Playing With Matches By Neal E. Flomenbaum, MD, Editor-in-Chief

On March 20, the results of the 2008 National Residency Matching Program were announced. More than 94% of the 15,242 U.S. medical school senior applicants matched with one of the 22,240 first-year residency positions offered, and 84.6% matched with one of their top three choices.

Because choosing a residency presently appears to be as much of a “buyer’s market” as purchasing a house, residency directors sometimes fret over whether a competing program requiring one less shift per month will attract more desirable applicants, even though all programs must operate within the 2003 workload restrictions set by the ACGME Resident Review Committee (RRC) for each specialty. These rules mandate a weekly maximum of 80 work hours, with 10 hours between shifts and one 24-hour period of free time per week—all of which seems reasonable and similar to the rules in effect in the state of New York since 1989.

The nature of residency training—or “postgraduate medical education” (GME)—has changed drastically since Osler introduced the German model to the United States in 1889. Today, the concept of the “resident physician”—an apprentice-specialist who literally lived in the hospital—is a relic of the past.

Although I sometimes wonder whether that famous question “Is there a doctor in the house?” should now refer to the hospital instead of a theater, I don’t begrudge present-day work rules for residents. But excessive enforcement of their fine points interferes with continuity of care and the need to make work schedules work in the real world. For example, one RRC insists that for its residents’ emergency department rotations, no additional brief period of “nonclinical” transfer of information can be allowed beyond the 12-hour maximum shift duration. In every other instance, a half-hour to an hour is allowed to “hand off” patients—a practice that is also now mandated by the JCAHO. This rule effectively precludes scheduling two residents for each 24-hour block in the ED.

Make no mistake about it, the history of residency training in this country before World War II was one of exploitation bordering on hazing. I do not think less of today’s residents whose schedules are more humane than ours were many years ago, but I do get the sense that we are reliving the history of the 20th-century U.S. labor movement and the ultimate emergence of  powerful unions. In some cases, those unions ultimately destroyed the domestic industries they were part of by creating economic conditions that forced employers out of business. If we have not yet reached the appropriate balance between resident education and patient service, we must be very close—and I hope that the RRCs recognize this before it is too late.

One difference between GME and “undergraduate” medical education is that the hospital plays a much larger role in GME and generally cares more about patient care and service than resident education and research (with or without federal support). Given a choice between hiring additional residents—with their RRC’s requirements and restrictions—and “midlevel providers” (NPs and PAs), hospitals will often opt for the latter to help manage increasing workloads and more rapid patient turnover.

Ironically, one of the latest concepts in providing hospital-based medical care is the “hospitalist,” a physician who “lives” in the hospital (at least for a shift) and cares for patients. Only now the hospitalist is typically an attending physician, which also sidesteps another issue that the RRCs should be at least as concerned about as work hours—direct attending supervision of residents, the best way to educate future specialists.

Emerg Med 40(4):8, 2008