Posts Tagged ‘Internship’

If Dr. Ezekiel Emanuel gets his wish, tomorrow’s physicians won’t deserve to be paid as well as physicians today because they won’t be as well trained.

Dr. Emanuel, a brother of Chicago Mayor Rahm Emanuel and a chief apologist for the Affordable Care Act, is the lead author of a startling opinion column in the March 21 Journal of the American Medical Association.  He argues that there is “substantial waste” in the current medical education system, and—in a time when medicine gets more complex every day—advocates cutting the training period for young physicians by no less than 30 percent.

Dr. Emanuel’s plan would reduce both the time spent in medical school and in residency training, which (as every physician knows from experience) is the period of three to seven years that a new graduate physician spends learning to practice a specialty.

Many people don’t realize that residents already receive less training than they used to, because stringent limits have been set on the amount they are permitted to work.  Since the duty hour rules were rewritten in 2003, residents are limited to 80 hours a week in the hospital, which includes overnights on call when they may be asleep (what the rules refer to as “strategic napping”).  First-year residents, or interns, as of 2011 aren’t allowed to work more than 16 hours at a stretch.

Many senior physicians are concerned that today’s residents aren’t seeing enough patients. Evidence suggests that board examination scores are on the decline in fields from neurosurgery to pediatrics, as reported in the Accreditation Council for Graduate Medical Education (ACGME) Bulletin in 2009.  The American Board of Internal Medicine reports that the passing rate for first-time exam takers slipped from 94 percent in 2007 to 87 percent in 2010.  Unfortunately there’s no evidence that residents are using their increased off-duty hours to pursue either knowledge or sleep.  There’s no proof that patient care has improved, or that medical errors are fewer.

Now Dr. Emanuel thinks that even this amount of training is too much.

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Overheard in the OR—a surgery chief resident ruefully explaining to a senior surgeon why no intern or junior resident was available to scrub in on his case. “Everyone in our department is either pregnant or on maternity or paternity leave,” he said.

The senior surgeon just shook his head.

From my vantage point as the anesthesiologist on the other side of the drapes, I thought to myself, “Really? What would give anyone the idea that residency is a good time to have a baby?” When I look back to what it was like to deal with pregnancy, give birth, and look after an infant, all I can say is that internship was easier. After all, as an intern—even in the bad old days—I had some nights off.

Yet having a baby during residency is increasingly common among male and female residents alike. For women especially, it sounds perfectly awful. We’ve all heard the stories—pregnant residents struggling with nausea and fatigue during long nights on call, or vomiting into a trash bag in the operating room; new mothers trying to breast-pump in the hospital locker room during a half-hour lunch break.

One possible response is to argue that senior physicians should be more sympathetic to pregnant and nursing residents, and give them longer lunch breaks. This would be in keeping with the kinder, gentler world of limited resident duty hours and mandated nap times.

But it’s equally fair to consider that residency might be a suboptimal time to have a baby.

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There’s been a great divide between the medical and surgical specialties ever since I can remember.   Surgeons believe internists perseverate too much when decisions need to be made.  Internists consider themselves the true intellectuals of medicine.  I suppose anesthesiologists like me fall somewhere in the middle–we work in surgery, but have to take care of all the medical problems the patient brings to the OR table.  Does that make us the last true generalists?

Recently I brought my patient from the OR back to the medical ICU and gave report to the nurse; made sure that the vent settings were appropriate and that the arterial line waveform was crisp.  When the patient was stable and settled in, I headed over to the ICU desk to finish the paperwork.  The case had been a video-assisted lung decortication and evacuation of empyema, a two-hour procedure involving one-lung ventilation and considerable blood loss, in an elderly patient with a host of underlying medical problems.  Sitting next to me at the ICU desk was a young medicine resident.  He turned to me and asked, “What was the indication for putting in an art line?”

For a second, I thought he was kidding, so I didn’t immediately reply.  “No, really,” he said.  “Was there an event or what?”

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