Are We Getting Softer or Smarter? A Retrospective on Duty Hour Reform | Andy White, MD

In 2003, the ACGME, the accrediting body for residencies, created limits on how much residents could be required to work. 

80 hours a week, a maximum of 28 hours of continuous duty per shift, at least 8 hours off between shifts, and a mandatory 4 days off a month.

When you say it out loud, it’s kind of insane that these were the limits, right.  How much more could you work?

We’re now 20 years out from the duty-hour policy.

Our guest for this episode is Andy White, my former pediatric residency program director at Washington University in St Louis and the current chair of pediatrics at Saint Louis University.

Click here to read the article published by friend of the show, Jess Adkins Murphy

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If you have any feedback, show/interview recommendations, or want to collaborate on the show, please reach out!

Email: Tama.TheMDM@gmail.com

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Host: Tama Thé | Pediatric Emergency Medicine
Producer: Melissa Puffenbarger | Pediatric Emergency Medicine
Communications Director: Katrianna Urrea | MD Candidate

Transcript

Untitled - October 9, 2024

00:00:00 Unknown: Hello and welcome to the MDM, a show about the ways medicine is adapting to the modern world. I'm Thomas. In 2003, the ACG meet the accrediting body for residencies created limits on how much residents could be required to work 80 hours a week, a maximum of 28 hours of continuous duty per shift, at least 8 hours off between shifts and a mandatory four days off a month. When you say it out loud, it's kind of insane that these were the limits, right? How much more could you actually work? I mean, if you were designing a torture program in hell, I'd say we probably can't torture them for more than 28 hours at a time, because anything more than that and you're probably just beating a dead horse when you're tired, you make mistakes. There have been tons of studies looking at drowsy driving versus drunk driving, and after 24 hours, awake impairment is equivalent to a blood alcohol content of 0.1%. I wouldn't want somebody at the end of a 28 hour shift to cut my hair, much less operate on me after the duty hours went into place. Quality of life in mental health for residents improved. And that's pretty obvious. But the duty hour restrictions were met with a ton of backlash. Critics will tell you and have some data to support that more hand off leads to not just fragmented learning for physicians, but loss of important information from shift to shift, which has harmed patients. They'll also tell you that less time in the hospital means less hands on experience with critical patients and fewer procedures for residents, all while the volume of health information continues to rapidly increase. There's a new 2 to 3 year Pediatric Hospitalist Fellowship that was created partly in response to some of these concerns about experience. We're now 20 years out from the duty. Our policy as medicine continues to become more and more complicated. How should residency programs evolve? Will we see further reductions in work hours as we try to manage work life balance? Or will we see longer residencies and more new training programs to compensate for lost time? And so for this conversation, I pulled in my old program director from when I was a pediatric resident at Washington University in Saint Louis. Andy White was in that role for 20 years, both before and after the duty our restrictions went into place. He's now the chair of pediatrics at Saint Louis University, although he came on the show representing his own personal opinions and experiences. So welcome to Season two Episode two of the MDM Residency Duty Hours, a 20 year retrospective with Andy White. Annie White, thank you so much for coming on the show. Happy to be here. So you are my residency program director now, ten plus years ago, and you are now the chair of pediatrics at Saint Louis University. When I first approached you about this project, about having difficult conversations about how medicine is evolving over time, you offered this 20 year retrospective on how duty hour restrictions have changed for residents. Looking at your LinkedIn, is this right? You were the residency program director for 20 years at Washington University. Yes, that's correct. I took over in 2002 officially as the residency director, and I held that role until 2022. I was the associate program director prior to that for a couple of years working with the infamous Jim Keating, James Keating, who was the residency director before me for three years while at Children's Hospital, Washington University. Then I put in my time as a 20 year veteran, if you will. Wow. So that there was like 50 years where you guys like totalitarian rule. That's pretty insane. But but so. So that predated these duty hour restrictions. And so why this question? Why does this still interest you? Well, first of all, because you asked me. Second, because I've been in medicine long enough that I've seen sort of this evolution of not just work hours, but everything in pediatrics and in medicine across decades, trying to understand people's motivation for what makes people want to work, for what makes people work, how they work, especially now as a fact, you know, as a chairman of a Department of Pediatrics now I'm hiring faculty members. My prior life, I was hiring residents. And so it's a little bit of a different mindset. It's interesting. I like humans. I like their motivation. I like trying to understand how this stuff works. So so I am trying to read between the lines and remember some fuzzy conversations we had ten years ago. But my impression is that you agree with many things about the work, our restrictions, but not necessarily all of them. Is that about right? Well, I think it would be foolish to say anything other than that. Yes. I think anybody can find aspects and parts of the duty hours that are both good and that are bad. I think there's no doubt about that. The first, of course, is that, you know, what we were doing in the older days was crazy. Honestly, you know, my father was a physician. He did five years of residency every other night call. And that's 36 hours on, 12 hours off, 36 hours on, 12 hours off. And that's if you got out in time post call. Yeah, I only had two months of every other night call with that same sort of schedule. But then I had several months of every third night call and luckily the bulk of my residency training was every fortnight call. That's still a lot of hours in the hospital and not a lot of time sleeping, and it had to change for a number of reasons. And so I think that that's a good thing. On so many realms, I actually jotted down a couple of numbers. I was just trying to get a sense for how much work that really is. Yeah. How many hours are in a week, Dharma? It's like 138, 168, so it's probably around 68. Okay. And now so in 2003, when the duty hours were first put into play, limited, the number of hours a resident physician could work to 80 hours a week, nothing more unless you're neurosurgery and it's 88. So out of 168 hours, you're working 80. That leaves about 88 hours free. So roughly residents from 2003 on were 50% of their time of life in the hospital, 50% of their time outside the hospital. Now, I do think that most programs don't work 80 hours a week on every single rotation. Okay. Yeah. In fact, I know that's the case in my old program, we calculated it out. It was about 60 hours. If you took the the hard rotations in the ICU or in the nick, you you're working 80 hours a week, but you take advocacy rotation or a rheumatology rotation where maybe a consult every other day, you might be working 30 hours a week on some rotation. So it averaged a 56 to 60 hours. So if you put that into play, that's not a 5050 time. That's now you're you know, 65% of your time is outside the hospital of life and only about 35% is in the hospital seeing patients. Compare that to what my dad did. Right. 36 on 12 out, 36 on that. 75% of life was in the hospital and only 42 hours a week were spent outside the hospital. Yeah, that's I feel like unsustainable and I'm glad that it wasn't sustained. Looking back on my training under, like I said. Or totalitarian dictatorship. Hey, we we had maybe two months of Q3 call, maybe three or four other rotations had call. But for the most part, we had gone to more of a kind of a night float system where you had night residents and day residents passing off to one another. That being said, things have continued to change since then. Since you were following the work, our restrictions from the beginning. Do you feel like there was a substantial difference in either the quality of learning from the residents or from the quality of life of the residents? All right. That's the big question. First, before we dove into that, I do to point out, you know, my first year didn't have duty hour restrictions and they were put into play in oh three. And so I saw the change repeat right before my eyes happened, and I tried to be scientific about it. You may remember. I don't. What year was your internship? 2013. 23. Oh, so you were ten years later, okay. Yeah, exactly that. I've tried to be scientific about it and you know, I put I did one floor, we had several wards, we did one floor away. I kept to three call, I did one four call, I did one with Q five call and we did a night float system on another floor and a day float system on on sort of a different team. And at the end of the year, we collected all the data, the pros, the cons, what worked well, what didn't work well, and what do you think? The best one you can guess, everybody ended all of it. That's correct. None of them none of them were better than the other, because only across the board there were a few sort of generalizations nobody really seemed to prefer Q3, call it. Sure. And there were a lot of complaints of Q5 call because there was the specific complaint was We're not getting to see enough patients. I know enough patients for my own education. That was interesting to me. Night Boat was okay, day float. And so what I ended up with after a couple of years was a very kind of almost Frankenstein monster hybrid schedule where I had some Q4, I had some night float, I had some day float. We mixed it all together to try to capitalize on the best components of each of those systems. Yeah. Now one of my favorite remnants from the old days and favorite and tongue in cheek. Yeah. Was a requirement from the Acme that was in play in the late nineties and right up until the time when the duty hours went into place. And that was how many months of call you were required to do during your residency as a pediatric resident? Yeah, you might find this surprising. So 36 months of training, how many months were required? Call? I'm going to say six. Okay. It's a good guess. The answer was, and they phrased it the backwards way you were required to have no more than one call free month a year. Wow. Okay, so is difficult logic. Jump. Wait, you could have no more than one call three months. She's what? What I did did vacation therefore count as your only call for a month? Yeah. So the trainee, the folks who were in charge of this wanted you to have essentially call through all of residency. That's fascinating. It is. And so once you throw in night, float and day float or other systems, or once you have rotations that don't have call, that's how they were able to chip away at the required, you know, the duty hours that really buys you some time. Yeah. Do you know what they call requirement is currently? I don't know. I don't think it's explicitly stated now. Yeah, it's not what I stated when I was a resident for a while. They made it so that you couldn't take call as an intern that only senior residents could do it. And then I think they ended up reversing that around like 2017 or so. You're starting to see that conversation marched down into the medical school where medical students are saying, you know, what's the point of me doing 30 hours of call on surgery? You know, I'm never going to be a surgeon. I'm going to be a psychiatrist. So I think that that, you know, that goalposts seems to continue to move. I'm glad that they took it off, though, because, you know, there's nothing magical, I guess, about going from intern year to second year where now suddenly are going to be more resilient or more able to to care for patients. Yeah, those are good points. I think. You know, in the old days we also used it clearly as a staffing. Oh, 100%. Right. When we were on developmental behavioral pediatrics rotation. We still to call every fourth night in the ICU. Wow. You know, you do Monday in the autism clinic and then Monday night you would cover the pick you. And then Tuesday he would be back in your autism clinic until the end of the day. You bring up a good point. Like, I don't think the powers that be ever thought of doing 36 hours would get you used to doing the 36 hours. So it sort of be it's like marathon training. I don't think chronic sleep deprivation used to being chronically sleep deprived. In fact, there probably are data that would suggest that that doesn't happen. Yeah. Whereas, you know, you run five miles, five miles, five miles, you'll be better able to run a longer distance. But probably people, some people did think that you'll just get used to being tired all the time. Yeah. Doesn't happen. Doesn't happen. Yeah. Now the other benefits that was touted for a long time, which was if you admit a patient the beginning of your 36 hours, you can watch your evolution of their illness in the first 36 hours. And and since a lot of pediatric care, you know, the length of stay is short. You get to see the evolution of that asthmatic or bronchial lytic because you're in and out of the room many times a day, provided, in fact, that residents go in and out of the patient's room. You know, you might see the patient eight or ten times in a 36 hour period, whereas if you admit them on a eight hour shift and you go home and come back the following day, you've missed out on the evolution of their illness. And one of the things that residency training is all about is accumulating clinical experience, right? It's becoming wise. It's recognizing the physical exam findings in the clinic, the trajectories of various types of illness, bronchiolitis versus asthma versus pneumonia. That's really what we're doing. And in some senses, ideally, you graduate from medical school knowing everything about pediatrics that you need to know, okay, now you have learned that asthma is sort of an inflammatory allergic disease that's caused by broncho constriction, increased mucus secretion, and you know how to fix that with bronchodilators and avoid the triggers, right You know that. But what residency is is this sort of this accumulation of clinical experience by achieving ten or 20, 50 or 100 as Maddox come into you yas up to the floors, respond to the medicines that you're giving them or not respond in certain circumstances. And knowing how to put those medicines into play. Residency is for you to accumulate the wisdom that comes with clinical exposure over time. Yeah, so this had come from at the beginning of that. You mentioned that medical students should be coming in with all of the knowledge about pediatrics. They should be walking in the door with that. And now we're just seeing the patients. Right. How true is that? And do you think that there's been a trend? You know, I do think medical schools across the board are doing a much better job at communicating the basics of pediatrics into people's brains. We're all fairly smart people and medicine is fairly complex, but some of the parts are not very complex. Yeah, well, it's not knowing that asthma causes wheezing. It's hearing what wheezing sounds like and then knowing how to get the albuterol out from some mythical wall where it's stored behind the patient's lungs, right? Yeah. Medical school. You learn, asthma causes, wheezing, bronchodilators fix it. And then somewhere along the line, you might learn that the one thing on your differential is not just asthma cause wheezing, but maybe there's, you know, some lymphadenopathy from tuberculosis that hasn't been diagnosed yet, leading to sort of compression of one of the airways. And that's what you're hearing. Yeah, hundred percent. This is a bit of a hard left turn, but it's kind of where I want to go. In my head. I remember you telling me and maybe you as a study that you guys did yourselves. But I remember one morning report, I was like, dead. I was like, I look like I had just gotten hit by a bus. And you looked at me and you said, you know, we did a study once, and nothing that you're going to hear here, you're going to retain in about four weeks. And all they were even doing. Do you remember this or do you remember that? I do remember that. We did we did a study I'm not sure we ever published because we were too embarrassed. But we did try to do a study in which we tried to assess how much you learned from our didactic lectures. Now, there's a lot of background that will say, you know, you were all adult learners, were adult learners. And the worst way for an adult learning to learn is in a didactic lecture. And yet we persisted doing those, and we still persist in having didactic lectures for a couple of reasons. The first, they're relatively easy to deliver. The second, you as learners, residents and faculty, everybody thinks that's the way to learn. That's the best way to learn. Please, just teach us about this. Yeah, doggone it. You still want that. And so we try to measure what you could retain. And so we gave you lectures, didactic lectures. We quizzed you before and after and then delayed. Now, what was delivered in those talks and we broke it down into sort of two categories, whether you were post all when you got that lecture. So you worked 24 hours and then 30 hours because there talks were at noon and you got lecture at noon. So you were third hours in Chase, right? And then we looked at the data and we showed that you could retain, if you were not post call, about 6% of the material that we tried to convey into their brains. 6%. Three disheartening, right. But when we compare that to what you retained when you were post call, when you were attending that lecture after 30 hours, it was zero. Yeah. Wrote. Yeah. Remember any of that? So yes, that's disheartening. But it also reinforces what we already know about adult learner theory in that prepackaged talks aren't the best way to convey information from one person's brain into the not. Well, how how should we be doing it? Well, there are several different theories about how this is, but the first is you actually have to want to know. Okay, the answer height and and if you are primed, if you want to know everything there is to know about scleroderma. If I try my best to teach you about scleroderma, but you're not really interested in learning about it, you're not going to retain a lot. But if your mother was just diagnosed with it or one of your patients, if there was a motivation or for you to want to learn, then your brain is primed to pay more attention to sort of put these bits of information into your head. Learning is intentional. If you think about and prepare to learn before you learn, it will stick in your head. And there actually, there's some interesting data coming out of Washington University. There's intentional practice, and then there's casual practice. And the best college coaches will say, you play 100% speed 100% time during practice, you practice at game speed. Otherwise you will play your game at practice speed. Okay. All right. So if you just sort of go out there and you, you know, you put in three fourths effort during practice, then you're going to be very good at three fourths effort. Yeah. But in the meantime, you're not going to be able to compete at full speed. Can I take one brief little tangent on a show? Because I know we're on radio only, but in my drawer. In my drawer, I still keep a stack of index cards. Oh, wow. About the things I want to remember because I've already learned them. Yeah. What have I already remembered? Because you're holding up like 200 index cards. I've got a large stack here, and this is just one of my piles. Lead poisoning. Hey, I think you can reduce almost everything that you need to know about any disease. Honestly, on one index card front. Yeah, and back. Led by everything I need to know about lead poisoning is on this card. I learned it at 1.30, 40, 50 years ago, but now I can go back and practice the scales. Look at this again. Okay. The normal lead level is zero. Will have been changing over the years here. It's what your risks are, you know. So you. After practice, I'm like, any skill. Knowledge is a skill. Anyway, we went on a little tangent there. Sorry. Yeah, we should it. Well, to that point you've published multiple books. You also had kind of your own ongoing diagnostic dilemma email system. Have you thought about publishing your index cards? No, I have not. I think lots of people do. Tips and tricks or pearls or everything you need to know those sorts of things exist. Yeah, but that this is the basic challenge is getting something from this stack of index cards or that book that you suggest I publish or anybody's book into my brain or indeed or brain. How do you gain from the page in your brain? In me at first is you have to either read it, but then you have to practice and you have to do this over and over again. Repetition is the key you were talking about. When you practice, you have to be practicing at the level or the stress that you would be functioning in the game. There's that curve that's like stress on the Y axis and then how well you perform on the x axis. And there's a point at which there's diminishing return. Like the more stressful things are, the more you get shaky, the less functional you become, which I think is where simulation starts to be super helpful. You know, you're talking about a crashing kid who's in a hard block and you're trying to figure out how to work the new XL machine while you're doing transcutaneous pacing on the kid and talking about this because this was the case that we had last week. It is just so stressful because the kid's blood pressure is 40 over 20 and you are essentially just call in help and you're like, I can't focus on this machine right now. And have you seen I know that during your time, but we're kind of talking about work hours, but we're really not. Have you seen this since we started doing more simulation that you see residents becoming more comfortable or as kind of a counterpoint? You also because we have now much more attending presence in the emergency department in the ICU and there's a lot less resident autonomy happening when these critical things go down. Are you starting to see less comfort with residents in these critical situations? Yeah, it's a good several questions either, but yeah, yeah, yeah. I think time to get you know where to have I observed that simulation is helping. I think definitely yes I think the the scenarios especially when we're talking about multidisciplinary team simulation for stressful situations I think has been useful in particular in pediatrics. Many of these circumstances don't happen very often. Yeah, in an adult hospital, they're there, their code teams are busy in a pediatric hospital. That doesn't happen very often. So yeah. So it's a useful way to, to maintain practice before you go on stage. Whereas in adult hospitals, if they're coding all the time, they're on stage all the time. So it's happening. So it's been useful. We need more simulation experience. I will throw in a caveat and I think nothing frustrates me more than taking patients and taking the doctors, the residents away from patients on the floor to put them in simulation exercises so they can learn how to take care of patients on the floor. But it's to fill in the gaps for what they're not getting. So if in the old days, residents spent 75% of all time in the hospital and now it's maybe 30%, then we are diluting our resident education, there's no doubt about it. We're trying to make it better by having simulation experiences, by improving our lectures, but we're losing out on clinical wisdom we used to get. So that's led to a number of consequences. I think the first is you're exactly right. Some residents are less prepared, less experienced in taking care of patients on their own. And consequently, we have other care providers are more often there will be more attending presence, more hospitalist presence, more subspecialists, presence. And what that does two things. One, it ensures that the patient is getting better care from a more experienced, more wise care provider. But it also further dilutes the experience that that resident is getting. They are less involved in making the decisions and in fact even providing some of the care for those patients right then they would have been 30 years ago. So so it's not only diluting the residents experience, it's also shifting it to a different phase of training or to a different set of care providers. I'm going to use Hospitalist as kind of a is a generic substitute. Why were residents called residents. Oh I assume because they lived in the hospital. Yeah. They, they, they their residence was the hospital. They they live in the hospital. Why are hospitalists called hospitalist? Why? I don't know. Because they only live in hospital. Because they work in the hospital. They're good. So. So at some sense, a hospitalist is the newer version of a resident. They're both sort of assigned to the house. The residents did it so much that they had to spend the night there. Hospitalists are sort of the new resident. Hmm. Okay. In fact, when do their really popularity take off or shortly after the duty hour rules in place? Because if the residents were doing that work, who was? Yeah, we had to hire hospitalists and nurse practitioners and other allied health providers to help cover the gap of what the residents weren't able to do anymore. And so it's in some senses the same role. If you have a resident covering a ward with X-number of inpatient pediatric patients, now you have a hospitalist doing exactly the same thing. Now, excluding fellowship with the same level of experience and training. Okay. Okay. To a certain extent. Now they've accumulated a little more wisdom. And I've even had some residents tell me they're going into a hospitalist medicine for a few years because they want to gain more experience and exposure to patients that they felt like they missed out on during residency. Yeah, they want to be the ones making the decisions. In the old days they were the ones making the decisions. Now they don't get to do that anymore. It's sort of the attending who does. So it's diluting the experience, but it's also shifting it to sort of another phase of training. It's not residency, it's hospitalist, Nancy. Do you think it's bad, though? Had I been there? Pros and gone? You know, it's not inherently bad. It depends what your outcome is. Which are. Yeah. In regards to patient care, it's probably better for patient care. Now you've got somebody more experience doing it. Probably the residents of old when they were working so long. This is better. We all know working a full time job is tough, right? Dolly Parton wrote a whole song about how hard it is working of five and how she how you come always. You need a psychiatrist after that knowing 9 to 5 that's a 40 hour workweek job eating is double that so it's yeah Ahmad got about it so in that sense it's better it's good that we're not overworking these resident physicians. It strikes me kind of in two separate but equal paths that we could take from this conversation. You know, the one conversation could be the fact that we are understanding that residents are seeing fewer patients and getting fewer time hands on with critical care situations. And so we're spinning off new things, like you said, a fellowship in hospital medicine where now you have extra training just to be the hospitalist, where ten years ago you just graduated residency and became the hospital is like the other side of that. At the same time, while we're bemoaning this situation, the University of Buffalo now has been on strike for about a week, and their arguments are that essentially they're overworked and they're underpaid and they are paid by salary and they have bad working conditions. They get locked out of the doctors lounge because they are just lowly residents. And, you know, how dare you try to have lunch with us anyway? I guess what I'm saying is that it sounds like their arguments are that they are an indentured servitude workforce and that a lot of times when you talk about how competitive residencies have become, you know, some hospitals are going to be at the bottom 10% of all hospitals and how they treat residents. That's just the way that math works. And so some of these residents are feeling like they match at this institution. They cannot change in. They're stuck here. And so they're starting to unionize and they're starting to strike. If I can try to bring it back to hospital medicine, what I like about having a hospitalist on the floors is that the residents are doing the work, but they're being supervised. You know, there's there's a conductor of the orchestra telling the residents that there are things that need to happen for this patient that you need to be preparing for. You know, that is just education, that you don't get it without having the experience. Yeah, let me just throw in the comment about that. And there was a lot that you were talking about there that we could branch off and probably should talk about. Yes, I think I think we have to be very careful how you learn when you're being told what to do versus how you learn when you're sort of forced to make some decisions. In other words, the nurse comes up to the intern and the attending and says, Hasan Jones as a fever, what do you want to do? And the attending says, Why don't you go examine them, order some blood gases, get me a chest x ray, get a blood culture and start some antibiotics. Great. There's your conductor. You might learn something from that, but the better teacher and the better circumstance, you say, Well, why don't you go down the hall, examine the patient and tell me what you think is causing this and what you want to do about it. But look for shortcuts. And so that in turn, looking to the attending and the attending. Taking a shortcut by saying, yeah, watch God and do these sorts of things limits the useful, the educational usefulness of those scenarios. So yeah, I agree. It's nice having a conductor, but you have to be careful. The conductor isn't just a conductor and responsible for helping the learner learn. Yeah. I also want to point out before I forget, you know, they're they're they're indentured servants, they're their workers. They're just there to do the work. They're not there to learn the work is the education. It like seeing the patients and getting all this experience in examining somebody. Ooh, that's a tough that's tough indentured servitude there. You know, that is the education. You're learning how to talk to people. You're learning what lung the sound like. And yeah, you know, not to mention that we all believe medicine is a bit of a calling. I have read thousands of not only medical student essays and personal statements about why they want to go to residency, but also I was on the admissions committee to get into the medical school. Everybody talks about I really want to go above and beyond. And this is a calling to me. It's a sacrifice that I'm willing to make in suddenly. Now we're no longer willing to make any sacrifices. Right. There are a couple of things that you were you said that are sticking my head. I don't get free food at the hospital. Yes, I get I don't get free food. Name one area of work where people do get free food. Well, no, I was at Starbucks this morning. Do you think their food is provided for free? I don't think so. What I would say is people who are in high performance jobs, where you don't want them to be distracted by trying to do the normal daily necessities of life. You don't Google has a whole, you know, say what you will about the way that the Google model is. But they know that their workers need to eat and that instead of spending half an hour to go travel somewhere, sit down and eat, come back. They're just like, here, here's the food, take it now go back to work. You know what I mean? Like, if we're expecting the residents to work, feed them. Yeah, well, I think every place they work, there's food around, there's food available. Should it be paid for? I mean, you have the attending lounge gets paid for medical staff due to this height. Do you know that now? Yeah. So it's not free. The faculty are paying for it themselves by taking by paying dues. So, you know, if the residents want to pay $500 a year to support the food and the medical staff lounge, that's an it. Stop me. I'm just saying, I reflect back to when I was a resident and when I was a resident, my program director supplied food for me every single day. A new. Yes, I did. Yes, I did. And it's an interesting back to sort of duty hours if we can like. Yeah. One of the reasons we're so focused on making the work environment better for trainees and for everybody, for faculty, for all sort of health care providers, because we're very aware and cognizant that it was a system of almost abuse in the past. Right. You're working 126 hours. In the old days a week, we lowered it to 80. The reality is it's now probably 60. It's still not 40 hours a week. So now everybody is so hyper vigilant at making the work environment better because we don't want burnout. We recognize this big problem. How often do you think in my days of residency when I was a resident, do we have burnout? Do we talk about wellness? Yeah, never. We didn't get burned out. We weren't burned out. Even though we worked twice as many hours as what people are working now. We weren't burned out. You are. You had to be burned out. We just didn't call it that. You didn't have moral fatigue about the ineptitude of medical care. No, no, no, no, no way. Like you had. How do you have a wife in a family in a life outside of residency if you're working 130 hours was hard. I had a wife, I had kids. We it was tough. There was no doubt it was hard, but we were expecting it to be hard. Now, I think people are looking for ways to make it easy. Yes, because it doesn't have to be the worst thing that's ever happened. You know, like it doesn't have it doesn't have the greed. But now, like when like how low is it? Let's go back to my study. Yeah, to three to 4 to 5 nights of call. What's right that you five people say we're not working hard enough like when our when is current society going to say, you know what, this needs to be harder because we're still working too hard. But like, where do you draw the line? When do we start saying, all right, here, you're going to actually have more hours, you're going to have more education, you're going to see more patients. The suit to the point that there was a time when we were training people based on X number of hours, we'll say 130 for the purposes of math, and now we are down to 80 and now maybe even 60. You can make the argument just purely based on that. At least half of your. Residency training is now gone, and yet we still spend the same three years in residency. If you assume that graduates from a residency program with these workout restrictions are not worse noninferior to the ones who worked for 130 hours. Where is that extra time? Is that extra time in the excellence that goes into knowing the difference between bronchiolitis and asthma and having the wherewithal to know not to give every single kid albuterol? Or is is the difference in a bunch of ancillary things that don't matter? You alluded very briefly earlier about technology helping or hindering. Have we gotten more efficient with our documentation? I don't think so. But maybe it's the fact that we do now have computers and now we don't have to memorize a laundry list of facts so we can just go straight to up to date and type in lead poisoning Are we seeing a change in the way that work hours are required? Because we're adapting to the technology and making it so that we are more focused in our education. Yeah, that's a good question and I think there are several possible answers. One of the things that people are doing is getting more sleep. Secondly, if the current residents work about half as much time as residents of the old days. One thing that we need to point out is, is the amount of medical knowledge has increased. Yeah. So it's not just half like we're getting a fraction of that exposure compared to what needs to be known in medicine. There's just so much. And that's why, you know, the Board of Pediatrics and the AC GMI, they've all said like, you can't learn everything there is to learn in three years or six years. So we're not going to double your training. We now expect you to participate in lifelong learning. It's going to take the rest of your life to keep learning all these things. And we recognize that there's no end to the amount of knowledge that's out there. So so that's part of it. And we've also changed the composition of what residency training is. It's much more focused now on the outpatient world. The rules now say roughly 50% of your time should be inpatient, 50% should be outpatient. But there's some ulterior motives here. We want more and more people to go into primary care. And so you're giving them more experience and exposure to that. The hope is that more will go. And yeah, we've created a bypass circuit even if you don't go into primary care. We recognize the second most popular field is hospitalist medicine in pediatrics. These days, it's certainly becoming one of the most popular, fastest growing subspecialty. So we've now diluted the residency in patient training by adding more outpatient training. So then how are your hospital is going to function if they're getting less inpatient experience? Well, we'll make a fellowship and we'll teach them more about that. And Tom, one other thing that seems to be occupying a lot of people's time is technology. Yeah, ideally, technology will help make our jobs easier, will streamline things. But in fact, and there are data to back this up, residents and physicians done with training are spending more and more time on the electronic medical records, documenting looking things up, trying to sort things out than we ever used to in the old days. You know, we would write things on paper and you have these affectionate little terms called crappy progress notes we like. Right, right. Quick little note. And you can jot all your documentation down in 30 minutes on your 12 to 15 patients, believe it or not. Now, you'd be hard pressed to finish one patient in 30 minutes a day, and you have to have sort of skills in Epic, and you have to have shortcuts and you have to have smart freezes and you have to have. I am really looking forward to, by the way, when your ambient listening tool will be able to document the note just based on how you talk to an examiner patient. That will save us a lot of time. But I do think hours a day are now spent on the computer were as they weren't. Yeah go back farther they were spent in the library. We'd go to look up articles and try to get knowledge and try to figure out where we go to library, look at books and try to pull papers and articles and read those. That's now easier if you use up to date or other evidence cultivating programs and sites, but the tools are still not where they need to be to make us more efficient. I am hopeful though that in the next few years we will be there once this ambient listening software and A.I., you know, working together to make your notes faster. Yeah. So some of our residents use one of those ambient listening apps and it is mind blowing if you've ever used them. I mean, it's not just the notes, but it's also like discharge instructions for families are more robust and evidence based. They're actually really impressive. Going back to what I was just saying, like we keep lowering the threshold to make residency training and medical life better for people. How low does the bar need to be? Yeah, as a perfect example, now we have the emergency room physicians across the country. Been very good about making their lives better. Standard, at least in pediatric emergency rooms across the country, is for a full time faculty member to work about 30 hours a week. Okay. Okay. The range is between 28 and 32. That's a normal full time job for a Pedes E.R. faculty member. That's a lot less than Dolly Parton's 40 out, you know, 9 to 5. Yeah. But what we're hearing is that those 12 hour shifts they sometimes happen are very long. And there's a push to only go to eight hour shifts in this just in the. It's hospitalist. Medicine's everywhere, like 12 hours. Just really hard. So soon there will be nothing more than an eight hour shift. So my my question for you is how low of a threshold to make residency and medicine training is low enough to make it sort of tolerable or enjoyable and yet not so dilute that it becomes a sinecure, a position without any real sort of responsibility. Interesting. So my knee jerk reaction to that is one of the things that go into your decision making about your future is a lot about lifestyle. You know, I think that on the one hand, emergency physicians do get to not have call. They do get to not have clinic and they get to be very efficient about how their time is spent. You know, in my mind, the time that you work down in the emergency department, you have a gun to your head and it is the worst 8 to 10 hours of your week. But by the end of it, you're done, right? I mean, it was one of the best 8 to 10 hours of my week. I loved working in the E.R.. Yes. Don't get me wrong, I love working down there, but it is grueling. You know, it is hard. Every single patient interaction truly is a hostage negotiation. In if that's your if that's what gets your heart rate up, then great. But what I would say is that the trade off, I think it's about efficiency. Earlier you mentioned as a rheumatologist, you might get a console every other day or so listening to your implicit criticism of the way that emergency medicine at least is running in pediatrics. Is that why do I, as rheumatologists have to work 60 hours a week instead of an ER doc working 30 hours a week. And I think it's about efficiency, right? It's about the fact that they're at all times the churn is going to continue in there, that patients are going to come in and out of the emergency department as opposed to, you know, kind of waiting for a console to come through. I like the way you say it's about efficiency, but it's but there's some aspects of this efficiency that are not dependent on the physician. It has to do with the decision. Correct. To move all my rheumatology consults until one day. Yes. Then I get a month of work in a week? Yeah. We're reliant on what comes to us. There are some ways you can actually generate some referrals and kind of work on that. But in a lot of academic settings, I'm not out there shaking the trees looking for autoimmune disease. It's not our efficiency. It's nature's efficiency, if you will, or lack thereof. I think that was my response. One of the things that we had not gotten the chance to talk about about due to our restrictions. When I prepared for this conversation, I just assumed that you were going to be like, No, the kids are soft today and we need to be getting them hard in. And, you know, I didn't get quite get that. But but, you know, some of the there are pretty substantial criticisms to do duty our restrictions. And we talked a little bit about how much time residents now get exposed to patients, but also now you're seeing more handoffs and now you're seeing, you know, less continuity of care. Have you seen that fragmented learning or the inability to follow patients over time? Have you seen that cause any changes in the quality of physicians that are graduating nowadays? Yeah, that's kind of a trick question. You're asking me that it's hard to assess quality physicians today compared to 20 years ago. And I know there are data that help back up some of these points that increasing handoffs can lead to worse patient outcomes. I think we understand that shift work mentality. I'm only here for the day. Somebody else's responsibility for tonight is becoming a part of medical life, and that's a problem. So. So what we hope for in medicine is try to find the people who are going to be able to supersede that shift work mentality and think outside that. In other words, I have my shift is over at 6 p.m., but I need to make sure that this person is going to do this at 10 p.m. tonight and follow up on that. That's what we're looking for in our personal statements when we're reviewing them for both medical school and for residency. You said a phrase that's still sticking in my head. Much more about lifestyle now. If I was reading somebody's personal statement and said, well, I really want to go to medical school now so I can have a good lifestyle, so that I can work 30 hours a week and get out on the week. I don't have to work a 12 hour shift and I never want to be in the hospital night. What would you do with somebody's essay? Who wrote that? What would you. Put them at the top of your rank list. You if you have somebody who walks in the door like, hey, I want to be a surgeon because I have a God complex and I want to lord over my patients as though I heal, you know, like you're not going to put that in your. Well, that's true. Right. That's still as true as what you just said about a lifestyle. Yeah. So there's a lot of salesmanship going on when people are applying both med school and residency. We have some surgeons here and we are debating I won't say that particular field, but we have to we're debating hiring a third and the two because they're on call every other night. Yeah. Need surgeons and they don't want to hire a third. Not because of a god complex, but because they don't want to dilute out their experience in their work, their experience, our views, their experience. Those guys are on a non r view based salary. So their salary, they don't want to dilute out what they're seeing. So there are still people who do it for the term. Addison And if you do, let's take something complicated. I don't know, a Fontan repair and you do three a year you know that you're going to be a better surgeon by having more experience with it. You're going to want to be doing more of it. So part of it is making sure that you have the skills to be able to do what you need to do Yeah. Now, maybe rheumatology you don't need I only need to see a patient once a month to have the skill that maybe there's no skill involved. It takes care of prototyping. Well, I don't mean to dismiss people who are focused on lifestyle. I tell them, you know, our program had a very malignant reputation back in my day. You know that back in your day, like when I was near back in your day. Like when you were there when I was there. Seventies, eighties, nineties, you were a malignant program. I tried my best to solve that because I recognize that, you know, there are fewer people going into pediatrics and. Yeah, but and you've got to recruit people into your program. It's, it's not the most competitive fields anymore. And so that's why we keep changing these thresholds. Oh, I make you work 65 hours a week, but we'll give you free lunch every day. Lunch? Yeah. The door. Yeah, that probably did it. So what if I was a program? If I said I were going to do 30 hours a week, the max you're ever going to work is 30 hours a return residency. We would probably have a pretty good match list that year. Yeah. Or would we? Are we only going to recruit the people who are looking at lifestyle and not really interested in the calling? No medicine, not really interested in learning. It's a selection bias. We're only recruiting the ones who are looking to work as little as possible. No, no, no. I hear you 100%. I think that if you could demonstrate excellence in your graduates who are only working 30 hours a week, 100%, I'm going to go to that program. Yeah, totally. Right. Yeah. Then then you're talking about like, how do you assess excellence? And that's that's a whole another. We could talk another hour about that if you want. Yeah. Anyway, thank you so much for coming on the show. I really appreciate your time. I know you're super busy out there. It was a pleasure being here and I appreciate the time to think about this. And there's still more we can talk about. Some of you ever want to branch into another topic? Let me know 100%. We'd love to have you back on the show. Yeah, you're welcome. And thank you. And of course, my opinions don't necessarily express those of Saint Louis University nor Cardinal Glennon Children's Hospital, nor some health. And in fact, I'm not even sure they they represent my own thoughts and process thinking out loud as we as we talk today. And I appreciate the time to reflect. I love it. Thanks again. When we talk about medical education, we often emphasize the curriculum in the data, in evidence based medicine and clinical skills and ethics, etc. But we often downplay the profound influence of mentors and role models. Mentors shape our identities, our values in the kind of physicians we become, both good and bad, for that matter. When I was in medical school, I had planned to do surgery, but I had the wrong mentors for that. It could mentor, can push you to be just a little bit better because they've earned your trust and you know, their intentions are rooted in your own growth and success because they know you so well, they can challenge you in ways others can't. Whether it's pushing you to take on difficult cases, embracing new ways of thinking, or to confront your own limitations. When I put together my residency rank list, why she was at the top of my list entirely. Based on the half hour I spent with Andy White, I was not disappointed. So Andy, thank you for being on the show and thank you for 11 years of mentorship. This week, Jess Adkins Murphy, who was featured on Episode five about mifepristone and miscarriage Politics in America, published an opinion piece in the Lexington Herald-Leader, which I think is the second largest newspaper in Kentucky. It had the title Kentucky Abortion Laws Made My Miscarriage More Dangerous Than It Had to be. It's a wonderful article and I am so impressed by how she's used her own personal health crisis to push back against a system that has failed her and failed countless other women. I put a link to the article in the show notes. I think she does an excellent job of making a seemingly complicated issue. Very simple. And it ends with a call for rational policies around miscarriage, which kind of seems trivial from the outside. You know, like I don't think any of this is a very controversial stance. And yet here we are. We're going to take a few weeks off for real this time to work on growth. But the next episode is with one of my research partners, Chris Nash. He and I are doing a fellowship together on artificial intelligence in medical education, and we've been working on using a large language model to assess written clinical reasoning. As always, my email is Tom Adobe, M.D. at gmail.com. This podcast was produced by Melissa Puffin. Catriona Oria is our director of communications and the music is by Spencer Brown.