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New Duty Hours: Bridging the Patient Encounter Gap

Hunter Woodall, MD, AnMed Health Family Medicine Residency, Anderson, SC

Duty hours are tightening, threatening to decrease the numbers of patients that our residents see, but the skill and knowledge required of family physicians continues to expand. How do family medicine programs meld these competing demands?

For decades the main “plan” to ensure a complete medical education was plenty of call and plenty of patients. A medical school attending once said, “I apologize to all of you (residents and students) that you can only be on call every other night, because you will miss half the patients.”

The assumptions about quality medical education were: (1) patients are a physician’s best teachers, (2) each patient encounter is an opportunity for learning, (3) teachable moments with colleagues (including faculty) enhance learning, (4) the more patient encounters and exposure to colleagues concerning those encounters the better the clinical learning experience.

The unspoken dogma was that a demanding clinical experience weeds out the unworthy and produces highly qualified physicians who have demonstrated a quality work ethic and superior dedication to patient care. The residencies adhering to these principles produced some of the best physicians in the world. They also produced physicians prone to overwork, burnout, divorce, and substance abuse.

Even now most residencies rely on plenty of patient encounters and long duty hours to maximize medical skills. The restrictions on duty hours create a patient encounter gap, and we can no longer rely on sheer numbers of hours worked and high numbers of patient encounters to provide a complete clinical experience. For the past 3 years, the number of new graduates passing the Family Medicine Boards has dropped under 90%.1 Some have proposed lengthening family medicine residencies to 4 years, but this is likely to make recruiting even more difficult, and it perpetuates an old inefficient educational system.

We can be more creative. If we must decrease the hours our residents work, then we must also use the hours they work to the fullest. Instead of lengthening residencies to maintain high numbers of patient encounters, why not make much more of the patient encounters that residents will have? Why not fill their downtime on call with Web-based learning opportunities? Why not make our family medicine centers into superbly effective learning laboratories? Centering on the competencies, let us formulate a new paradigm for family medicine education, writing an overhaul that can become the model for other disciplines.

_____________________

Experience, the most brutal 
of teachers; but you learn, my God 
do you learn.” 
—C.S. Lewis

_____________________

Patient care and medical knowledge could be enhanced by founding a national clearinghouse for the development of Internet-based modules on the 200 most common problems faced by family physicians. Each module would be based on an archetypical patient and provide current knowledge in diagnosis, management, procedural skills, and patient education. Completion of each module would be tracked and required for graduation. We must stop developing curricula in parallel that only a few learners use. It is time for collaboration, not competition.2

Practice-based learning and understanding practice systems can be enhanced by upgrading each family medicine center to a Patient-centered Medical Home.3 Our centers must become laboratories for modifying continuous quality improvement into a tool for maximizing the health of our patients. Learning to measure one’s clinical effectiveness is as important as learning correct procedure coding. We must teach information mastery. Learning to use electronic clinical aids is just as important as learning to use a stethoscope.

We must teach effective communication techniques, such as motivational interviewing, that will make family physicians experts in promoting the lifestyle changes necessary to battle obesity, sedentary living, smoking, and poor diets. We can use modern connectivity to make the resources required to teach medical ethics available to all programs, not just a few.

The new duty hours provide an opportunity to rethink family medicine education. Bridging the patient encounter gap will require extraordinary vision, innovation, and collaboration. We dare not fail.

References
1. https://www.theabfm.org/cert/passrates.aspx
2. STFM’s C4 task force is working already on a national curriculum for medical students.
http://www.annfammed.org/cgi/content/full/7/3/281
3. http://www.aafp.org/online/en/home/membership/initiatives/pcmh.html

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