IOM Report from Dec 2008

The Institute of Medicine (IOM) recently published a report on residency duty hours regulations. Basically, the report states that residents are still fatigued and that action is needed to guard patient safety. This report is a very serious document, and a response from ACGME was immediate. The next Annual Educational Conference of ACGME will take place in March, and it is expected that a lot of discussions and decisions on this matter will dominate the conference.

Here are a few comments on this new report (and on the survey that ACGME asked all residents to take):

1. Currently, there are no work-hour regulations that apply to attending physicians, who can therefore work an unlimited amount of time. An that choice is not always theirs to make; it can be imposed to them by their Division Chief or Chairman, just like my work hours can sometimes be imposed by my chief resident. Does this mean that current residents grow and develop their work mentality into a fake bubble of work-hour protection that has no application to real life? If I will have to work 100 hours as an attending, then learning to be a physician with a limit of 80 hours per week, is probably bad training. Is the public going to realize that attendings can also be over-worked and fatigued and demand work-hour limitations for them as well?

2. All the literature so far (see review in JACS, Nov 2008) demonstrates that the 80-hour work week regulations have decreased fatigue (at least chronic fatigue). However, there is no concensus on the effect of the regulations on the quality of training. The IOM 08 recoomendations seem that they will further decrease fatigue (maybe even have an effect of acute fatigue). However, only a few of the recommendations ("limit non learning time" etc) are designed to enhance education. If we keep cutting down the hours, without paying extreme attention to the methods of training and making changes to that domain as well, we risk "cutting down on education".

3. If the new IOM recommendations are approved and applied, there will be many duty-calls that will be uncovered by residents. This would mean that more residents need to be hired or more physician extenders need to be hired. The first solution costs money and also raises the concern that education opportunities will be divided to more people (this is mostly true for surgical residents, as the same number of total cases will be divided to more residents). The second solution is at least 4 times more expensive than the first solution. So, to the minimum these recommendations are very very expensive. Who will be asked to pay for this? Most hospitals (especially in today's economy) will refuse to put money into this; they will likely shut down their programs; and this is not limited to "small community hospitals". And I am sure that DoD and Medicare will be very excited to pour money into residencies. Money makes our world go round, so I think this will be the reason why the recommendations cannot be applied.

To conclude, I think that the ACGME will eventually adopt many of the new IOM recommendations, because the public wants at all cost to protect the patient safety. To the minimum, the new regulations will involve more strict and frequent monitoring of residency programs, less flexibility with violations and higher penalties for violating programs. The extend to which the recommendations will be adopted will be determined by the funding agencies. I do believe that these changes will improve residents' fatigue. On the other hand, I am very skeptical about the effect on training. I believe that in our era of expanding technology, endless paperwork in the hospitals and the transformation of patients into clients-customers, the way residents are being trained seems archaic. Changes are imminent and, I believe, necessary.

Match and the Surfing

Match day is coming up for this year. I still recall how during my interviews I met residents who made their rank lists based on how great the surfing is in the area. Come on people. You have to be at least smart enough to realize that your rank list (even though for competitive programs, you are not the one who decides) will affect your future for the rest of your life. So surfing or weather are just too unimportant to have any role in your decision making.

How to find a Research Position in the US

I got asked this question in a forum, so I figured I should post this on my page as well. If you are into Surgery, then look at the Department of your interest.
Past publications are not that important (they are not bad either!). You need to find people who are faculty in Surgery at some uni that you are interested in, and that are ACTIVELY involved with research. So,
1. You find out what university you would like (think broadly, not just the what-you-think-is big names)
2. Go to the Department of Surgery website and find out if they have any research going on (90% there is a link 'Research')
3. Find out who are the Surgeons doing research
4. Go to pubmed, and search for their names
5. If their past paper was 2 years ago, dont bother and look for somebody else
6. When you find somebody who is actually doing research, email them, letting them know who you are, what you are doing now and what you want to do. This is called a letter of intent (you show your intentions). Attach your CV. Let them know that you WANT to do research (besides that you need it for residency) and that their research topic is interesting to you (eg sepsis).

NOTES:
A. USMLEs are NOT necessary, since you will have no patient contact. However, it is a lot better if you are done with USMLEs, since this way you show you are a serious person and not just looking around, and when you will be doing research, you will not need to study for something tedious as Biochem.

B. Any communication with people you find on the net that can be crucial. So make sure you have no typos, and your grammar is perfect. Your future may depend on this, so make sure your email and CV are PERFECT. Keep reading them on your own before you send them to make sure it doesn't get better. Have somebody who speaks English better than you read it (don't ask too many people though).

C. Mention in your letter that you are looking for a volunteer job (aka no money). Let me remind you that you are not looking for a job (if that is what you are interested in, dont do research), but a way to increase your competitive-ness for residency or applying for a fellowship or professorship in the future. If they are looking for somebody to do research, then most likely you don't have the experience to be as good as a lab tech with years of experience. So if I had a salary to give out, guess whom I would give it to? Having 5-7 publications or even more, is priceless, and look at it as a great investment. If you think you cannot afford it, try to afford it. If you still cannot, don't do research. Look for a preliminary spot (in case you ultimately want to do residency). However the prelim spot will have NO OTHER value. Publications put your name out there; make your existence known to the world. Once you get your foot in the system, and you show you are productive, you can ask for money. If they like you, they will find a way to pay you. However, if you go to do resaerch at a very small place, where there is no funding, it will be more difficult (if a center has basic science/bench/animal research, they have funding somehow, so it is a good sign).

D. For an H1 visa you will need a salary when you sign a contract. That makes your chances very bad. Why would anybody want to hire you when they don't really know you and you are a salary and difficult visa (it is difficult for some assistance to file for H1 compared to J1, MUCH more difficult)? I personally would not - never. Know that there are many others that will do this for free and just a J1. Ask your self if you really need a H1? Don't blindly believe rumors that a J1 research has a 2-year requirement. Two friends of mine had no requirement with a J1 visa. Your country might be different than mine - Greeece, so look into it carefully. Asking for an H1 is not good for you.

E. Expect to send A LOT of emails. Most will never respond. Some may. Don't email more than twice to the same people. If you email to more than 1 in the same place, don't copy/paste the same email for god's sake. Consider, taking a trip to the US (everybody has friends or relatives here) and then travel in the US to go to universities/hospitals that interest you, and make an appointment with some of the Faculty who does research. Show your face, be pleasant and hope for the best.

~ Good luck