Systems Give Us What They Are Designed To Give: Work Hour Restriction Outcomes

A colleague of mine (DB) has a great blog ( He posted ( an excellent observation that ABIM pass rates are declining since the work hour restrictions have gone into place. I commented back that why would we expect any different because systems give us exactly what they are supposed to give us. In this case less knowledgeable residents.

The proof is in the scores. Why? My theory is that they waste their off time with being off and not studying. When I was a resident in the mid 90s we had no restrictions, no admission caps and only 1 guaranteed day off a month. We stayed at the hospital until late afternoon at least if not early evening routinely. We studied alot during the day in our down time. The satellite library at the hospital was full of us studying (and yes BSing). I saw alot more patients and did alot more to them than this current generation. Interestingly I dont recall mass killings and mayhem at my training hospitals. But for some reason we have accepted a system (work hour restrictions and admission caps) without testing it ahead of time. No drug gets to market this way but for some reason its ok to let doctors get to market this way.

Doctors are on the clock

Being a doctor is complex. Clinical reasoning relies on matching the patient’s story to an illness script. You build illness scripts from studying books (print or electronic…doesnt matter) and by patient interactions. You have to see lots of patients to enhance and mature your illness scripts. Therein lies the problem…..less studying and less patients. Wow…how did we ever get these lower passing rates. Its hard to understand (sarcasm detected). Oh well it doesnt matter. I am sure the wonderfully designed quality measures will make it all better.