An Exercise in Frivolity

Why Suffer?

There are two broad categories to keep in mind when selecting and ranking residency programs. One type is at a large academic teaching hospital. The other is at a smaller “community” hospital that may have only a polite affiliation with a university or even none at all.

You can get good training at either type of program but all other things being equal, life will be a lot more pleasant if you opt for a community program.

Take a big institution like Duke where I did my intern year. A good place to train. World class faculty. Impressive facilities. All of that crap that looks good on a brochure. On the other hand it is a relatively miserable place to do an intern year unless you are a robot with no interests outside of medicine. I am repeating intern year in a community program at a small regional hospital. I like it a lot better, mostly for reasons that some of you might find frivolous.

It is hard to believe that although I have no outpatient rotations whatsoever this year and have done three critical care months almost back to back, I have had more weekends off in the last four months than in my entire intern year at Duke.

At Duke, which you may take to represent big academia anywhere, they have the old-school attitude towards the house staff, namely that residents don’t deserve time off and have to earn it by becoming attendings. Thus, they make a big deal about the rare times in your schedule when you have Saturday and Sunday off. In fact, they call this a “Golden Weekend” under the insulting premise that you should be happy and grateful to have been awarded such a special treat.

At my new program, on the other hand, we have weekend call but the residents on most services decide among themselves if everybody needs to come in. We usually don’t need to. This works out to two or three full weekends off per rotation. The difference is that our attendings are usually in private practice, don’t want to come in on the weekend either, and are generally a lot more easy-going than their academic counterparts.

It’s not as if you’re going to be following the ideal model of intern education where you admit, follow, and lovingly discharge a small group of patients with whom you become intimately familiar. If that were the case, maybe it would make sense to come in every day and see how they were getting on.

In a real hospital, however, you will work on service with a steady stream of admits and discharges and it will be impossible to follow all of the patients you admit. You will dive in and out of the torrent following patients somewhat randomly. If this is the case, you may as well round on patients you don’t know over the weekend because you hardly know your own from day to day. (At most residency programs, big or small, residents are just cheap labor. Learn and understand this.)

At a small community hospital, nothing much gets done on the weekends anyways unless it is an emergency.

How about rounding? Academic physicians have the tyrant’s love for an audience. The more academic the institution, the more you will round and the longer the rounds will take, even if this is not the most efficient way to either learn or conduct business. You can learn valuable pearls of wisdom from rounding but a good deal of the time the discussion devolves to merits of competing studies which address the patient’s treatment. Fascinating stuff, no doubt, but I have no dog in the fight. I’ll follow whatever practice guidleline is eventually developed after the adults hammer things out as I am uninterested in the nuances of research.

I’m not saying that you will not round at a community program, just that the odds are your attendings will not have such a zeal for it. Remember, it is a deliberate decision to go into academic medicine. Most people do not. Odds are that if you want to work in academia you like how they do things and will trade a little bit of salary for an entourage and a team of residents to do your scutwork.

Big institutions are also a good deal more bureaucratic. Duke was almost insufferable. They have a form for everything and you can hardly wipe your ass without some kind of certification that you have completed the mandatory yearly ass-wiping seminar. This is all driven by the legal department and is part of risk management. The idea is that if you ever yell racial epithets at a patient the institution is protected from liability because they can demonstrate that you had a certain number of hours of diversity training.

They are out of control. I received almost daily notifications that some compliance requirement or another would expire in a certain number of months. The emails always ended with a sinister threat of being fired or otherwise disciplined for failure to comply.

Intern orientation at Duke took two days and I must have filled out fifty forms acknowledging that I wouldn’t sleep with patients, call them bad names, and had read and understood that surfing for porn on a Duke computer is verboten. It’s all horseshit, of course. They preach at you for an hour, you sign a piece of paper, and then you forget about it. If you’re the kind of guy who hits on patients you’re not going to be deterred by a signed disclaimer.

That’s mostly my point. They make a big deal about things that should be common sense. Everybody knows not to date patients. It happens, of course, but do I need two hours of instruction on it?

They were also mad, absolutely barking-mad, for evaluations. Quality control is great but is it necessary for any instititution to be so self-centered that they’re always asking, “How’m I doing?”

You’re doing fine. Now fuck off.

Asking for evaluations is a way to dilute responsibilty. Bureaucrats hate making decisions, especially decisions for which they will be held accountable. Evaluations and other forms of “decision support” are tools to deflect criticism if something goes wrong. Consensus is a totally gutless form of management employed by the spineless.

I suppose that ever since Press Ganey, the Fifth Horseman of the Apocalypse, issued forth from management hell it is inevitable that we will have to fill out evaluations. Smaller programs seem to have less of this and take them less seriously. Nobody at my current program has ever threatened to fire me if I didn’t turn in evaluations which did happened at Duke.

Pick your program carefully.

The Devil, for those of you wondering how he will come: