of examining the human body is being taught less and less.  Unless we confront the reality of medical training and future health care, we are heading for a health care system that is inferior to that of many countries in the world.  Residency training needs to be extended.  Doctors need to be compensated appropriately.  If residents are unable to deal with the difficult training in surgery, they should look at doing an easier medical specialty.

    - Michael F. Richman MD, FACS, FCCP

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