Shifting Awareness in Quality Care

An opinion piece on the cover of the November 2010 issue of the Psychiatric Times¹ had many in my residency class talking. In response to more restrictive regulations of resident work hours issued by the ACGME,² Dr Sidney Weissman penned “Are We Training Residents to be Shift Workers?”¹ 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.

References1. Weissman S. Are we training physicians to be shift workers? Psychiatr Times. 2010:27(11):1.
2. ACGME Common Program Requirements (page 17). http://acgme-2010standards.org/pdf/Common_Program_Requirements_07012011.pdf. Accessed November 23, 2011.