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Residency training and social justice

It is axiomatic in medical education that an individual is not a mature physician until having learned to assume full responsibility for the care of patients. Thus, the defining educational principle of residency training is that house officers should assume the responsibility for the management of patients. To acquire this capacity, interns and residents evaluate patients themselves, make their own decisions about diagnosis and therapy, and perform their own procedures and treatments. House officers assume responsibility in a graded fashion: the more senior the resident, the more responsibility allowed. For safety and learning purposes, residents are supervised by and accountable to their attending physicians.

The result is a system of training in which house officers receive major responsibilities for the care of patients. They typically are the first to evaluate the patient on admission, speak with the patients on rounds, make all the decisions, write the orders and progress notes, perform the procedures, and are the first to be called should a problem arise with one of their patients. The distinctive feature of the system is that residents are given full responsibility for the diagnosis and treatment of seriously ill patients. Such responsibility allows house officers not only to develop independence but also to acquire ownership of their patients-the sense that the patients are theirs, that they are the ones responsible for their patients’ medical outcomes and well-being. Medical educators have long recognized that the assumption of responsibility is the factor that transforms physicians-in-training into capable practitioners.

The ethical challenge of residency training is to find a way to balance the educational needs of residents, who require increasing independence, with the safety needs of patients, who benefit when being cared for by the most experienced physicians and surgeons available. The learner will benefit, as will patients of the future, when the least experienced resident is permitted to perform the appendectomy or cholecystectomy. The needs of the patient at hand are best served when the most experienced surgeon available performs the operation. This tension has always afflicted the residency system, but during the past few decades it has become particularly intense, as hospitalized patients have become much sicker and medical practice ever more powerful but dangerous. Mistakes of omission and commission potentially carry greater consequences today than before.

Operation by frank23. CC0 via Pixabay.
Operation by frank23. CC0 via Pixabay.

The assumption of responsibility has thrived as the dominant principle of residency training because graduate medical education in the United States developed within a system of charity care. It is this historical fact that has allowed the residency system to provide interns and residents the opportunity to assume major responsibilities in patient care. The United States, like the rest of the industrialized world, has always used indigent patients as “clinical material.” These patients, in keeping with a long-standing Western tradition, receive free care in exchange for their participation in clinical education and research. In contrast, paying patients are used in much more limited ways in medical education. Professional responsibility for their care belongs to their personal physicians, and this responsibility is only sparingly delegated. Only the medically indigent patients on the “teaching service” afford house officers the full opportunity to develop management plans, make important therapeutic decisions, and perform surgery and other procedures.

The residency system-and, specifically, the principle of graded responsibility-clearly serves the national interest. There is no avoiding the moment when a doctor operates or assumes the management of complex patients for the first time without the direct supervision of a more experienced physician. From this perspective, the only question before medical education and the public is the circumstances in which this would happen. There has always been unanimity on this matter. The profession and public have both believed that it is far better for this moment to occur as part of the graded responsibility of residency, where help can be immediately summoned, rather than to wait until physicians are in practice, where help might not be immediately available and where mistakes from inexperience on their unsuspecting patients would pass undetected. Medical educators have always pointed out the importance of appropriate supervision and the immediate availability of help to residency training, as well as the high quality of care provided by the resident staff.

Nevertheless, most resident learning continues to take place with less advantaged patients. Though the number of insured patients has risen as private insurance, Medicare, Medicaid, and most recently, the Affordable Care Act have taken effect, the number of uninsured and medically indigent patients remains large, and it is with such patients that medical and surgical residents continue to derive their major educational experiences. Most medical teaching and learning continues to occur on the vulnerable¬≠ those with lower incomes and less social status. This is in marked contrast to a true one-class system of care, where all patients would be used equally in teaching. In such a system, the surgical resident might operate on the bank president, while the patient on Medicaid would have the same opportunity as a wealthy individual to have his operation performed by the hospital’s most senior surgeon.

In short, neither medical educators nor the public have figured out a way to involve private patients more fully in residency training. Some educational leaders have tried, arguing the quality of care provided by residents at major teaching hospitals is as good as or better than that provided by private physicians. However, most private physicians like maintaining control of their own patients, most well­ to-do patients do not wish residents to replace their private doctors, and there is little national will at the moment to change the system. A modified two-class system of care continues. Part of the challenge of achieving greater social justice in America in the future will be to determined procedures for using all classes of patients equally in medical education.

Heading image: Doctor care by DarkoStojanovic. CC0 via Pixabay.

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