Monday, April 09, 2007

The Economics of Residency Part IV: Malpractice

Every surgeon will cut for the first time. Every anasthesiologist or ER doc will perform his first intubation. Every internist will have to make his first solo decision, without having to run his plan by an attending. With all of the negative things that I have said about residency, one of the things that it did traditionally accomplish was allowing new physicians to engage in these sorts of practices in an environment in which backup was available and a wise elder was at most a phone call away. In fact, the whole argument for the necessity of residency stems from the idea that this should be necessary before physicians are independently unleashed on the world. Here's the problem, someone still has to be the first patient.

In the earliest days of yore, when life was simple and residents slept on call, most teaching institutions were charity hospitals. There was no entitlement to healthcare at that time, and residents engaged in a mutually beneficial exchange with the less fortunate. The destitute masses that had flocked to the cities and had no family to take care of them were taken in, given a warm place to stay, and nursed until death or disease resolution. In exchange, they gave their bodies as learning devices for the new crop of physicians. The outcomes might not have always been perfect, but we have to remember that this was a simpler time, and inexperienced decision making probably didn't lead down the same rapid road to death as often as it does today.

In today's world, charity is a lot more convoluted. Between Medicare and Medicaid, many of the former patients are now covered by insurance. Add EMTALA to that, and pretty much everyone has access to some entitled healthcare. In this modern world, there are no more good samaratins. There are only doctors, expected to be 100% correct at all times, expected to take the team approach and take care of patients perfectly. Everyone is a possible malpractice suit. Any mistake could be $1 million. Understandably, this has created an environment where everyone from the hospital CEO to the hall janitor lives in fear of the next subpoena.

In this environment, there is no one more dangerous than the resident. Every step of the way, he has to upgrade his level of responsibility. He has to try new things. For every new procedure or decision, someone is the first patient. This is no more evident anywhere than the surgical specialties, where someone is always the first to go under a new surgeon's knife.

This fear has in many ways defeated the entire purpose of residency. Programs are often afraid to let resident's operate autonomously. They should be, residents are a huge legal liability. It is no coincidence that many people who train in community programs with legal immunity often come out with greater technical skill, even if they often fall short academically of their university trained colleagues. A resident performing scut work is a cheap boon to the hospital, but a resident actually attempting to work autonomously is not just slower, but he is a potential legal disaster for the hospital. Thus, malpractice directly inhibits autonomy of residents. A resident who isn't gaining progressive independence is wasting his time as slave labor, period.

The most telling example of this is in the surgery programs, where many residency graduates will flock into a plethora of fellowships in order to actually get some independent operating experience with backup. Others will work independently for the first time as community physicians. They will have never made their own decisions. They still have to do it for the first time, but they will no longer do it under the protective cover of residency. This of course increases their risk of malpractice, and the cycle of destruction continues. There is never any protection from law suits.

In the charity hospitals of old, resident labor was cheap, and their services were almost given away. This was basic supply and demand economics. A man with no money and a raging appendicitis was willing to take the increased risk of a resident surgeon. He had no choice, it was that or death. The supply and demand curve yielded only training surgeons at the price of free. In today's controlled environment, where everyone gets paid the same for the same procedure, trainees can no longer bargain down their services in order to train. They are just a less experienced doctor at the higher price. No one wants that, and who can blame them?

Residents can't train by selling services at rock bottom prices. At the higher prices, they are still held to the standard of fully trained attendings. They cannot become fully trained without spending time practicing at a lower level of experience. They cannot get this experience without opening up themselves and the hospital to huge liabilities. Ah well, bring on the malpractice suits.


Anonymous Anonymous said...

Why wouldn't resident surgeons get to wield the scalpel themselves before leaving residency? Are the attendings that possessive of it?

5:15 PM  
Blogger MiamiMed said...

I never said that residents didn't get to cut. I said that they were often given a less than ideal amount of autonomy at different points during training due to the risk of malpractice.

6:21 AM  
Blogger Someonetc said...

the loss of autonomy is not only because of the malpractice issue but because of some of the restrictions of the hospitals and government agencies (HCFA). in the mid 90's it became a requirement by the government that attending physicians be present for at least supervision during cases for what was considered the "key portions of a case". over the years these restrictions have become more and more strict. in some hospitals, the attending surgeon is not allowed to leave the OR suite until the patient is out of the OR. this is one of the reasons a lot of community hospitals has trouble (aside from the financial issues, they couldn't get attendings to come into the hospital for these charity cases.

9:53 PM  
Blogger MiamiMed said...

A prime example of government meddling causing damage. One questions why an attending physician would have to be present when a licensed physician performed an operation (as most upper level residents can be licensed). An FP in rural oklahoma can operate without attending supervision. The whole system is made on gut reactions and feel good policy. The consequences of actions are systematically ignored.

5:10 PM  

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