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Government will force associations to lower standards to meet the seemingly infinite demand, or they will start their own boards to qualify doctors through a revolving door. It will be like glorious Cuba!
The government plans to use nurse practitioners and physician assistants to cover most of the increased demand.
The problem is that NPs and PAs can get in over their heads and need MD supervision. They are valuable when the patients they see are mostly doing well and just need periodic monitoring. But when they see patients with new problems and their work is not well supervised the result is often unnecessary testing and referrals to specialists. I know some docs who are very unhappy when they refer a patient to a specialist and the patient does not get to see the MD, only the NP.
So, yes, the potential for a reduction in overall quality of care is large.
FWIW - FAA regulations forbid a commercial pilot from flying without enough sleep. They also have limits on alcohol consumption.
Abuse does not lead to learning and only justifies abusing others to the student. Sleep depravation does not make people any smarter or better skilled. Both together only lead to disaster.
I agree. If you went to a residency before the time restrictions went into place, you were worked to death. Practice is easy in comparison. In the first ten years of my practice after fellowship, we were on call every third night and usually worked all night. There was no "day off" after call- you just had to work and hope for the end of the day. "Regular days" usually started at 0600 and went to 1900 or 2000. That was tough, but not as hard as residency.
I finished residency 25 years ago and fellowship 23 years ago. A lot has changed (in my opinion for the worse). Keep in mind that with all these restrictions of work hours, residents are being exposed to far less "hands on" experience than they should have. If they are going to cut the hours, then extend the number of years in residency.
The younger docs coming out now are not as well trained as a result and have a hard time adjusting to a "normal" medical work schedule.
Quote:
Originally Posted by odinloki1
These ego posts make me laugh.
I'd like to know how many patients you had in your years of iron man shifts would agree that you are as fully functional as you think you are when you're sleep deprived. Do you think theyll all say "oh I didn't know that doctor was sleep deprived, he didn't mess up anything"
I hear about botched or screwed up operations all the time from patients and old doctors from these "glory days" making mistakes all the time. I see it happen, I'm far from perfect, I'm a lowly mid level, but I've never had a supervising doc that has been perfect either, and most of them are old enough to collect social security.
Providers make mistakes, mistakenly prescribe drugs that have potentially bad interactions, and they can make mistakes in procedures. The only difference between you and these weakling residents you want to bash is that your brain is probably far more capable at this point of performing mental gymnastics to forget about the cases you screwed up when you were sleep deprived.
Drop the ego and focus on the patient well being, not your egotistical boot camp that sacrifices patient well being for doctor training.
To be fair, I do agree, lengthen a residency out to give more experience but the exhausting hours aren't a learning experience. The only way someone remembers something when they've gone 40 hours without sleep is if they screw something up and the adrenaline rush of fear burns it into their brain.
If people are coming out of residency less well trained, I suspect it is not the work hour requirements that are to blame. Someone is not teaching them.
Certainly, if they are not seeing enough patients, then increasing the length of training is a good idea. The problem there is that postpones the new doc's entry into practice and increases his debt load. Most residents are paid less than nurses. If you are going to extend the length of the residency, they need to be paid more.
Note that the higher salaries are weighted toward people who do mostly procedures. The primary care and many internal medicine subspecialists earn much less.
I could see how an opthalmologist with a heavy Medicare practice could get to the point where the income is just not there, particularly if he did not do something that is mostly not covered by insurance, such as refractive surgery.
It is ironic that you talk about economics but want to impose artificial demand by placing a hard ceiling on a market. As long as you are on the topic, look up the term 'economic deadweight loss'. Do you care to address the points I made responding to you in my previous post?
But of course, following your logic, shouldn't we further limit spots? After all, if we cut the current number of doctors by 25%, the quality we get would be even better, so with your logic that is a great thing, isn't it?
But I don't want to impose artificial demand. I want to impose some sort of quality control. Yes, if we limited the medical school spots to 3, you could be damn sure that those 3 students would be the absolute best 3 superstar candidates. But that is not feasible or practical, nor is it what I am advocating. I am not taking my position to extremes. There has to be a balance. The Hollywood Upstairs Medical College that you advocate IS taking it to extremes, and will lead to many people getting sick or dead before the problems get resolved. You are not selling defective widgets here. You are putting people's lives at risk. For example, about a year ago, I read an article about someone doing silicon injections in a non-sterile hotel room with builder's grade silicon bought at home depot. This was not a doctor. This was a snake oil salesman selling this procedure to poor uneducated women in Newark NJ. 6 women ended up in the hospital before this charlatan was exposed. These women paid a hell of a price for the crime of being uneducated and/or just plain stupid. Under your free market medicine extreme, this would be acceptable and would happen to a much greater degree.
I see the difference every day. It is not a subtle difference. The residents I train today are not nearly as well prepared. I have 3rd year residents that have a hard time placing a central line. This is something that we had perfected in the first few months of residency. It's easy to sit there and dismiss it as "ego" when you do not see it every day. I don't doubt that mistakes were made in the 40th hour, but I wonder where more mistakes are made? In the 40th hour? Or by docs that are not as well trained?
Again, why are they having trouble? Are there fewer patients now than when you were a resident, or are there restrictions on who can place a central line?
Did you put in any central lines when you were a medical student? Are students allowed to do them now?
Back when I was having my kids (over 30 years ago), I had an obstetrician who had gone to a medical school that let medical students have a lot of responsibility. The teaching hospital was high volume, and he saw a lot of pathology. He went to another state for his OBGYN residency. Soon after he started, he saw an OB patient with severe toxemia. Having seen a lot of patients with it, he admitted the patient, started her on the appropriate treatment, then notified the chief resident. He got blasted for not calling the chief and the attending before he did anything. It turned out that he had seen more toxemic patients than the attending, because it was much less common in that community.
So, what difference does it make if the residents are working 40 hours straight if there are not enough patients for them to train on?
Where's the data saying all of those who qualify are getting seats then?
My second post is the same as the first. The "artificial limits" are not academic ones, but school capacity ones.
Maybe it's a lack of capacity problem, and not quality of the student. Medical school applications have exceeded expansion in capacity by a large margin for awhile.
I haven't answered your question because your example is asinine and not related to either post. Not about lowering the bar...
I am glad to see that you think the example is asinine because that tells me that you do agree with SOME sort of limit. But you can't make the statement that the artificial limits are "not academic ones" because the two cant really be separated. The limits are the reason academics are the determining factor in acceptance. Again, there is no escaping that reality. If you want to say that many qualified people are turned away from medical school, and there is certainly more room to accommodate them, then we have something to discuss. In fact, in recent years, more medical schools have been approved for opening than in the previous 5 decades, so your concerns are already being addressed.
But I don't want to impose artificial demand. I want to impose some sort of quality control. Yes, if we limited the medical school spots to 3, you could be damn sure that those 3 students would be the absolute best 3 superstar candidates. But that is not feasible or practical, nor is it what I am advocating. I am not taking my position to extremes. There has to be a balance. The Hollywood Upstairs Medical College that you advocate IS taking it to extremes, and will lead to many people getting sick or dead before the problems get resolved. You are not selling defective widgets here. You are putting people's lives at risk. For example, about a year ago, I read an article about someone doing silicon injections in a non-sterile hotel room with builder's grade silicon bought at home depot. This was not a doctor. This was a snake oil salesman selling this procedure to poor uneducated women in Newark NJ. 6 women ended up in the hospital before this charlatan was exposed. These women paid a hell of a price for the crime of being uneducated and/or just plain stupid. Under your free market medicine extreme, this would be acceptable and would happen to a much greater degree.
What I am concerned about is the use of government intervention to protect a guild. Software developers are tasked with systems that are much more critical than what a doctor is responsible for, because they affect many peoples' lives in a very disruptive manner. I'm not talking about your internet not working so you can't view **** anymore. I'm talking about systems folks who are tasked with protecting power grids, preventing cyberhackers from threatening nuclear reactors, etc. We don't have a particular guild that we belong to. My area of study is actually using the Watson system that won Jeopardy to solve problems relating to cancer treatment. I didn't need a special board to designate me as qualified to do such a task. Since my area is self-limiting where demand far exceeds supply of qualified persons, I'm actually paid more than many doctors after you've taken into account malpractice insurance, overhead, etc. Similarly, doctors can be paid based on their qualifications and health care can be market driven and accessible rather than artificially limited due to "I'm a special snowflake" groups.
Again, why are they having trouble? Are there fewer patients now than when you were a resident, or are there restrictions on who can place a central line?
Did you put in any central lines when you were a medical student? Are students allowed to do them now?
Back when I was having my kids (over 30 years ago), I had an obstetrician who had gone to a medical school that let medical students have a lot of responsibility. The teaching hospital was high volume, and he saw a lot of pathology. He went to another state for his OBGYN residency. Soon after he started, he saw an OB patient with severe toxemia. Having seen a lot of patients with it, he admitted the patient, started her on the appropriate treatment, then notified the chief resident. He got blasted for not calling the chief and the attending before he did anything. It turned out that he had seen more toxemic patients than the attending, because it was much less common in that community.
So, what difference does it make if the residents are working 40 hours straight if there are not enough patients for them to train on?
Central lines are just 1 example. There is not less patients. Most teaching hospitals are very busy and have procedures that need to be done around the clock. The amount of procedures one does is directly related to the amount of time one spends at work. If I am a resident, spending 100 hours in the hospital, it makes sense that I am going to be doing roughly twice as many procedures as someone who spends only 50 hours there. To compound the issue, the more you do of a procedure in a short period of time, the better you will get at that procedure. I see this in my own practice today. If I do a new (to me) procedure 4 times in a week, by the end of that week, I am a lot better at that procedure than if I do it 4 times in a month. To get back to the example of central lines, when I was a resident, by living in the ICU, I did so many central lines that I was proficient to the point where I will never lose that skill. I hardly ever place them now in my practice, but when I do, it is very easy because that skill has become ingrained.
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