Howard Forman, MD

 on the cover of the November 2010 issue of  the 

 had  many in my residency class talking. In response to more restrictive regulations  of resident work hours 

 Dr Sidney Weissman  penned “Are We Training Residents to be Shift Workers?”

  Regretfully, I agree with Dr Weissman that there are programs that are training  my generation of psychiatrists to think, behave, and feel like shift workers-but  I disagree with him about what is causing this phenomenon.

At my residency program, we often joke about who is the  busiest resident. We are not given any statistics concerning our productivity  because, according to our clinic director, we should “think about patients, not  numbers.” This approach always struck me as overly protective until I ran into  a fellow third-year resident from another local program.

My colleague shared with me a scenario illustrative of shift  work mentality run amok. At his program, one of his classmates requested a more  discreet office because she felt that her comings and goings from the clinic  were being monitored. Lending credence to her concern was a recently held and  specially scheduled meeting with her residency program director where she was  chastised for having only 55 patient encounters during the month of December.  She was shown that the next lowest number of encounters by her classmates  eclipsed 90. The resident was informed her output was unacceptable and she would  be getting a large number of new cases to get her “numbers up.”

Here, both the concern of the resident and program direction  are poor proxies for actual patient healing. The resident’s greatest concern is  the judgment made by those who see her entering and exiting her office rather  than the success or failure of those she is treating. Likewise, the program  director is solely concerned with the “number” of patient interactions with no  expressed concern for what is going on in those interactions.

Is it possible the resident is doing exposures that require  her to leave the office and limit her ability to see higher numbers of  patients? Does her patient panel achieve success with less frequent visits  thereby saving the patient the hassle of needless appointments and New York  State Medicaid from having to pay for unnecessary care? Is the resident missing  out on valuable opportunities to help patients because she lacks confidence in  her skills as a therapist? Although these are the questions that would lead to  fruitful conversations, they are not the questions being asked.

The resident here is being molded into a shift-worker-not by  ACGME regulations but rather by those entrusted to train her in the art of  science of psychiatry. Essentially her program director called her in from the  assembly line and said, “You are just not making enough widgets; how can we  ensure that you make as many widgets as the people working on the other  assembly lines?” ACGME regulations did not induce a shift work mentality, but  are a response to residents being viewed as turbines of economic productivity.

Ultimately it is those who incorrectly equate productivity  for quality that pose far more harm to our profession than any governing body.

Weissman S. Are we training physicians to be shift workers? 

ACGME Common Program Requirements (page 17). 

http://acgme-2010standards.org/pdf/Common_Program_Requirements_07012011.pdf

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A recent opinion piece on the cover of the November 2010 issue of the Psychiatric Times had many in my residency class talking. 

Author | Howard Forman, MD

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