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.