PERSPECTIVES
Residents Teaching Residents: How the Duty Hour Limits Have Changed Us
I
t was 7 PM during my fourth-year ‘‘away rotation’’ on neurosurgery. The chief resident was ‘‘pimping’’ me and the other subinterns on everything from CSF hydrodynamics to odontoid fractures. Once he felt we were sufficiently well educated, he got up and said, ‘‘Well I better go…haven’t been home since I left for work yesterday morning. Haven’t seen my kids in days and my wife probably thinks I’m cheating on her. See you guys at 4:30, sharp.’’ He and other residents like him strongly influenced my development as a physician. They were hardworking, competent, confident. They put the needs of the service and the responsibility to educate their junior residents above personal concerns. These residents had begun their training before the institution of Accreditation Council for Graduate Medical Education duty hour limits, and all stayed long past the allowed working hours to do their jobs. In fact, this commitment represented a core ideal of the profession. The key component to instilling this in junior residents was role modeling by their seniors, who were in a unique position of authority and, unlike faculty, were more often visibly called upon to demonstrate dedication to the patient’s welfare through their own actions. Since the initiation of resident work hour rules, the ideals of the surgical profession have changed little, but a senior resident’s ability to demonstrate commitment to these ideals through role modeling has changed significantly. How do we instill in our junior residents the primacy of patient care over our personal needs if we have to leave after overnight calls? How do we demonstrate responsibility for our postoperative patients if we don’t see them on our days off? How do we role model a lifelong commitment to our field if we are simultaneously counting hours? How can we demonstrate the qualities of those chief residents who so influenced us if we are not allowed to act as they did? I have wrestled with these questions for years as I’ve progressed through the ranks of a neurological surgery residency. I think the answer for senior residents is to recognize the underlying qualities that we are modeling, be
Cara L. Sedney, MD, is a Resident Physician in the Department of Neurosurgery, West Virginia University School of Medicine, and a Graduate Student at the Neiswanger Institute of Bioethics and Health Policy, Loyola University Chicago. Corresponding author: Cara L. Sedney, PO Box 9183 HSCN, Morgantown, WV 26506, 304.293.5041, [email protected] DOI: http://dx.doi.org/10.4300/JGME-D-11-00252.1
Cara L. Sedney, MD
creative within the restrictions of residency to refine and compress them, and encourage these qualities through positive rather than negative reinforcement. A commitment to our patients is clearly nonnegotiable in spite of the duty hour limits. However, rather than the classic individualistic surgeon approach, a team approach can be emphasized. Teamwork is an essential skill that can be role modeled. Rather than idolizing the independent surgeon who can handle everything and needs no one, the ability to integrate into a team of individuals and perform as a seamless whole has now become the goal. Communication, in particular regarding handovers, has become an essential skill to impart to our juniors. Continuity of care likely has suffered from the work hour restrictions. However, senior residents can make extra efforts to maintain continuity for their juniors through scheduling and case assignments. Pushing for cases to be done so the admitting resident can assist is one way to impart continuity of care, as is allowing residents to perform cases for the patients they have seen in clinic. The importance of responsibility for patients can still be demonstrated by calling or texting for updates on postoperative patients while absent from the hospital or by doing the discharge paperwork immediately postop for planned overnight admissions. Teaching is a major responsibility of senior residents. Although the residency program as a whole has protected education time, senior residents have to fit in teaching whenever they can. Because of the demands of the job, this often happens at the end of the day when all the work is done. Although this is most convenient, it also strains compliance with the duty hour standards. Integrating teaching into the daily work rather than waiting until the work is done is an important skill in the era of duty hour restrictions. Additionally, an old fashioned ‘‘pimp session’’ is a good way to stimulate the use of off-duty ‘‘free time’’ for reading. What is the effect of the duty hour limits in getting junior residents involved in research and surgical lab training? These extras can make the difference between excelling in residency and just getting by. In many programs the senior resident is in charge of motivating the juniors in these pursuits. According to some faculty mentors, in the past this ‘‘motivation’’ consisted of punitive strategies, such as running stairs or a prolonged run of q2 calls. Clearly this strategy isn’t acceptable anymore. Journal of Graduate Medical Education, December 2012 413
PERSPECTIVES
Positive reinforcement, such as allowing residents to go to meetings to present research or to reward excellent performance in the clinical service, may work better. Similarly, creating time away from clinical duties to practice in the surgical lab can encourage this practice, which then can be rewarded by allowing residents to do a case for which they have practiced in the lab. The essential qualities of the neurological surgery profession have been historically passed on by osmosis through mentorship and role modeling. However, limits on duty hours are here to stay. As senior residents we can no longer directly model many of the qualities valued in our profession through sheer stamina. However, we may be
414 Journal of Graduate Medical Education, December 2012
able to instill these qualities through a conscious effort to demonstrate specific qualities to our juniors, an emphasis on teamwork, and positive reinforcement of desired performance. Before leaving after a hectic 24 hours of call, I supervise the handover process with the interdisciplinary clinical team and junior residents. I close with the remark, ‘‘I’m off and will be sleeping for the morning. This afternoon I will call in to discuss the progress of our patients and any new questions. Everyone has their reading assignments; we will quickly review our findings tomorrow morning.’’ Is this idealistic? Possibly…But unrealistic? Based on my experience, I would say, not at all.
Residents Teaching Residents: How the Duty Hour Limits Have Changed Us
I
t was 7 PM during my fourth-year ‘‘away rotation’’ on neurosurgery. The chief resident was ‘‘pimping’’ me and the other subinterns on everything from CSF hydrodynamics to odontoid fractures. Once he felt we were sufficiently well educated, he got up and said, ‘‘Well I better go…haven’t been home since I left for work yesterday morning. Haven’t seen my kids in days and my wife probably thinks I’m cheating on her. See you guys at 4:30, sharp.’’ He and other residents like him strongly influenced my development as a physician. They were hardworking, competent, confident. They put the needs of the service and the responsibility to educate their junior residents above personal concerns. These residents had begun their training before the institution of Accreditation Council for Graduate Medical Education duty hour limits, and all stayed long past the allowed working hours to do their jobs. In fact, this commitment represented a core ideal of the profession. The key component to instilling this in junior residents was role modeling by their seniors, who were in a unique position of authority and, unlike faculty, were more often visibly called upon to demonstrate dedication to the patient’s welfare through their own actions. Since the initiation of resident work hour rules, the ideals of the surgical profession have changed little, but a senior resident’s ability to demonstrate commitment to these ideals through role modeling has changed significantly. How do we instill in our junior residents the primacy of patient care over our personal needs if we have to leave after overnight calls? How do we demonstrate responsibility for our postoperative patients if we don’t see them on our days off? How do we role model a lifelong commitment to our field if we are simultaneously counting hours? How can we demonstrate the qualities of those chief residents who so influenced us if we are not allowed to act as they did? I have wrestled with these questions for years as I’ve progressed through the ranks of a neurological surgery residency. I think the answer for senior residents is to recognize the underlying qualities that we are modeling, be
Cara L. Sedney, MD, is a Resident Physician in the Department of Neurosurgery, West Virginia University School of Medicine, and a Graduate Student at the Neiswanger Institute of Bioethics and Health Policy, Loyola University Chicago. Corresponding author: Cara L. Sedney, PO Box 9183 HSCN, Morgantown, WV 26506, 304.293.5041, [email protected] DOI: http://dx.doi.org/10.4300/JGME-D-11-00252.1
Cara L. Sedney, MD
creative within the restrictions of residency to refine and compress them, and encourage these qualities through positive rather than negative reinforcement. A commitment to our patients is clearly nonnegotiable in spite of the duty hour limits. However, rather than the classic individualistic surgeon approach, a team approach can be emphasized. Teamwork is an essential skill that can be role modeled. Rather than idolizing the independent surgeon who can handle everything and needs no one, the ability to integrate into a team of individuals and perform as a seamless whole has now become the goal. Communication, in particular regarding handovers, has become an essential skill to impart to our juniors. Continuity of care likely has suffered from the work hour restrictions. However, senior residents can make extra efforts to maintain continuity for their juniors through scheduling and case assignments. Pushing for cases to be done so the admitting resident can assist is one way to impart continuity of care, as is allowing residents to perform cases for the patients they have seen in clinic. The importance of responsibility for patients can still be demonstrated by calling or texting for updates on postoperative patients while absent from the hospital or by doing the discharge paperwork immediately postop for planned overnight admissions. Teaching is a major responsibility of senior residents. Although the residency program as a whole has protected education time, senior residents have to fit in teaching whenever they can. Because of the demands of the job, this often happens at the end of the day when all the work is done. Although this is most convenient, it also strains compliance with the duty hour standards. Integrating teaching into the daily work rather than waiting until the work is done is an important skill in the era of duty hour restrictions. Additionally, an old fashioned ‘‘pimp session’’ is a good way to stimulate the use of off-duty ‘‘free time’’ for reading. What is the effect of the duty hour limits in getting junior residents involved in research and surgical lab training? These extras can make the difference between excelling in residency and just getting by. In many programs the senior resident is in charge of motivating the juniors in these pursuits. According to some faculty mentors, in the past this ‘‘motivation’’ consisted of punitive strategies, such as running stairs or a prolonged run of q2 calls. Clearly this strategy isn’t acceptable anymore. Journal of Graduate Medical Education, December 2012 413
PERSPECTIVES
Positive reinforcement, such as allowing residents to go to meetings to present research or to reward excellent performance in the clinical service, may work better. Similarly, creating time away from clinical duties to practice in the surgical lab can encourage this practice, which then can be rewarded by allowing residents to do a case for which they have practiced in the lab. The essential qualities of the neurological surgery profession have been historically passed on by osmosis through mentorship and role modeling. However, limits on duty hours are here to stay. As senior residents we can no longer directly model many of the qualities valued in our profession through sheer stamina. However, we may be
414 Journal of Graduate Medical Education, December 2012
able to instill these qualities through a conscious effort to demonstrate specific qualities to our juniors, an emphasis on teamwork, and positive reinforcement of desired performance. Before leaving after a hectic 24 hours of call, I supervise the handover process with the interdisciplinary clinical team and junior residents. I close with the remark, ‘‘I’m off and will be sleeping for the morning. This afternoon I will call in to discuss the progress of our patients and any new questions. Everyone has their reading assignments; we will quickly review our findings tomorrow morning.’’ Is this idealistic? Possibly…But unrealistic? Based on my experience, I would say, not at all.
