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Safeguards keep Patients in Hawaii hospitals needn't fear they will get poor care from overworked medical residents, say University of Hawaii medical school administrators and recent residents.
burnout in check
Medical residents offer
Residency hands-on
good care despite stressful
conditions, UH officials sayBy Helen Altonn
haltonn@starbulletin.com
In fact, standards of medical care may be better because of the residents, says Dr. Samuel T. Shomaker, associate dean of academic affairs and education of the John A. Burns School of Medicine.
A recent study of the University of Washington's internal medical residency program found three out of four residents suffered from burnout, and half of those said they sometimes gave "suboptimal" patient care.
Locally, Shomaker said, "I think actually having residents improves quality of health care because they're in the hospital 24 hours a day, seven days a week, so they're immediately available to handle whatever problems come up."
The medical school has about 240 residents distributed at any one time across hospitals in training programs, which are conducted under strict national standards and safeguards, Shomaker said.
"Obviously, if a resident is too tired, their judgment will be impaired and patients won't get optimal care," he added, "but I don't think it happens that very often, and the reason ... is there are lots of fail-safe mechanisms built into patient care."
Dr. Jim Hastings, director of the UH Internal Medicine Residency Training Program, said in his six years with the school, he could recall only one case of an internal medicine resident dropping out because of stress, and he returned after a couple of years.
He said concern nationally about fatigued residents led to tighter regulations by the Accreditation Council of Graduate Medical Education.
"What we do is adhere to the internal medicine requirements, which is 80 hours and one day off a week," he said. "We look at limitations for our residents to try and prevent this kind of problem (burnout) from happening, but they do work 80 hours a week.
"On the one hand, we don't want residents to be tired out. On the other hand, we want them to be able to interact with patients through the course of the acute part of an illness when major decisions are being made," Hastings said.
The hours sometimes stretch longer because "there is so much to learn" and a patient may require continuous care, said Dr. Mevan Wijetunga, 38, who recently completed a three-year internal medicine residency and is working at Kaiser Moanalua Medical Center. But that doesn't happen often, he added.
Besides their patient workload, residents must attend teaching sessions, conferences and medical grand rounds with a lecture by a specialist, as well as weekly evening lectures, Wijetunga said.
"There are moments, certainly, when the human factor kicks in," he said. "It's particularly true if you don't get any break."
Most of the time, residents get breaks, and they generally feel they can overcome fatigue with an hour of uninterrupted sleep, he said. "But it's seldom you get an interrupted sleep."
He said he felt as long as he was standing and working, "my thinking was clear," but sitting down, particularly at a lecture the next day, "it is not uncommon to see a lot of people asleep because of fatigue."
Wijetunga chose Hawaii for his residency after attending medical school in Sweden and getting a general medical license there. He plans to go in June to Washington Hospital Center in D.C. for subspecialty training in cardiology.
"I think intensive training is part and parcel of the whole health-care system," he said. "You get into reality and work as a doctor, and you still have to work long hours continuously without any break and still make major decisions."
Although he felt rushed at times during his training, Wijetunga pointed out, "You're not the only pilot in the seat."
Dr. Rebecca Gelber, 29, chief medical resident supervising other residents at Kuakini Medical Center, also described many safeguards to protect against fatigue and prevent it from affecting patient care.
All interns (first-year residents) are supervised by a senior resident; interns and residents are supervised by an attending physician; and chief residents at each hospital review residents' work, she said. Every hospital also has a director of medical education, she said.
Gelber, who was born in Hawaii and attended Washington University School of Medicine in St. Louis, also dispels the notion that women have a harder time than men in medical school.
"We have a growing number of women in each class," she said, noting she was one of 11 women out of about 21 third-year internal medicine residents last year.
Gelber plans to join the medical school faculty in July and do research and primary care at Queen Emma Clinic.
University of Hawaii
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The University of Hawaii's medical residency program is designed to teach medicine at the patient's bedside. UH residency has
hands-on approachBy Helen Altonn
haltonn@starbulletin.com"The fundamental issue is, you learn medicine by taking care of patients," said Dr. Jim Hastings, who directs the internal medicine residency training program at the John A. Burns School of Medicine.
"We want young physicians to be able to evaluate patients when they are sick and follow them through the course of an illness."
Training begins with a "nontraditional curriculum" for undergraduate medical students that relates more closely to what physicians do in practice, said Dr. Samuel T. Shomaker, associate dean of academic affairs and education.
Instead of traditional biochemistry, anatomy and microbiology lectures, students in the "M.D. Program" are divided into groups of five or six that meet with a faculty member and discuss actual patient cases from the first day of school, he said.
"They are presented with a clinical scenario that is used to get into a discussion of biochemistry, anatomy, cardiology or whatever might be appropriate to that case."
Students participate in the discussions, research problems and share information with the group, Shomaker said.
In the residency programs, which range from three to six years, he said the school tries to maintain a balance between what is optimal for a resident's well-being and what is optimal for training.
One factor driving the workload, he said, is that medicine is becoming increasingly complicated with new technologies, drugs and therapies.
Trainees must learn these, so demand on their time is greater, he said.
"We have to constantly be looking at the rotation schedule and curriculum the residents are required to complete ... to assure they're getting the most up-to-date information," he said.
Also, people get sick all hours and someone must be available to care for them, Shomaker pointed out. If residents worked only eight hours a day, patients would see three different residents in 24 hours, he said, stressing the need for continuity of care, both for patients and physicians.
Hastings said efforts are being made to develop other tools to try to improve the education of young physicians "without putting them into these tremendously strenuous environments, and that is a challenge for us."
For instance, they're looking at things like simulators, standardized patients and computerized training scenarios, he said.
University of Hawaii
