The Resulting Challenges of Changes to Physician Training

April 24, 2014

In the NEJM article “Graded Autonomy in Medical Education – Managing Things That Go Bump in the Night” (March 20, 2014) Scott Halpern discusses the importance for physician trainee autonomy. Physician training over the years has offered learning opportunities that help prepare the trainee to become more clinically independent in decision making, thus better preparing them for their careers. In the past, the training model was an apprenticeship model that enabled a trainee to gradually gain autonomy and responsibility after working under close supervision for long periods of time. And historically, trainees had the most responsibility and independence at night. In 1984, the death of Libby Zion triggered the first measures to modify this training approach in order to improve patient safety. Although the Bell Commission report on the case cited that insufficient supervision was a more important factor than fatigue, the first actions in 1987 reduced the work hours for trainees. However, analysis over the last few decades has concluded that additional sleep has not improved patient safety or outcomes. More recently, changes are being implemented to increase supervision of trainees. Together, these changes may not be accomplishing their goal of reducing medical errors, and instead, are reducing the opportunities for trainees to make independent decisions, thus posing challenges for new physicians as they graduate to become independent practitioners and potentially affecting quality of patient care in the future. Instead of applying a one size fits all restrictive model to physician training, a better approach would be to implement different training models with different levels of supervision and work hour requirements in order to measure different effects on quality of care. In time, the data would help identify the best model for not only ensuring the best patient care, but also training physicians to become the most qualified practitioners.

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