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It Is Time to Prioritize Education and Well-Being Over Workforce Needs in Residency Training

Wolpaw, Jed T. MD, MEd

doi: 10.1097/ACM.0000000000002949
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Residents inhabit an ambiguous world. They are no longer medical students but are still learners. They are not yet attendings but are still paid employees. This ambiguity leads to a misalignment of departmental incentives and trainee expectations. Trainees expect their learning and well-being to be prioritized, while departments are under pressure to meet staffing needs and cut costs. This sets up a fundamental disconnect between the “formal” Accreditation Council for Graduate Medical Education (ACGME) message of well-being and the dominant “hidden” workplace forces that pull in the opposite direction, possibly contributing to the epidemic of burnout in trainees. It is critical that all parties—health systems, graduate medical education (GME) programs, the ACGME, and residents—recognize this disconnect and collaborate to meaningfully implement current ACGME requirements to decompress work intensity and address well-being. Real change will require more than general directives. The ACGME will likely need to take the lead and consider taking a design-thinking approach to structuring regulations governing how and when residents work and how they are supported. It would also be worthwhile to revisit the Institute of Medicine recommendations on GME from 2014 related to funds flow and transformation initiatives. Taking a more comprehensive approach to residents as people, workers, and vital health care professionals is the right thing to do and may well improve retention, reduce burnout, decrease medical errors, and improve care.

J.T. Wolpaw is assistant professor of anesthesiology and critical care medicine, Johns Hopkins University School of Medicine, Department of Anesthesia and Critical Care Medicine, Baltimore, Maryland; ORCID: http://orcid.org/0000-0002-7738-9291.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Please see the end of this article for information about the author.

Correspondence should be addressed to Jed T. Wolpaw, 1800 Orleans St., Zayed 6222, Baltimore, MD 21287; telephone: (410) 955-9942; email: jwolpaw@jhmi.edu.

The original residents were so named because they were residents of the hospital; they lived there. They were trainees, or learners, only to the extent that as a by-product of their labor, they were also expected to learn.1 Today, residents inhabit an ambiguous world between medical school and employment as attendings. Students in medical school are widely accepted to be just that: students. They pay tuition, and the expectation is that their experience will be structured in a way that will prioritize their education. Attending physicians are paid a full salary, and while universities and practices provide opportunities for continuing medical education, the emphasis is on getting the work done. Residents, however, are still very much learners but at the same time are paid (albeit at a very low hourly rate) for the work that they are expected to do.

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The Current State of Resident Wellness

The problem with the ambiguity of residency is that it creates a tension between trainees and their departments by misaligning departmental incentives and trainee expectations. Trainees expect that their education and well-being will be a priority, and the Accreditation Council for Graduate Medical Education (ACGME) reinforces this. Trainees, for example, are asked on the ACGME yearly survey how they feel about the balance between service and education as well as other questions that, taken together, essentially mean, “Is your education prioritized by your program?” Updated ACGME program requirements include requirements for programs to give “attention to scheduling, work intensity, and work compression that impacts resident well-being” and to give residents time during working hours to attend medical, dental, and mental health appointments.2

Departments, on the other hand, are under pressure to meet staffing and access needs and to cut costs. This incentivizes them to do exactly the opposite of what the ACGME is asking, that is, to prioritize labor (and resident labor is cheaper than advanced practice provider labor) over education and to increase, rather than decrease, work intensity and compression. With increased work compression comes a change in the kind of work that residents do, prioritizing work that increases system efficiency, such as codable notes and patient discharges, rather than the learning, critical thinking, relationship building, and interpersonal skill development that come from spending time with patients and teachers rather than in front of a computer.

This sets up a fundamental disconnect between the “formal” ACGME message of well-being and the dominant “hidden” workplace forces that pull in the opposite direction. Could this disconnect and the resulting misalignment of resident expectations and departmental incentives be contributors to burnout and depression? They may well be. A 2015 analysis found that nearly 29% of residents suffer from depression3 compared with just 17% of the general population.4 Up to 56% of trainees experience symptoms of burnout with the likelihood of burnout increasing as training progresses.5 Burnout has been associated with impaired cognitive function, reduced quality of patient care, and increases in medical errors.6–9

A recent 3-part series of posts on in-House, an online peer-reviewed publication for residents and fellows, called “Resident Wellness Is a Lie,” observes that residents do not believe the ACGME actually cares about their wellness. The ubiquitous commentary about emphasizing wellness feels hollow because there is no support given to actually make it a reality.10

If we are going to comply with ACGME requirements to decompress work intensity and to address the well-being of trainees, we need to have commitments from our institutions to rely less on resident labor. Consider the recent decision by the American Board of Anesthesiology to allow up to 2 months of family or medical leave for residents, effective July 1, 2019.11 Until this change took place, anesthesia residents who took time above and beyond their 4 weeks of vacation per year (e.g., for maternity or paternity leave) had to make up the time by extending their graduation date. This situation discouraged residents from being present for their families at critical times—there is no do-over for these life-changing events. Although this problem was resolved for anesthesia residents on July 1, 2019, there are many residency programs that have not made this move. Despite the fact that this is clearly a more humane and supportive approach, it will be extremely challenging for departments that rely heavily on residents for staffing to deal with the increased number of residents taking longer leave. Traditionally, departments have addressed absences by requiring even more work compression from the residents who are not on leave. This approach would only serve to exacerbate a vicious cycle of burnout.

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A Path Forward

It is time to consider whether or not a system designed more than 100 years ago, when residents lived in the hospital and were assumed to have no obligations outside the hospital whatsoever, is still viable in today’s world. It is time to consider how we can best focus on the training we want to provide to our residents rather than prioritizing the labor they provide. Residents are no longer permitted to work more than 80 hours per week, averaged over 4 weeks. But this change does not make it easier for residents to get to a doctor’s appointment in the middle of the day, for programs to encourage trainees to stay home when they are sick while still being able to staff their services, or for programs to provide adequate staffing when residents take 2 or 3 months off for parental leave.

The U.K. health care system has recently started allowing a flexible training program in some specialties such as emergency medicine. Trainees can opt, for example, to work 50% or 75% time rather than full time.12 This allows their trainees to start a family, perform research, focus on self-care, and learn at their own pace. To consider a similar program in the United States, we would need to address debt burden and competency-based advancement. Most residents carry significant medical school debt into their training, and prolonged residencies would accentuate this burden by delaying residents’ ability to achieve independent practice and the accompanying high salary needed to pay down education debt. And we would need to have a way to assess when a resident who is working part time is ready to finish training. Competency-based advancement has been a tantalizing goal for many years. It is possible that taking into consideration wellness and protracted debt burden would add additional incentive to bring us to the finish line. Happier, more intrinsically motivated residents might well accomplish more in less time.

It is time to redesign how we invest in the education and professional development of our residents. The Institute of Medicine report on graduate medical education (GME), published in 2014, argued for a reshaping of Medicare funding for resident education to better reflect the needs of an evolving health care workforce and system.13 The report recommended a better alignment of funding with resident training needs and the designation of a portion of the budget for a “Transformation Fund” to incentivize best practices in training.13 While these recommendations have not yet been implemented, another substantial effort to support change is in progress. The American Medical Association (AMA), in 2013, launched its Accelerating Change in Medical Education initiative. The initial 5-year funding cycle focused on undergraduate medical education. The second cycle is directed toward the GME space, allocating $15 million to 8 proposals over 5 years.14 One of the 3 primary goals of this program is resident wellness. This AMA initiative and proposed Transformation Fund both recognize that change in GME is a complex adaptive challenge that will require multiple perspectives and the input of diverse stakeholders. A design-thinking strategy would likely be a good approach to this problem, bringing residents, educators, system administrators, medical students, and patients to the table to align expectations and look for opportunities for meaningful solutions to the problem of resident well-being. If, for example, a Transformation Fund were created, and if its payments were linked to, among other things, trainee well-being, it could create both the incentive and means to produce significant change.

A first step in aligning departmental drivers with resident and ACGME expectations would likely need to start with the ACGME. When the ACGME decides that a change in the structure of our system of GME is important, they mandate the change. For example, residency program directors, once given no guarantee of protected time for their administrative role, are now required to be given at least 20% or 40% time depending on the size of their program. When it comes to well-being, the ACGME has mandated a change in work hours but not in the work environment or in the way well-being is effectively prioritized in that environment. It will take more than telling programs to focus on well-being if real change is going to happen and if there is to be a move away from resident labor and toward resident education and well-being. The ACGME should focus now on how to structure the regulations governing what residents are doing while they are at work and how they are supported there.

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Achieving Meaningful Change

It sounds good to say that we should pay attention to trainee well-being and address burnout. It feels good to remove barriers to more maternity and paternity leave time. But to make it work on a practical level, institutions must be given a reason to do it when their financial incentives seem to point the other way. The ACGME needs to consider requiring institutions that train residents to rely less on their labor and to focus more on their education and well-being. It will not increase revenue, at least not in the short term, but it may well improve retention, reduce burnout, decrease medical errors, and improve care. Our trainees are learners, not just laborers, and we need to consider major changes to a system designed when the labor was the only thing that mattered and it was considered reasonable to require residents to literally live in the hospital. An evening yoga session, the formation of a wellness committee, and encouragement to be resilient are not sufficient. Structural, systemic changes are needed. Those changes may require a complete reimagining of what it means to be a physician in training.

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References

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