Tell It To The Marines

The Good Old Days

As some of you know, I spent a considerable part of my misspent youth in the Marines. I enlisted in 1983. Back then they still had something called “mess duty” which many of you probably know as “KP.” Periodically, non-rated Marines would be pulled from the company to work in the chow hall doing all kinds of menial labor, from swabbing the decks to scrubbing pans in the pot shack. It was hard work requiring a young Marine to get up early (early for Marines, you understand, which is extremely early) and to work sixteen-hour days for an entire month without a day off. The Marines are serious about both the quality of our chow and the cleanliness of our mess halls, all of which requires plenty of labor, much of which was traditionally supplied by the line companies.

Generally, a typical non-rated Marine (Private, Private First Class, or Lance Corporal) could expect once a year to do either a month of mess duty or a month of guard duty (walking a post as a sentry). I hated mess duty. Everybody did. The general consensus was that while the life of a Marine infantryman is a hard one requiring endurance and a stoic disregard for personal comfort and safety that many of you can’t imagine, we hadn’t enlisted to scrub floors. Indeed, the recruiters didn’t breathe a word of this to me although to their credit the Marines have never tried to sell themselves as a jobs program or an easy lifestyle.

Retention is important to a military service and in the early 1980s the Commandant of the Marine Corps asked his subordinate generals to find out why Marines weren’t reenlisting but instead leaving in droves after their first four year hitch. The answer was not surprising but probably counter-intuitive to civilians. Historically the units that spent the most time doing hard, meaningful training or on combat operations had the highest retention rates. Reasons given for not reenlisting on exit interviews included, among other things, the military equivalent of scut work, foremost among this being mess duty which, along with the rest of it, in many units seemed to take up more time than training.
Other reasons included the requirement that young Marines live in the barracks which were even at that time were mostly long open rooms (squad bays) with bunks of the kind many of you have seen in war movies.

The Marine Corps is fairly conservative but is still flexible enough to change direction when required. Marines are famous for pivoting around a bad situation, throwing out the rule book, and adapting the plan to the real situation on the ground. Over the objection of the traditionalists who believed that mess duty was a form of character improvement, something that they had endured and which they believed everyone else should as well, it was abolished as part of a program to improve the quality of life for junior Marines. This included among other things building comfortable modern barracks with rooms to replace the troop barns that had been the previous standard.

You see, America had changed but the Marines had not. The son of an Arkansas sharecropper in the 1950s might look at a squad bay as an improvement and a month in the chow hall as just another struggle in life but the typical recruit of the nineties, while every bit as motivated to kick a little ass was used to a higher standard of living. Mess duty and squad bay living, things of extreme importance to the narrow-minded traditionalists had become obsolete and more importantly, were detrimental to the mission of the Corps, part of which is to retain enough junior Marines to form a cadre of experienced NCOs.

Fortunately, despite the dire predictions, the Marine Corps has survived and still fields the toughest, most disciplined regular infantry on the planet, at least the equal if not better than any previous generation of Leathernecks.

I’m sure many of you can see where I am going with this.

The current system of residency training, like the Marine Corps of the early 1980s, was organized for a different era and a different kind of person. The resident of the 1950s was with few exceptions a young, geeky, unmarried male who’s career was an uninterrupted arc from high school to college to medical school to residency, free from the encumberances of marriage, family, and outside resposibilities that are almost the norm today. Not only that but as medicine was not as highly specialized or even as advanced as it is today a single year of internship was all that was required for a physician to set himself up in private practice. Since medical malpractice suits were almost unheard of and the dangerous interventions that physicians could even attempt were few and mostly the purview of the few specialists, most physicians felt comfortable hanging up their shingles after even this limited training.
As for the few physicians who pursued advanced training in surgical and medical specialties, the residency training system in which they worked, although designed at the turn of that century, was still fairly well-suited to the pace of an American hospital circa 1950. The explosion in medical knowledge and technology which started in the late 1960s was looming but had yet to take place and hospitals were still generally sleepy boarding hotels for the sick in which nature, not the skill of the physician, had a leading role in the patient’s prognosis. They were not the 24-hour-per-day high volume patient processing mills that they are now become nor were the typical patients nearly as sick as most of our patients are today.
A multiply comorbid patient who barely raises an eyebrow in 2007 would have been a miracle in the 1950s as surviving even one of the serious conditions of which modern patients commonly have half a dozen would have been impossible.

Both the science and the logistics of medical care have changed radically since the 1950s but the residency training system has not. On top of the huge increase in basic medical knowledge required of a modern physician has been added a paperwork and compliance burden that would have been unimaginable to physicians from that earlier time. Liabilty concerns, for example, have ensured that nothing happens in the hospital, neither a tree fall nor a sparrow perish, without the event being redundantly documented and explained to the lawyers; the true purpose of most medical records. Necessary, perhaps, but this sort of thing takes time and the one thing that we have not yet managed to accomplish is to add more hours to the day or make people function well on less sleep.

Not only do modern residents operate with this increased logistical burden and increasing complexity of patients but there are a host of new interventions of which a resident is supposed to be familiar, hundreds of new drugs, thousands of adverse drug interactions in polypharmic patients, and the expectation of the public that all their medical problems must be addressed immediately or there will be legal hell to pay. There are simply not enough hours in the day and rather than looking for ways to streamline the system, eliminating resident functions that are incidental to medical training, the slack has been taken up by depriving the residents of sleep on a regular basis and ensuring that they get as few days off as their respective residency programs can manage.

“Call,” for example, once a relatively painless nap in the hospital interrupted infrequently for the occasional admission or floor emergency has become “work,” just an extension of the normal day. They might as well even stop referring to it as call. It’s not “call” at all but a continuous grind performed by exhausted physicians being paid less than the janitors. For my part I work harder on call than I do during the day because there is usually the same if not more work to do with a small fraction of the staff.

The older generation laments the seeming lack of interest of the modern resident in conferences, rounding, and the other traditional niceties that were once the foundation of medical education. But since residency training has become nothing more than a poorly paying job with horrible hours (even the vaunted 80 hour work week is ridiculous if you think about it) and a resident is evaluated by how well he moves the meat around on his service, a tired resident will have a great deal of difficulty listening to a lecture when he has been up for thirty hours and every minute of the noon conference is another minute separating him from sleep. You, my long-suffering readers, who have never been sleep-deprived on a regular basis (and I have been regularly deprived for most of the previous two years) cannot appreciate the biological imperative of sleep. Certainly the drone of an uninspired speaker talking over stale pharmaceutical representative sandwiches cannot overcome it nor can any textbook yet written pry open the eyes of a tired resident who has barely had time to sit down, let alone rest, since the shift workers have come, gone home, and returned for a new day.
In this way has residency training become an obstacle to education. Yet the old guard, the inflexible traditionalists of which there are many, are so afraid of change that the very idea of a resident sleeping every night is viewed as a mortal threat to the practice of medicine and one which will spell the end of the profession. This despite the fact that very few practicing physicians conduct business in a manner even remotely similar to the peculiar way we do it during residency.

There will eventually be a flight of graduating medical students from specialties that subject them to treatment that would be considered war crimes in many countries. Already the smartest medical students gravitate towards the so-called lifestyle specialties or do you really think that they entered medical school with a burning desire to be dermatologists? If physician compensation continues to decrease we will rapidly arrive at the point where rational people decide that the abuse isn’t worth it and it will be surgery programs scraping the bottom of the medical school barrel.

All for fear of a little sleep.

46 thoughts on “Tell It To The Marines

  1. Great post.

    Have any suggestions for what current medical students/residents/even doctors can do? I really, really don’t want to be a dermatologist, but man, the idea of having a life sure does seem tempting.

  2. someone referred me to this article
    which talks about many of the changes that they have seen in the military (specifically the army) in regards to the “new recruit.” i thought it may be of some interest to you.

    i am not in one of the cognitive specialties and therefore my perspective is biased toward the surgical fields. that being said, you bring up some of the major issues in todays world in comparison to when medicine was a little less complicated. one of the problems we have in the surgical specialties is getting residency all of the technical skill sets in the allotted time. this is not an 80 work issue though, it is the fact of not having enough time in the day (working day 7a-6p). my residents would argue then let them operate more. my response usually is then so when will you develop your clinical knowledge. you have to learn what the outcomes of procedure are, proper non-op management, and (probably most important) when not to operate. so there has to be a balance of outpatient and inpatient care, surgical technique, and ER management.

    we are already seeing some of the backlash in my specialty. many younger surgeons refusing to take call. so much so the government was going to some how link medicare payments to taking ER call. we’ll see what the future holds.

  3. What do you do to save your feet during clerkships? I knew that scutwork and surgical cases were hard, but I didn’t know I would develop so many blisters. Even though I wear scrubs and tennis shoes everyday, my feet are taking a harder pounding now than they ever did when I was a cross country runner.

  4. Well said, and an indicator of things I went through in my (Australian) internship and early surgical residency. Not, perhaps, quite as bad as that… but still bad, with a hospital full of sick surgical patients to look after, rounds to do with a demanding boss, and surgical patients backing up in an otherwise unstaffed ER… all on a Saturday morning, and with ten hours left to run. Horrors.

    I defected to pathology.

  5. Residency is a strange beast indeed…..some of us learn to flee the rampent dysfunctionality of many university-affiliated-tertiary care centres….some of us flee to the more humane corners of the place (only in the pathology dept. does there seem to be time enough to take morning tea, and while it is only 5 minutes out of the morning, I’m sure it adds greatly to the quality of the lives of those who work there)….some of us become what we used to hate.

    As a resident I remember being told that I “had to learn to function exhausted”. Really, in this day and age that’s a silly idea. Anyone who has worked a 30, or more, hour stretch and bothered to review their own charts the following day will probably realize that the main thing to be learned is that people should not be working while exhausted. Exhaustion impairs judgment. It starts with little slips, to make things easier, antibiotics instead of an argument, T3’s you wouldn’t usualy perscribe….but it all comes from the fact that people, for the most part, don’t do their best work or learning in an exhausted state.

    Change is needed, unfortunately we may have to pry it from the cold dead hands of those who hold the keys to the system….

    Dr. J.

  6. Part of the problem is that the system isn’t evidence based. How many c-sections does the average ob-gyn need to do as a resident? We don’t know. How do all of these work hours limitations impact training in any important way? We don’t know. Should we consider lengthening residencies in order to make them more humane (ala the 48 hour work limit in Europe)? We don’t know. This system was implemented without any serious educational research, maintained without any research into its implications/outcomes, and changed with very little research.

    Someone needs to do the research on this stuff before it’s too late.

  7. In the early 90s, many of our patients were even sicker than they are now because we didn’t have effective AIDS treatment, and so these patients were dying right and left. Now I rarely see any HIV patient who has any sort of opportunistic infection at all. Back then, they all seemed to have them, and our ICUs were full of septic 25 year olds with Cryptococcal meningitis, Cryptosporidium diarrhea, Kaposi’s sarcoma, PCP, CNS lymphomas, etc, all sicker than hell and circling the drain.

    Better treatments for disease, increased availability of CT/MRI, more efficient laboratories, more aggressive hospital administration/discharge planning/social services and such all make today’s residents have it a bit easier in many respects.

    I think there are two approaches to internship. You can skip the conferences and get stuff done on your patients so you can get home sooner and make the next day easier, or you can mope around and drown under your sea of patients, thus giving you more reason to complain about how unfair life is. My goal was always to get patients off my service and out of the hospital as soon as possible, so I chose the former approach. YMMV.

  8. The point about conferences and lectures really hit home with me. As a medical student on IM I was constantly reminded to “know your patients better than anyone,” yet q2h we were paraded off to listen to some old fossil drone about “pulsus paradoxus.” All the work happened while we were at required lectures meaning a) we didn’t do shit to help the interns and b) we ended up scrambling around trying to find out what the hell was up with our patients.

    Another point, from a surgery attending. Keep in mind that this person was a total bad-ass herself and was the daughter of a surgeon who invented a procedure that all of you have heard of…

    “Those old surgeons who brag about when they were on call they covered 70 patients by themselves are totally full of crap. Back in their day we NEVER operated on sick people. What they had were 10 semi-challenging patients who would be considered a light snack today and 60 35 y/o healthy guys s/p a hernia repair on POD #3.”

  9. i was a military flight surgeon. my pilots had strictly enforced sleep regulations and so do airline pilots. seems that they need the sleep in order to pilot their aircraft so as not to kill themselves or others. lots of good medical evidence to back this up. crazy huh?

    great piece.

  10. Military pilots do have regulations governing how much sleep we have to be allowed, but even those aren’t well thought out. They start out *ok* but the minute there’s a war, they change them to expand their options and then it becomes just stupid.

    We were often required to do 26 hour “flying” days, which includes at least an hour on the front side getting to the plane and an hour or two on the back side getting the plane shut down and the paperwork completed. So we could often complete the last landing of the “day” at 27 hours. That was ok, though, because we had a bunk… it was rare to get more than two hours in it, often interrupted by alarms from the airplane.

  11. granted,
    especially with up-tempo or combat ops in the military the sleep regulations go by the wayside for a bit. i was authorized, in these cases, to prescribe “go pills” or amphetamines. civilian pilots, those who carry our lives in their hands, get sleep. thanks for your service moose.

  12. Wow. This is by far, in my opinion, the best post you have made in the 1.5 years I have been reading your blog. You have a very sound argument, and made some seriously valid points.

  13. It’s not just the old school attendings with this view but also the delusional med students and residents. Sadly these are the individuals who will be running residency programs in the future.

  14. You are very right, Dan. The worst part about all of this is that there are PLENTY of delusional med students and residents who gobble up all that those old school attendings are spewing and thus the cycle does not change. When that happens to one of the people in my class, I feel like I have been stabbed in the back.

  15. Scalpel: No offense, but dude, you did an EM residency. At worst you’re talking one year of hell. People can tolerate Guantanamo for a year. Doing it for 5 years is a whole different ballgame, so take it easy with the “moping” accusations.

  16. Actually, I did an IM residency, but it doesn’t really matter. If you approach your job (or your life) with the “poor me” attitude then suffering is your destiny no matter how easy they make it for you. If you love what you do, then things are much more enjoyable.

    You don’t HAVE to do a residency, you know. You can still get a medical license (at least in my state) after one year of internship. Open up a clinic and hang out your shingle. Pull some shifts in doc-in-the-boxes. Yeah, your options are limited and there are jobs you won’t be able to qualify for, but you are still a licensed physician.

    If you want to be a fully-trained physician, then suck it up and get fully trained. Or not, it’s your choice.

  17. Bottom line: What drives the system is economics not education. We all know that there is a tremendous amount of “low yield” education that happens in residency. How many rule out MI’s do you have to do before you’re proficient? How many hernia repairs? How many central lines? No one knows…

    There’s no doubt that everything teaches and if you’re awake and providing “cinical service” you’re probably learning *SOMETHING* but is that something useful??

  18. scalpel,

    again, i think your points are well taken but i must kindly disagree. one issue we may be running into here is that there are marked differences between residency programs. mine had a reputation for being particularly malignant AND being one of the best. i do not think that ‘best’ and ‘malignant’ have to go together. i do have some colleagues who frankly enjoyed their residencies and they are excellent physicians.

    i wouldn’t do it again and i did, in fact, ‘suck it up’ for four years. i knew in advance, however, that there was no way i could do a surgical residency and i think that cutting into humans on no sleep in 36 hours is criminal.

    in fact, in my particular residency, the residents, if scheduled, covered the ED so the attendings could go to teaching conferences. WTF? the answer was that “we have always been a completely resident-run ED”. big fucking deal. that’s supposed to impress me? on the one hand i don’t know shit, on the other hand go ahead and run the whole department?


  19. I’m playing devil’s advocate as much as anything. I accept that there might be other ways to teach, and I’m not necessarily wedded to the concept of Q 4 night call. I’m done, so I don’t really care either way.

    But come on. When Panda is even complaining about the “stale drug rep sandwiches” I get the feeling that he’s complaining a bit too much.

    (Go back and re-read my post.  I wasn’t complaining about sandwiches, just pointing out that it takes more than a sandwich, standing rib roast, or dancing girls to keep a resident awake in conference who has been up thirty hours…which is kind of the point.  “Education” is impossible when you are sleep deprived.-PB) 

    I wouldn’t have been as gung ho about my training if I had had kids at the time either, or if I were having to pull 36 hour shifts at age 40 instead of my late 20s. So I cut him some slack.

    Still, if any of you didn’t know what residency training was going to entail, then you should have paid better attention. It’s not like they tricked you with mess hall duty or anything.

  20. I’ve probably had hundreds of free drug rep meals over the years, and I can say with all honesty that each and every one of them has been absolutely wonderful.

    (I don’t eat drug rep meals or take their crappy pens.  Nothing against drug reps but we eat for free at our hospital and their pens suck.-PB) 

    When you’re bitching about the quality of your free meals, it suggests a Katrina refugee sort of sense of entitlement that seems foreign coming from the pages of one of my favorite bloggers.

  21. I wonder what the modafinil abuse rates are. Care to prescribe me some? 🙂

  22. At what point then do the hours actually become abusive. Obviously Dr. Scalpel and I disagree on this. I think eighty is too much and he thinks it isn’t enough. How about 100? 120? 140? At what point would he stop admonishing residents to suck it up and stop their whining?

    Surely if left to their own devices most residency programs would work their residents as many hours as they possibly could without actually driving them to a psychotic break. There is, or has been in the past, little incentive for residency programs to treat their residents well. Most people will tough it out and, as residents have their gonads in someone else’s safekeeping, there is not a lot they can do about it.

    Is this something to celebrate?

    “Huzzah! My program can work me 18 hours a day, seven days a week! I’m lovin’ it!”

  23. Stay as long as you need to in order to make sure all of your patients are well-cared for and as long as your team needs you there. Some months will require more hours than others.

    (That’s a platitude.  How long I stay is entirely out of my hands on almost every rotation.  Even if I finish all of my work and have all of my patients arranged and planned to my complete satisfaction I will still have to stay in the hospital until my attending tells me I can go home.  Not to mention the necessity to hang around to admit new patients and not to mention call.  There is no reqard for efficiency at all on most rotations and almost none in the whole residency training system in general.-PB)

    You can’t look at residency as a job. It isn’t. You are still in training. If you want to get a job, you can quit right now and quadruple your current salary with less hours worked.

    (It is a job. That’s the point. It may have been some glorious socratic interlude fifty years ago but it has now become nothing but a source of cheap labor to many hospitals and just another job that needs to be done by somebody.  While this is not universal, residents make and save money hand over fist for their employers. As for quitting now, forces beyond my control dictate that for my cohort, board certification will be a requirement to work in an ED.  That is my other point.  Nothing will ever change because residents are completelely and firmly grasped by the gonads.-PB)

    As long as you are getting good cases, you are getting good education and experience. I don’t think limiting the number of hours is as important as limiting the number of new workups per team per night.

    (The hours need to be limited to keep hospitals from unfairly taking advantage of their cheap labor.  I don’t trust the honor system where money is involved, and since residents in most non-surgical specialties are an economic boon to their hospitals, the tempation is too great to just ask the residents to take one for the team, mom, and apple pie. -PB)

    I only went to the conferences to sign in, grab a free meal, and catch a few minutes sleep as soon as the lights went down. I rarely learned anything from any lecture….I prefer to learn by doing.

  24. “It is a job. That’s the point.”

    Nonsense. It’s training that you are fortunate to get paid for at all. You can get a job right now and make an easy 120K with your medical license. You wouldn’t be working in a Trauma Center, but you could work in various minor care centers and eventually open up your own “Panda Bear’s Urgent Care” and do quite well for yourself.

    You are choosing to take on the responsibility of more training so you can get a BETTER job. And though the training is difficult and the pay less than you would make otherwise, it is still sustenance wages.

    Once you finish your program, there will be limited if any further opportunity for the type of training such as you are receiving right now, in which you are closely supervised by layers of better-trained individuals and insulated somewhat against errors and assisted by other trainees subservient to yourself.

    Make the most of it.

  25. It seems to me that this issue can be broken down into two questions: what do the residents get out of residency, and what do the hospitals get out of the current residency system?

    Residents are there to get trained to become good physicians, and also to get board certified so they can practice their chosen specialty. The consensus on this forum generally seems to be that a resident can work on a sufficient number of patients to be well-trained while working far fewer hours, if the program is structured efficiently. And that residents are physically incapable of learning anything useful while sleep deprived, something that numerous studies have borne out. Not to mention the unethical practice of subjecting patients to the impaired medical judgment of said sleep deprived residents, since numerous studies have also shown that sleep deprivation *always* impairs certain types of judgment, no matter how hard a person has worked to learn to function in such a state. Thus, long hours and sleep deprivation are actually counterproductive to the learning process, and limit a resident’s ability to acquire and retain knowledge.

    So what do residency programs get out of it? They get cheap labor, which increases their profit margins. They are not doing it for the benefit of the residents, and certainly not for the benefit of the patients, who would be better served by highly trained, well rested, and expensive attendings. They’re using their monopoly power to force doctors-in-training to work ridiculous hours simply because they can.

    And as for the argument that “you knew what you were getting into so suck it up,” well, everyone here wanted to become a physician and is willing to make sacrifices for that goal. And I think most people here would happily make reasonable sacrifices if it actually benefited themselves or their patients. But if, for example, residency programs said that to graduate you had to have a red hot poker shoved up your butt before you could graduate, I bet a lot of people here would still do it, but I’d sure as hell complain about it, even if I knew what I was getting into beforehand.

  26. The idea that we should suck everything up because we are told to do so by our betters is completely alien to the American spirit. I hope through my blog to give future residents the conceptual tools to challenge the conventional insanity. Currenly they are too easily shamed into silence by underhanded appeals to their sense of duty. I say underhanded because unlike in the Marines where the officers and NCOs suffer the same hardships as the troops, the “non-rated” physicians are definitely treated like cattle.

    As if a physician can’t be trained in 72 hours a week which, if you think about it, is six 12-hour days a week. Or even 60 which is five very long 12-hour days. All the rest is just the hospital tryng to get as much sugar for their dime as they possibly can.

  27. Moreover, it is impossible to “know” what you’re getting into with residency until you’re in the thick of it. And IT sucks!

    3rd/4th year do not prepare you for what it is like, day in and day out.

    I’ve started telling all pre-meds I meet to go and shadow an intern for at least a week, taking call with them if possible, before they decide to take the plunge into medicine.

    Nice post PB.

  28. when I was an intern I had to get up three hours before I went to bed, walk backwards three miles through the snow, climb the hospital stairs on my hands while making rounds only to have the attendings whip me for every mistake with a cat-o-nine tails and by golly I LIKED IT!

  29. Again, what people are missing in this discussion are the naked economics driving the situation. If the economics changed, then the self-sacrificing platitudes and hand-wringing would evaporate faster than you could ever imagine.

    Moreover, you can not depend upon those with an economic self-interest opposed to your well-being to advocate effectively on behalf of your well-being. That should be obvious. In order to maintian the status quo, the hospital industry and medical education industry keep Housestaff in an ambiguous position: Are they students/trainees, credentialed and privileged members of the medical staff, or hospital employees??

    Well, it depends upon the needs of the situation at hand. Sometimes they are and sometimes they’re not. Moreover, the hospital industry exploits the simple fact that because housestaff are “passing through,” they have very little incentive to try to change their situation, they just “suck it up.” If you’re exhausted and tired all the time, you have very little personal energy left for “fixing the system.” You just want to do your work, go home, and “keep your eye on the prize.”

    I dislike “Big Government” solutions, but the only way things will meaningfully change for Housestaff will be when those who hold the purse strings (Congress) write the changes into the laws that pay hospitals and medical schools for the work they do. Depending upon the simple beneficence of “the system” is a fool’s errand.

    Case in point: In 2005, in the 109th Congress, Senator Corzine (NJ) introduced Senate Bill 1297 “Patient and Physician Safety and Protection Act of 2005.” The House version was HR 1228. This was not a perfect solution, but it would have at least provided for mandatory reporting and oversight provisions that are currently lacking today.

    The hospital industry and their well-paid lobbyists (as well as and several national medical organizations)opposed it vigorously. More importantly, the AAMC (which represents medical schools–specifically, their professors and Deans–also known in some circles as our “mentors”) opposed it:

    Out of perfunctory procedural obligations, the bill was read twice, referred to committee, and promptly died. So, now you know who’s looking after your best interests…it is certainly not your hospital’s lobbyists nor the industrial trade group that represents the interests of medical school professors and Deans.

  30. Just out of curiousity, if you went in the Marines in 1983, how old were you when you started medical school? And no, I’m not calling you old, it’s just that I know practicing MD’s that were 4 or 5 in 1983.

  31. “Nonsense. It’s training that you are fortunate to get paid for at all.”

    So you disagree with Panda’s contention that residents generate a significant amount of income for the hospital?

  32. I don’t disagree with that contention, but I don’t think it’s all that important when considering the residents’ salaries. How much lifetime monetary benefit do residents receive by completing residency training? It’s still a good deal for them.

  33. I’m 37 as well, and although I know I could make it in med school, I fear that I couldn’t make it through residency without punching some deserving authority figure in the face.

    Which is why your prediction resonates with me: I did choose to stay far away from any track that would subject me to the abuses of residency. I’m in PA school.

    Sure, there are some serious limitations to practicing a different sort of astonishingly medicine-like-discipline. And they are so totally worth it.

  34. I did two internships. The first one (Transitional internship)in 1991. Programs CAN be humane if they want to adjust and JUST DO IT! The internship was at a busy county hospital but it WAS WONDERFUL. They set up a night float system for OB/GYN, PED, IM, and they even got the surgery department to buy into it.

    Generally, once a month you did the night float for 6-7 days from approx 6pm-6am or 7pm-7am. (therefore max 84 hrs/week). That week could suck, but you still got 12 hours off a day, and maybe even some downtime in the wee hours. The other 3 weeks of the month you worked like a normal human being never staying past 5pm unless you were on for admissions until the night float came.

    I learned and did a helluva lot and my health didn’t have to suffer. I think almost any type of program could do this, but are just permeated by jack asses.

  35. 911doc, I especially appreciated your comment about dispensing amphetamines to the troops when they can’t sleep. I guess it’s not surprising that some medical students thrive with a 10K/yr. cocaine habit over the course of their training. Kind of makes you want to cringe.

  36. I’m of the era wherein an 80 hour week would have been a walk in the park. I didn’t like it all the time, but I was (perhaps wrongly) of the opinion that it was the only way to get the training required to be a competent surgeon. From that point of view, I’d say the jury is still out on the 80 hour week. My friends in academe are worried.

    I didn’t much like conferences; it wasn’t just about trying to stay awake. It’s that they kept me from the mounds of work piling up on the wards.

    I served in Vietnam. The only time our base was safe was when the Marines or the ROKs were on patrol. Tough and confident, those guys made me relax whenever they were around. One Marine accidently shot himself in the leg; asked if I could patch it up without entering it into his record, and without taking him off duty. I did, of course.

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