Choi et al1 shared an innovation model to pace admissions to internal medicine resident teams in order to streamline workload for residents. Given that a recent study found burnout is prevalent in many residency programs despite duty hour restrictions,2 we applaud this program for implementing innovative strategies to improve its residents' learning and working environment. While the results from the resident surveys seem to support a change to the standard 90-minute window for completion of admissions, this study raises several questions.
Does this system allow for enough engagement for interns and residents to develop progressive expertise? The concept of deliberate practice developed by Ericsson3 has been studied as a means to facilitate progressing from beginner to expert, and could be applied to the resident admission process. It requires goal-directed practice, activities that are challenging, and increasingly refined and detailed feedback to allow for improvement with repeated opportunities to practice skills. The goal of internship is to refine the skills of patient interviewing and physical examination, clinical reasoning, and clinical efficiency, with progressive independence.
While restricting the admission window allows for time to accomplish tasks such as performing a history and physical examination, it would be interesting to see how this affects the growth and overall efficiency of interns and residents. Although the authors of this study proposed potentially decreasing the time allotted for each admission as the year progresses, a standardized time period for each admission may not create a sufficiently challenging environment to foster improvement. It would have been interesting if Choi et al had assessed the intern transition to a senior resident or assessed recently graduated residents. As approximately one-third of internal medicine residents pursue a career in hospitalist medicine,4 the proposed approach may shield residents from the practice they will face after graduation.
How does reducing work compression affect outcomes such as resident work hours and patient safety outcomes? Choi and colleagues surveyed residents' perceptions of their work hours after the intervention, yet were these changes also reflected in their logged hours? Data from participants' work hour logs would be helpful, as would examining potential reductions of adverse events in care or improvement in patient outcomes resulting from this intervention.
Finally, where do medical students fit into this system? An integral part of medical student education is the opportunity to begin to evaluate patients and develop treatment plans. It would be interesting to know whether medical students would have a more cooperative role with interns while admitting patients, or if protected time would be allotted for the medical student interview and examination.
As we continue to look for innovative approaches in resident education, it is important to balance resident wellness and patient care with training residents to have expert-level performance at completion of training.