I agree with Dr. Knight's assertion that the ability to triage and efficiently manage numerous patients in a short time period is an essential skill for modern physicians. He rightly points out that time pressures exist outside of residency programs and are ubiquitous in today's health care system. As I previously wrote, the time constraints on residents have many sources and were increasing even before the new work-hour rules were enforced.

Nevertheless, I worry about how such onerous time pressure will affect physicians right from the starting blocks of their education. As Dr. Knight points out, physicians of his generation had time during training to delve deeply into their patients' problems. This undoubtedly prepared them for later stages of their careers when the health care system forced them to do more with less time. For my generation, there is no such warm-up period. From day 1 of internship, we manage large numbers of patients in a severely restricted amount of time. How will we learn to effectively triage patients with only limited and often cursory observations of disease progression over time? How will we competently manage patients if we have always handed off the difficult decisions to specialists in the name of timeliness? Although we may be learning the important efficiency skills Dr. Knight writes about, I wonder if we have obtained them at the cost of education.

I appreciate the comments of Dr. Zanders and agree that the schedules of attending physicians have been affected by the work-hour rules as well. One way to push back against the time crunch is to have academic medical leaders who emphasize quality care. If we reach a point where attending physicians also find there is no time for learning, we will have lost a critical resource.