New Residency Requirements Divide Training Directors

Abstract

Back to table of contents Previous article Next article Education & TrainingFull AccessNew Residency Requirements Divide Training DirectorsEve BenderEve BenderSearch for more papers by this authorPublished Online:4 Apr 2003https://doi.org/10.1176/pn.38.7.0014Regulations issued by the Accreditation Council for Graduate Medical Education (ACGME) will forever change the way training directors educate residents and the way residents work with patients.But even though regulations calling for competency in psychotherapy and general medicine are a “done deal,” training directors who gathered at the annual meeting of the American Association of Directors of Psychiatric Residency Training (AADPRT) in Puerto Rico in March had an opportunity to debate their concerns about them.“When does setting specific requirements pass the point of guaranteeing the minimal level of education and choke and stifle the education process?” asked AADPRT President Bruce Levy, M.D., who moderated the debate, “and when does the one-size-fits-all model make it impossible for programs to achieve their educational mission?”During the debate, panel members considered the pros and cons of the regulations issued by the ACGME’s Residency Review Committee (RRC) in Psychiatry on resident competency and work hours (Original article: see box).Panelist Cathy Frank, M.D., director of psychiatric education at Henry Ford Health System in Detroit, in her endorsement of the psychotherapy competency regulations, recounted examples of incompetence from her experience: the resident who held fast to the belief that all it took to be a psychotherapist was to be nice to one’s patients, for instance, or the patient who was a victim of incompetence—the patient had been in psychotherapy for more than 10 years, yet experienced five to 10 panic attacks a week and had never been prescribed psychoactive medications.She argued that psychiatry as a field must embrace evidence-based medicine, and “competency requirements are a step toward that.”Frank’s debate partner, Richard Summers, M.D., agreed. “I think that psychiatry will benefit from being more systematized in thinking about education,” said Summers, associate director of education at the University of Pennsylvania’s department of psychiatry.“We all know the problems with competencies,” said William Greenberg, M.D., in his counterargument. “None of us knows what constitutes competency for a graduating resident, nor what standards should apply.”Greenberg, training director at the Harvard Longwood psychiatry residency program, also questioned the RRC’s decision to target psychotherapy practice as an area in which graduating residents must prove their mettle.“As a longtime board examiner,” he remarked, “it is not having these skills, or a lack thereof, that leads to painfully low pass rates on Part II of the board exam.” Instead, he said, it is the “failure of residents to demonstrate more basic skills,” such as conducting an interview with a patient, making a differential diagnosis, or shaping a treatment plan.In response to Frank’s and Summer’s argument that the competencies embrace the concept of evidence-based medicine, Greenberg said there is no evidence that the competencies lead to better training; moreover, they mean more work for everyone. “I fear they will lead to an enormous amount of time, effort, and lots of paperwork with nothing to show for it.”Greenberg also fears that the competency requirements will stifle the creativity of training directors and residents alike.Money Concerns ExpressedThe creativity in other training directors’ responses to panel members was boundless—a few of the respondents even used literary references to express thoughts about the RRC requirements.One altered the poetry of William Wordsworth to make his point: “The world is too much with us/Late and soon/Monitoring and documenting/We lay waste our powers.”Another training director said he felt like the protagonist in Franz Kafka’s novel The Trial who “is not allowed to know what he is accused of or allowed to ask any questions of anyone. He only knows that on a certain date, he’ll face trial on some serious charge.”John Urbach, M.D., director of residency education for the department of psychiatry at the Medical College of Virginia, raised the all-important issue of funding.“The reality is that 40 of the U.S. states are facing massive budget crises,” he said. “[The competencies] are extremely expensive to implement. . . .I wonder if anyone out there is seriously worried that we will become too expensive for some graduate medical programs to want to fool with.”Daniel Winstead, M.D., a director of the American Board of Psychiatry and Neurology and past chair of the RRC, said that the decision to establish psychotherapy competencies came out of meetings between the RRC and other psychiatric organizations in which “the clear message to the RRC was that psychotherapy was quickly becoming a lost art” and that the ACGME, in issuing the regulations, sought to protect the public.He did acknowledge that some small training programs may have a difficult time funding the implementation of the competency requirements.To Sleep or Not to SleepIn her opposition to the way in which ACGME regulations limit resident work hours, panelist Elizabeth Auchincloss, M.D., vice chair for graduate medical education at New York Presbyterian Hospital-Weill Cornell Medical Center, listed decreased time spent with patients and colleagues and “a decrease in professionalism and personal accountability” as reasons why the regulations are problematic. The work-hour regulations are scheduled to go into effect on July 1.Fewer work hours for residents, she said, mean less continuity of care for the patients they see. This, in effect, will “reduce patients to an object passed from resident to resident.”Furthermore, she added, work-hour limits may prevent residents from spending additional hours above and beyond those limits moonlighting—where many gain valuable clinical experiences and learn to do unsupervised work with patients.The counterattack launched by Summers and Frank went deep.“If [Auchincloss] was the keynote speaker for the Federal Aviation Administration, you could go to the airport and get on a plane in which the pilot had been flying for 36 hours straight,” said Summers.Like pilots, or anyone else for that matter, Summers said, residents can’t function well in a clinical capacity when they haven’t had enough sleep, nor can they learn as well.Frank recounted advice she had received from senior residents about how to stay awake after being on call all night and being faced with hours of additional clinical work. Their advice? “Don’t cut your fingernails. Make a fist so that your fingernails dig into your skin.”One of the discussants, Sonya Rasminsky, M.D., lent a personal perspective to her support of the work-hour regulations. She is a PGY-4 resident at Cambridge Hospital in Massachusetts.Rasminsky said that within a day of arriving in Puerto Rico, she had emergency surgery, which was performed by staff physicians. “I’m glad I didn’t have to worry about having sleep-deprived residents working on me,” she said. “I wouldn’t want either myself or my family cared for by someone who hadn’t gotten adequate rest.”As a member of the Committee of Interns and Residents, a union representing more than 12,000 medical residents affiliated with the Service Employees International Union, Rasminsky signed a petition to regulate resident work hours that went to the Occupational Safety and Health Administration in 2001. She cited data about how inadequate rest has been linked to increased rates of automobile accidents, depression, and pregnancy complications among sleep-deprived residents.One training director said that in his experience working at the Massachusetts General Hospital emergency room as a staff psychiatrist, he saw 1,000 patients in a six-month period. “What is the net learning curve after the first 500 patients,” he asked, “versus the sleep deprivation that caused me to become incredibly incompetent during that process or in conducting psychotherapy with patients whose sessions disappeared because my memory was so impaired?”Information on the ACGME requirements on work hours can be found on the Web at www.acgme.org/new/ProgramDutyHours.pdf; program requirements for psychiatry residency programs are posted at www.acgme.org. ▪ ISSUES NewArchived