“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Sunday, February 18, 2007

Don't quit in February

“Build me a son, O Lord, who will be strong enough to know when he is weak, and brave enough to face himself when he is afraid, one who will be proud and unbending in honest defeat, and humble and gentle in victory.” ~Douglas MacArthur


I trained prior to the 80 hour work week. I remember my first week of orientation. All of the interns went through all of the initial paper work and getting acquainted with the hospital. It was a great week. We met all the previous year interns. Life was good. I was finally out of medical school; I could finally officially call myself doctor. It was all good until the evening prior to our official first day. We went into a room and the previous years interns came into the room with the new chief surgery residents. We had been all well rested and most of us tanned from our month of relaxing and celebrating our graduation from medical school and matching into our residency program. We watched the previous years interns walk to the front of the room. They were all pale from the lack of sun; black circles were under their eyes. They looked tired. They proceeded to go through what needed to be done, what a normal day was like, how not to get into trouble, some basic survival tactics. But, there was only one thing that stuck out in my mind. It was this one statement, "Don't quit in February." That scared me, as well as many of the other baby faced new medical grads, half to death.

It was a tough year. There were months of every other night call. Times were time I took days of in house call in a row to get a full weekend off. It was hard. We could sleep anywhere. My wife still teases me and my friends about it today. She still tells people about the time my friends and I were all sleeping sitting up in a restaurant; or the time I was answering the alarm clock instead of the phone. At the time, I thought it was awful. When I look back at that period in my life, it was one of the best years in my life. My fellow interns are still some of my best friends to this day. Regardless of our specialty, general surgery, neurosurgery, urology, orthopaedics, ENT, and plastics, we all had gone through the same aches and pains, and it made us closer.

In the military, there are values that instilled into each soldier. These are things that are driven into every soldier in basic training and important ultimately for the development of that soldier into a leader. They are put though grueling tasks made to do many things that most of which seems senseless. But, over time, they develop a sense of:
  • Loyalty - a faithful adherence to a person or unit
  • Duty - a moral obligation to accomplish all assigned or implied tasks to the fullest of you ability
  • Respect - treating other with consideration and honor
  • Selfless-service - placing your personal duty before your personal desires
  • Honor - being honest with one's self and being truthful and sincere in all of our actions
  • Integrity - adhering to a code of moral and ethical principles
  • Personal Courage - overcoming fears while doing what is right even if unpopular
And this is what my internship was like, boot camp. In the end, I would and will do anything for my classmate and they would for me.

The 80 hour work week has change the attitude of the "New breed" of resident. It has created shift workers. Once their time is up, they are gone. Lost is the sense of loyalty, duty, and selfless-service. Character traits that are I feel are essential when taking care of patients. Getting the work done no matter what it takes and not leaving it up to others. It is your patient, complete the task. Today's resident is more likely to pass over a case that they admitted to go home rather than stay to see the interesting case. It is not their fault; and I am in favor of the work hour restrictions. It is the implementation with which I have a problem. It has helped change the face of American residency as did the insurance companies rules on number of hospitals days allowed. But, remember the back lash from the woman forced out less than 24 hours after delivering their baby?

Residents need time for study. They need rest. They need a life. They need camaraderie. The question I have now is how do we teach them to complete the care of patients and not hand it off? There is no one that scrubs me out of a case. How can we train to have more stamina for the long days? When you are in practice, if you are up all night, will you cancel you next days cases or clinic? These are questions I think many people have. When the 80 hour/weekers graduate and come to your practice, will they leave work left undone because it's "not their shift?" Or, will they step up and do what is best for the team and group? This will be seen in the coming years. For now, I will keep working on trying to instill the values that were given to me in that year of internship and my army training; and I will hope some of that rubs off on our new physicians.

“The trick is in what one emphasizes. We either make ourselves miserable, or we make ourselves happy. The amount of work is the same." ~Carlos Castaneda

4 comments:

Anonymous said...

I did intern year before the 80hr rules and it was implemented during my 2nd year and was more formally required during my 3rd.

I fell asleep at the wheel and hit a teenage mother and her <1yr old daughter as an intern. It was on an uban street at a light. No damages, injuries, etc. The 3 of us were scared to death. I probably dosed off a few more times before I made it home. It wasn't the first time I slept while driving, wasn't the last. I wasn't about to stay in house those post call nights, ave q3, minimal sleep if any.

I remember hearing my staff complain about the new rules. Most were from the guys who expected at least 2 residents (1 being a chief) at every case, including bread and butter trauma stuff that we were all comfortable with even early in yr 3 just to watch the staff do it and put on a big stink really for no reason better than they had an audience. Others were from the guys who only let the residents retract and dictate. My favorites were from the guys who would always point out everytime they actually came in on call that they didn't get paid more for coming in, only the flat sum for taking call... and punting everything else to the morning people.

I asked myself where the comraderie would be if I was serving time for vehicular manslaughter?

The "old generation" has already answered your question about working the day after a night of call. Listen to the OTA talks about lack of call support in the community or read about the referal patterns to trauma centers at night or on weekends or holidays. If you haven't, contact the OTA, ask about getting a speaker at a grand rounds - its worth listening to. These are not 80hr residents slacking off now that thet are out. Very few are actually out yet. The rules did not effect the senior residents who are now fresh out as much.

I used to be ashamed to be in the "new generation". Then I began job interviewing and saw how most practices are driven... how upset they are if state legislation limits their referals to their own MRI or PT. How surgicenter reimburcement is taking a hit and how the MD's or groups should have bought hospitals instead.

How many of the insurance and government changes are results of abuses of the old system. Its not all because the greedy insurance companies have created so much overhead by developing such elaborate billing systems. How important was the role of the "old generation" protecting their own liability in developing the 80hr work week? Were there even any residents involved in that process? Did everyone really fold because of one complaining Yale derm resident as legend has it? The same could be said of how worthy of scrutiny the physician-vendor relationship now is because of actions and abuses of the past.

Last, I have read about the fall of the Detroit program. I have met guys who have had to leave there. Read about the physicians and hospitals who let their training program be destroyed. Hospitals that wanted more control, a medical school that wanted to (suprise, suprise) own its own surgicenter/clinic in the suburbs and more guaranteed call money in the city. Tell those 40 guys they should have been working 100+hrs a week for those people insead of "only" 80. Ask them about loyalty or any of your other 7 points. The role of the resident is clear: secure CMS money for the system and provide a warm body to staff ER's, clinics, and dictaphones. I take it I don't need to point out how many of the "new generation" was responsibly for those decisions.

Anonymous said...

I did intern year before the 80hr rules and it was implemented during my 2nd year and was more formally required during my 3rd.

I fell asleep at the wheel and hit a teenage mother and her <1yr old daughter as an intern. It was on an uban street at a light. No damages, injuries, etc. The 3 of us were scared to death. I probably dosed off a few more times before I made it home. It wasn't the first time I slept while driving, wasn't the last. I wasn't about to stay in house those post call nights, ave q3, minimal sleep if any.

I remember hearing my staff complain about the new rules. Most were from the guys who expected at least 2 residents (1 being a chief) at every case, including bread and butter trauma stuff that we were all comfortable with even early in yr 3 just to watch the staff do it and put on a big stink really for no reason better than they had an audience. Others were from the guys who only let the residents retract and dictate. My favorites were from the guys who would always point out everytime they actually came in on call that they didn't get paid more for coming in, only the flat sum for taking call... and punting everything else to the morning people.

I asked myself where the comraderie would be if I was serving time for vehicular manslaughter?

The "old generation" has already answered your question about working the day after a night of call. Listen to the OTA talks about lack of call support in the community or read about the referal patterns to trauma centers at night or on weekends or holidays. If you haven't, contact the OTA, ask about getting a speaker at a grand rounds - its worth listening to. These are not 80hr residents slacking off now that thet are out. Very few are actually out yet. The rules did not effect the senior residents who are now fresh out as much.

I used to be ashamed to be in the "new generation". Then I began job interviewing and saw how most practices are driven... how upset they are if state legislation limits their referals to their own MRI or PT. How surgicenter reimburcement is taking a hit and how the MD's or groups should have bought hospitals instead.

How many of the insurance and government changes are results of abuses of the old system. Its not all because the greedy insurance companies have created so much overhead by developing such elaborate billing systems. How important was the role of the "old generation" protecting their own liability in developing the 80hr work week? Were there even any residents involved in that process? Did everyone really fold because of one complaining Yale derm resident as legend has it? The same could be said of how worthy of scrutiny the physician-vendor relationship now is because of actions and abuses of the past.

Last, I have read about the fall of the Detroit program. I have met guys who have had to leave there. Read about the physicians and hospitals who let their training program be destroyed. Hospitals that wanted more control, a medical school that wanted to (suprise, suprise) own its own surgicenter/clinic in the suburbs and more guaranteed call money in the city. Tell those 40 guys they should have been working 100+hrs a week for those people insead of "only" 80. Ask them about loyalty or any of your other 7 points. The role of the resident is clear: secure CMS money for the system and provide a warm body to staff ER's, clinics, and dictaphones. I take it I don't need to point out how many of the "new generation" was responsibly for those decisions.

Someone interested medical student and resident education. said...

thank you for your comment, I appreciate all your points. As I said in the body of the text, I am in favor of the work hour restrictions, it is some of it's implementations I have problems with it. We are at a the busiest trauma center in St. Louis and also cover the other, we have several of the OTA speakers hear, so I am acutely aware of the things you have brought up. I also am aware of the Detroit situation from the residents we have from that failing program as well as my partners who were a part of that system at one time.

I am not in dispute of work hour restrictions, I have a problem with a mentality that developes when some restrictions provide shelter, unions and goverment workers for example. I make this statment to put the seed out in the young physicians head. Kinda like preventative care.

Thanks

Anonymous said...

So sorry. After 24 years in the service and one year of internship I can tell you there are no such values as duty honor courage commitment lloyality or selflessness in medicine - never met a more self interested self important no nothing bunch of men and women in my life .
And talk about poor leadership skills - it's like an instructional manual on what not to do - what a crock!