“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

Tuesday, February 6, 2007

The residents and medical students now adays are soft .....

5am this morning .... I am out running ... 8 mile run ... training ... marathon training ... it's been cold outside ... today, cold and a fresh coat of snow ... the numbers of runners are far fewer ... several people walking dogs ... very few footprints in the snow .... I run past a older man (grey mustache and hair) ... I've seen him before ... We are the dedicated few ... continuing our training regardless of the weather ... like the postal service .... rain or shine, we will be there .... we smile at each other with a kind of understanding not understood by those still in bed ....

I look at the young doctors coming into medicine now a days and their perception of what is expected of them and what they are willing to do is less. Will they run in a storm. Will they stay until all the work is done or will they say, " my shift is done" and leave.

Times are changing, but the patients are not. The amount of work that is needed to be done does not. Residency programs are now dealing with how do we adapt to the 80hr work week. It has become difficult for most programs to accommodate the restrictions. A number of things within residencies have changed to adapt to the changing hour restrictions. As programs become more accustom to working within the restrictions, so do the young physicians. They become more likely to schedule those hair appointments during the day (4:30pm or so) etc. The medical students leave without even checking out. I say strange. This is a definite change from when I was a medical student or resident. The expectation is different.

You may say, "Well, it is a different time and place. We don't need to do every other night call or stay in the hospital 2 days straight to be a good physician." And I would say, "You are exactly right." I do not think that you should spend countless hours in the hospital doing nothing. I would agree that more time spent reading and not doing busy work is probably better in the long haul. Andrew Palmer, MD, former president of the American society for Surgery of the Hand, made an opening address several years ago making a plea to many young physicians to find other interests outside of medicine. He felt that after many years dedicating his life to medicine, researching, operating, and teaching, he learned that there is a need to develop other interests. A need to develop yourself without medicine. So, I do feel that this is an important.

The problem we have now is the same problem that you get with unions. Yes, being formed is protective, but a certain mentality develops. The mentality developing now is that of a sense of entitlement. A sense that menial work is beneath them and that they should only do meaningful things. They don't need to prove themselves before we let them make decisions or make incisions.

Some may read this and say, "he is full of it. I am not like that." Well, not now, but there is a changing mentality. We had a visiting lecturer from the UK who gave us a lecture of the system in Britain. He was describing their work hour restrictions and how they have adapted. They are now down to, I think, 48 hrs a week. He says now they have more residents, to cover the time; the number of "hand off" errors have increased; and the operative case number is dropping. He reported to us when the restrictions began, the residents there said, "we will stay, regardless of the restrictions." Now, when time is up they just leave, regardless if they are in the middle of a case or in clinic, time is up and they are gone.

This mentality will creep slowly into the mentality of most as it has done in the auto industry. I fear the development of shift workers. I say that the medical students and residents are weak to incite anger in you. I want you to prove me wrong. Prove to me, yourself, that you have the fortitude to weather the storm, the cold, and the snow. Maybe one day when I am old and grey I will see you and we will smile together with an unspoken understanding.


Anonymous said...

i was told the 48 hour rule in europe was enforced with very steep penalties for both residents and the programs. if i was going to be fined a 1000$ for being there an extra hour, of course id leave in the middle of a case.

why should we have to prove ourselves with doing busywork when in the end practicing orthopods work 6-5 jobs with call once a week? ive already spent most of my twenties with a book in front of my face; i think most of us have already proven ourselves and ability to do seemingly pointless tasks (like memorize the krebs cycle). and lets not forget, when residents are overworked, patients die.

Someonect said...

In reply to this comment, there are a few of things I most point out to Anonymous.
1. Depending on practice, location, and specialty, your hours very. I would say for most orthopaedic surgeons it is not a 6am-5pm job. What you have not been privileged to see is the behind the scenes work that is also done. Although the clinic and OR may be done, the paperwork is not. Calling patients back, discussing the bills, following up patient information, remember not all orthopaedic surgeons have residents or nurses.
2. In Europe, everyone is on the same restriction. That includes the attending surgeons. And yes they do get fined, as we do here in the US.
3. You mentioned when residents are overworked, patients die. Well, actually it is when people have inadequate time to rest errors are made. And this is true, and I am fully aware of this and agree that things need to be done to prevent it. That being said, we have exchange the fatigue related errors for "hand off" errors. The more times there is a change in the caregiver (physician team), the more likely something will be missed or forgotten. This was countered in the UK by having the attending surgeon being on for a 24 hr shift to span all of the changes in the resident physicians.
4. As far as proving yourself, this is a continued process. Just because you have done work and studied in medical school, does not mean you have proven yourself; it means that you have done the work necessary to complete medical school. Krebs cycle, I can't remember what that was all about, I guess I should read up on it again, something about ATP. In residency, you WILL have to prove yourself again. You will have to prove that you are smart, prepared, trustworthy, and teachable. Depending on were you are trained, they may require different things of you. At the beginning you may be asked to do things like patient care, seeing patients in clinic, and in the ER, and maybe these at the time may seem pointless. Eventually, the collection of experiences will help you in developing a basis for how you will treat patients.

So, the point of me calling out medical students and residents is to say in the end it is not only about you. Remember in residency you are not training to be a resident, you are training to be a orthopaedic surgeon. Treat the patient as if he/she is your own. Have pride in your work. What I really want to prevent is a mentality that will follow you into practice. You know what the coach probably told you "If you don't do it in practice, you won't do it in the game. Please don't give half ass care because you have to leave. Make sure your patient is taken care of and in good hands, then leave.

Anonymous said...

You probably need to accept the fact that times are changing. The sacrifices you made when you trained were made in the knowledge that when you became an attending you would have certain perks - high pay, not having lawsuits hanging over your head, not battling insurance companies to the death constantly. As a result, you were willing to make certain sacrifices.

Our generation knows that we're not getting your deal and we're not even going to get the current situation. In 20 years we'll have socialized health care, shifts and salaries of 100k. In Germany all doctors work 32 hours a week and make 65k. Do I want to be the best physician I can? Yes. Does this involve sacrificing my entire life in training? No. Like the old saw about "How do you ask a man to be the last one to die in a war" goes, "how do you ask a resident to be the last sacrifice for a dying system".

Someonect said...

i love these questions ... the generational issue i do address in a future blog ... sacrifice, i don't ask any of my residents to sacrifice ... i ask them to care about the quality of their work and the care of their patients ... the care of patients is a team effort ... and when you get into practice you will have to care for patients more than you do as a resident ... you will end up dealing with social issues ... if you are callous, you probably won't care ...

Anonymous said...

How can anyone possibly be the best physician they can be without sacrificing some aspect of their life?

No athlete who strives to be the best in the world will succeed if he doesn't sacrifice his life during training.

Anonymous said...

Another perspective on this discussion: Someone, I don't know how old you are, or when you went through medical school or residency -- but the fact that you're an attending allows me to make some rough assumptions.

To put it bluntly, times have changed, dramatically. And in a different sense that you allude to above. What older attendings fail to realize (older residents too, in fact!) is that we are far, far more efficient these days than we were as recently as 5 years ago. Technology -- while slow to be fully implemented in healthcare, as compared to other industries -- allows us to complete the 'meaningless' tasks a lot faster than we would have otherwise. The point is, many people of my generation operate under the following assumption: we have learned to make use of available technology to make ourselves more efficient --> we get done with our work faster --> we feel 'entitled' to the 'free' time this provides.

In a sense, I'm echoing some old economics equations I can barely recall from macro/micro. Technology has improved, and with it productivity -- and yet the expectation is that we should stay in the hospital for the same amount of time as 'old-timers' (my apologies) used to. Forgive me for being blunt -- but this is nonsense! We get done with things faster (not incidentally, with a greater energy expenditure (per unit time, if you will) -- the famed 'multi-tasking' of Gen Y is not 'free'), and we expect to be able to reap the benefits of being more efficient.

The overwhelming impression I got from residents, and fellows, was that it was time put in -- regardless of productivity -- that was valued. This meant that we spent time chafing at inefficiency as our seniors meandered through their tasks, doing in 4 hours what we could probably have done in 1.

When challenged with this very point, the responses were oh-so-nebulous. The extra time we spent (painfully prolonging processes) were indicators of our passion, and commitment to medicine, to our fellow residents, to the patients. This was patently ridiculous. But to bring it up was taboo. I would much rather have spent time with my patients, or reading up about cases, than prolonging something simply to give the indication that I was 'truly committed'.Don't get me wrong -- under no circumstances would I, in the middle of caring for my patient, check my watch and say -- "oops, time's up! A bit of hard cheese, old chap" -- and leave. I -- and, I think, most of my generational colleagues -- would always choose to stay and make sure our patients were taken care of and well accounted for. This is THE trump card. But staying, when there is no patient benefit, and when the work could have been accomplished faster -- I see no justification.

So, in summary -- yes, I believe there is a fundamental disconnect in the way our two generations of physicians believe we should spend our time. I think the 80 hour work week is a good idea -- reflecting the reality of the fact that we get a hell of a lot more done, in less time. I think older residents and attendings are pissed about the perceived 'softness' of the new generation simply because they don't recognize we get stuff done faster. I think that staying in the hospital for 37 hours straight because it's good to show your commitment is idiotic. And I believe that abandoning my patient, regardless of time constraints etc, is the worst possible thing we can do. These aren't mutually exclusive beliefs.

Someonect said...

Anonymous, thanks for the comment. if you keep reading some of my other blog listings, i actually address the generational differences including the differences in out looks on time, mentoring, and working. i also address the gen Y (mellinials) in how do we train the next generation part II.

as far as doing things faster, this is true only to an extent. in surgical specialties, the surgical time has not changes and the time to develop the surgical dexterity has stayed the same or increased (this has to do with volume). technology has improved surgery and also required more skill sets to learn. because surgery is a craft, it must be practiced.

so has i said, this is not about the time (80 hours). a significant disconnect is to believe that patient care can be learned from a book, computer, or patient simulation. this is a false hood. you must see patients to learn this. as much as people talk about this in medicine, the generation y has been discussed at length in business, law, and education. you bring up a topic that i am intimately familiar with.