Strategic Nap

The world of medicine is an interesting place these days, especially if you fancy yourself a medical educator, like I do. We are a couple of months in to another change in the way that resident doctors are educated in their chosen field of expertise. The first change came back in 2003, the year before I started my pediatrics residency. For the first time, there was a limit on the number of hours per week (80) that a resident could be working in the hospital. There were also limits on what activities residents could undertake after they had been in the hospital overnight (essentially, finishing up the work from the night before) because they needed to get out of the hospital by 1pm.

The thought process behind these initial changes was that residents who had limits on hours worked would be less fatigued and make less medical errors. There was some concern on the part of veteran physicians that by not spending as much time in the hospital (especially following the new patients that they admitted to the hospital overnight) the education of the new generation of physicians would suffer greatly. I believe there was also some degree of sentiment that “we made it through the old system okay, you new residents don’t care enough and aren’t tough enough to be ‘real’ doctors like us.”

Despite all of the grumbling, the changes came and, despite bumps along the way, things went relatively smoothly. The work hour restrictions were all I have ever known, but I do not feel that my education in the field of pediatrics suffered. I gained a great deal of knowledge and experience. Sure when I first was out on my own, there was a steep learning curve, but I would have to believe that this is the case no matter how many years your residency is.

Maybe it is because it was the only system that I have known, or maybe it is because I am already becoming a bit curmudgeonly despite only having been a full-fledged pediatrician for 4+ years, but I felt like it was working well. I really didn’t think it needed to change. Was residency hard? It certainly was. There were a lot of long hours and time away from family. There were some sleepless nights (technically for me, there was only one night that I got no sleep. Even the night of 13 admissions as an intern, I still managed to lay down for 45 minutes. But enough of me bragging…) and some nights that were so filled with problems that it seemed like they would never end. But never once did I feel like I was too tired to maintain patient safety or my own personal safety for that matter.

However, the powers that be felt otherwise, even though there is no empirical evidence that the reduced work hours have shown any benefit to resident safety or patient safety. The overall work hours have not been reduced, but there has been some changes in the amount of time that a resident can work consecutively. Now interns (aka first year residents) can only work for 16 hours straight. Resident are allowed to work for 24 hours in a row with an extra 4 hours afterwards to facilitate transition of care. The best part is that it is recommended that residents utilize alertness management strategies, including “strategic napping”. (Sorry, I can’t take care of that crashing patient right now, I need to go take my strategic nap!)

As you can imagine, these new regulations were met with about the same amount excitement and rejoicing as the first stage of work hour changes. In fact, the uproar and disappointment may have been worse. Another round of sturm and drang about the end of effective residency training and ruining the future generation of doctors. With all of this time away from the hospital, how can anyone expect to learn all of the things that one needs to learn to be a pediatrician or neurologist or internist or pathologist or radiologist? Well, I can’t speak to how this is going to affect procedure-based specialties like anesthesiology or surgery, but my personal opinion is that most of the other specialties will be just fine. We just need to change our focus.

I graduated from residency and am now a board-certified pediatrician despite the fact that I never got to see first-hand the following key pediatric diagnoses from the beginning: appendicitis, meningitis, intussusception, pyloric stenosis.  I am sure that there are probably a handful more that should be included on this list. I cannot quote a differential diagnosis list that is 20-25 diseases deep. I am sure that to many “old-school” pediatricians this is a heresy. However, as mentioned before, I do not feel like my education was lacking. But how do I dare feel comfortable in my knowledge and skill as a pediatrician when all evidence seems to be pointing to the contrary?

Because being a doctor has changed. It is not about being able to be a repository of knowledge and experience anymore, just waiting for the right situation to discharge that knowledge. There is too much to know. A phrase I once heard was that back in the late 1880’s, when medical schools first started being founded, the entirety of our medical knowledge was contained in a few books. By the early to mid 1900’s, all knowledge of medicine could be stored in a large library. With the dawning of the computer age and our rapidly expanding knowledge, it took the Internet to be able to store it all. At this point in time, the entirety of medical knowledge is most certainly unable to be quantified. It’s not even humanly possible to keep up with all of the new information that is discovered and published in a given month. Add on to this that things are always changing and evolving (the common saying is that half of what you learn in medical school will be determined to be wrong a handful of years later) and it is a fallacy to think that in this day and age you can learn everything you need to learn and see everything you need to see during residency to be an effective pediatrician, geriatrician, pathologist or psychiatrist. In fact, this has probably been the case for a great number of years. Only most people want to keep doing things the same old way that we always have.

No longer should medical education be about memorizing or cramming as much information and experience into your brain as you possibly can. It should be and must be about how to utilize and access that information most effectively and efficiently and how to deliver that information in a caring and professional way. Experience and knowledge are necessary to form the base, but it is problem solving and critical thinking that need to be placed to the forefront now. There are a great number of novel situations that we as physicians have and will continue to come across (even more now in this time of increased patient hand-offs). How to think through that new situation and gather the information that matters and discard the less important is now the key. Leave the storage of information to the computers and electronic databases and focus on how to access and manipulate that information.

Every year, I see a new class of residents come in eager and ready to learn. And I also see a class that I am pretty sure that I would not have been smart enough or talented enough to be a part of. The future of medicine is bright because our learners are brighter and smarter than ever before. Our job now as educators is to get them to put those smarts to good use. Not to make them smarter.

Some people lament the loss of the hour long lecture about hypertension or leukemia or so many other topics. But I welcome it. I have always been more impressed by someone who can think through a problem and why something is happening than someone who can reach down to the bottom of the differential diagnosis. Get medical students and resident out of the lecture hall and into a more interactive environment. Get them talking and working together. Show them how to think through a problem. Then let them work through the problem. And then afterwards, maybe we can all strategically take a nap.

 

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About ironsalsa

I'm just a man who likes to hear himself talk, yet pretends he can't stand himself.
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