1. Residency Training in the United States: Past, Present, Future Society of University Otolaryngologists November 14, 2015 Kenneth M. Ludmerer, M.D.

2. No Financial Disclosures Financial Disclosures

3. To understand: 1.The evolution of the American residency system 2.Current challenges and opportunities in residency training 3.Potential solutions and future direction Learning Objectives

4. 1.Creation: Johns Hopkins Hospital, 1889 2.Roots: –Apprenticeship tradition –Teutonic inspiration 3.Academic emphasis: residents of JHH = research fellows at JHU Origin of Residency

5. 1.The diaspora from John Hopkins 2.Objectives: academic leaders first, specialists second 3.For some, not all 4.Alternative paths Spread of Residency, World War I to World War II

6. 1.Educational principles ­ Assumption of responsibility ­ Explore problems in depth (reflective learning) 2.Moral dimension –Unswerving commitment to solving the patient’s problem –Thoroughness and scrupulous attention to detail The American Residency

7. 1.Charity care 2.High professional authority; quiet consumer voice 3.Attitudes toward work and personal fulfillment Cultural Influences

8. “What about the wife and babies if you have them? Leave them! Heavy are the responsibilities to yourself, to the profession and to the public. Your wife will be glad to bear her share of the sacrifices you make.” Sir William Osler

9. 1.The presence of time 2.The presence of ward patients 3.Intellectual excitement – atmosphere of discovery 4.Close personal relations with senior faculty, junior faculty, hospital administration, and each other 5.Absence of commercialism at academic medical centers The Learning Environment

10. 1.Hard work 2.Paternalistic 3.Rich learning environment 4.Presence of faculty 5.Exhilaration – sense of being engaged in doing “good work” The Life of a Resident

11. “I am remembering the internship through a haze of time cluttered by all sorts of memories of other jobs, but I haven’t got it wrong nor am I romanticizing the experience. It was simply the best of times.” Lewis Thomas

12. Conditions of work are what matter, not work hours alone

13. 1.Excessive work load (“scut work”) 2.Graduate Medical Education (1940) and all subsequent reports 3.Problem persists because hospitals benefit “Education vs. Service”

14. 1.Establishment of Boards 2.Abolition of alternative paths 3.A reforming profession – change from within Triumph of Residency

15. 1.The triumph of specialization 2.The democratization of residency 3.Declining research emphasis. Produce practitioners, not investigators 4.End of era of paternalism 5.Decline in sense of family 6.Learning environment remains strong: time, autonomy, scholarly atmosphere, service values permeate academic medical centers, patient- centered care 1945-1970

16. 1.Safety - Sicker patients - Greater consequences of error - Inadequate supervision 2.Disappearance of faculty 3.Continuation of sleep deprivation and heavy workloads Cracks in System

17. 1.Memoirs; House of God; studies, observations, house staff unions 2.Causes: excessive workloads, sense of marginalization 3.Root problems not addressed 1970s: Discovery of Burnout

18. 1.July 1, 1984 – DRGs (diagnosis related groups) 2.Learning environment erodes: –Too many patients to be thorough or to engage in reflection. Transformation of “scut” –“Eurekapenia” –Commercialization of academic medical center 3.Decline of patient-centered care The Era of Throughput – 1980s to Present

19. 1.1984 – Libby Zion case 2.1990s – Highly publicized medical errors 3.1999 – IOM’s To Err is Human 4.Concern was patient safety The Era of Work Hour Regulations – 1984 to Present

20. 1.External forces 2.Consumerism 3.Loss of trust in physicians Context of Work Hour Regulations

21. 1.2003 -- ACGME establishes work hours regulations 2.2008 -- IOM report 3.2011 -- ACGME issues revised rules Work Hours Chronology

22. 1.Safety: no impact 2.Learning: decline of educational value of residency. Shift from professional education toward vocational training. 3.Work compression. Demoralization of house staff and far less joy in work. Residents cry out: “Let Me Heal”. 4.Further decline of patient-centered care Consequences

23. 1.Back to basics: conditions, not hours, of work are what matter. 2.Eliminate the “+4” 3.Back to Johns Hopkins: the Aliki Initiative 4.Lesson: real improvement in residency education is costly. - 2009 IOM report on GME - $1.7 billion/year 5.Finding the funds: IOM report (July 2014), recapturing IME. Solutions

24. 1.The dilemma of autonomy 2.Needs of present vs. future patients 3.Continuity of care vs. rest 4.Work-Life balances 5.Who are the patients? Perpetual Tensions

25. 1.Caring vs. commercialism in our health care delivery system 2.Our opportunity: parsimonious care improves quality and lowers cost. The Future