More Rambling Conversation With a Lumbering Asian Bear-Mammal

Is there anything you like about residency?

Well, it has it’s moments. I’m the the ICU senior resident this month which is kind of cool, especially because this is one of those rotations where you get paged to make real decisions and not, as is often the case as an intern in the ICU, to be guided to the right decision by the experienced ICU nurses. Not to say that this doesn’t happen but I do know a little bit more than I did two years ago (thanks in part to ICU and ED nurses) so even though the call is just as tiring as any call it’s not that bad. We still work for peanuts but I certainly don’t go home in the morning feeling like I was nothing but somebody’s cheap, place-holding labor. And we have a great set of attendings who give us a lot of latitude to make decisions.

It also affords the opportunity to do a lot of procedures and I haven’t done enough lumbar punctures, for example, to get tired of doing them.

Generally, however, with the exception of working in the ICU and the Emergency Department I have not liked residency all that much. I don’t think anybody does but the culture of medical training makes it very difficult for people to admit that they dislike any if not most of it. People complain about being tired of course but nobody wants to appear weak. As I am confident in my masculinity and so totally not into any of that macho bullshit I can, with confidence, state that I hate being deprived of sleep, treated poorly by people hiding behind their credentials, and working for taco jockey wages. If that disturbs anyone or if you feel that makes me a traitor to the Cult of Aesclepius, well, that’s your lookout. Deal with it. The fact that people have put up with this kind of thing for so long is the real tragedy. But that’s what you got when medical schools were full of people with no other life experience but the slow slog to becoming an attending. Things are different now. Medical training is no longer a monastic experience reserved for young, single, white men. Many of us have families and are not willing to sacrifice them to make the traditionalists feel good about themselves. This explains the popularity of the so-called lifestyle specialties with medical students and the relative unpopularity of specialties that guarantee brutal hours and divorce.

The key point here is that you cannot put your life on hold and say, “I will take my son fishing when I am done with residency.” Those four, five, or six years are precious and once lost are never to be recovered. And that is why, oh you who long for the good old days when residents kept their mouths shut and were prisoners in the hospital, I resent call and pointlessly long hours. It’s like theft. The two extra hours you keep me every evening which contribute almost nothing to my training, taken as a whole, are a large portion of the time I could spend with my family. If you can’t understand this or think that a regard for family disqualifies me for the medical profession, well, you can keep the motherfucker…and lament mightily the flight of otherwise decent, intelligent people from your malignant residency programs.

Now, realistically, as a third-year resident I have it pretty good. I work shifts and while I am worn out when I come home, I get plenty of time off to rest and recover. And while this may not be universal, at my program our attendings work hard to teach us and only ask that we bring our so-called A-game when we are in the department and charge hard for the entire shift. It takes some getting used to but that’s why I like Emergency Medicine. We work towards a goal, we work harder than anybody in the hospital, but I can tell my wife when she can reasonably expect me to be home. Most residency programs could be structured like that if education were the primary goal which is sadly not always the case.

How is Residency Different than the Marines

I compare the two often but mostly facetiously. They are not really similar. Being a Marine Infantryman is several orders of magnitude more difficult than being a resident. Memory being what it is I tend to forget how hard it was to hump (march) twenty miles with a ninety pound combat load or what it was like to be cold to the marrow with no expectation of going indoors in the near future. Residency has never once brought me even close to the limits of my mental and physical endurance, even taking into account that I am twenty years older now and, to be charitable, no longer the fine physical specimen that I used to. I complain about residency but it’s generally because I am annoyed by a lot of it. Some of the things we did in the Marines were so difficult that they were almost beyond rational complaint. So bad that all we could do was grimace and say, “Ain’t it great to be Marine?”
Marines do whine and bitch about things of course, but mostly about the petty indignities and bad luck that follow the infantry like a plague. When things get really bad we just suck it up. I remember a training operation where my unit came ashore after a twenty mile ride through heavy seas on our unit’s twin-engine boats (my unit was the designated small boat raiding company for the Battalion Landing Team). These boats were modified Boston Whalers and had enough power to jump from wave top to wave top. After a harrowing launch from the well deck of our ship we spent the next hour getting beaten to pieces as we thrashed through the moonless night towards Sardinia. Not only was it bitterly cold (although it didn’t seem that cold while we staged on the flight deck) but the spray soaked everything and I had the wind knocked out of me every twenty seconds or so. Clinging grimly to the rails we finally got under the lee of Capo Teulada and, after a brief run through smooth water, beached the boats and literally crawled ashore as hardly anybody could stand.

An hour into the operation with five days to go most of us had already taken a beating the likes of which many of you cannot imagine. But we unstrapped the guns (I was the Mortar Section Leader at that time), shouldered our packs and moved out for our objective several miles inland. What else could we do?

So my point is that physically and mentally, being a Marine Infantryman is a good deal harder than being a resident. We may complain about being tired but I have never actually gone more than 36 hours without sleep as a resident and at the end of it I knew I could get some sleep in a nice, comfortable bed. As a Marine you often have nothing to look forward to after a week in the field but another week in the field and an uncomfortable couple of hours of sleep, on the ground, with nothing but a poncho liner for warmth. Try thinking coherently after three days of sleep deprivation. What keeps you going is self-discipline and the sure knowledge that if the Marines ever lose their reputation for toughness it won’t be because of you. We’re very idealistic that way.
Sleep deprivation is required for combat operations. Our military is not that big, especially the pointy end of it, and what we lack in numbers we have to make up in mobility and lethality. That’s just a fact of maneuver warfare and we should train under the same conditions that we fight. Sleep deprivation is not required for medical training. Very few praciticing physicians pull Q3 call or work 100 hours a week doing the kind of labor-intensive administrative tasks that are allowed to exist in the inefficient residency training system.

But I digress. I want to also add that in the Marines, if you complain about how hard it sucks (and in fact we sometimes refer to the Corps as “The Suck”) nobody thinks less of you. You’d have to be a retard or a kiss ass to pretend everything is hunky dory. Of course we also laugh at the complainer and say, “Oh well, I guess it sucks to be you” but as long as that man carries his weight and charges hard when required no one thinks less of him. In the medical world, however, to even suggest that you’re tired of pointless bullshit and would prefer to go home is to invite screeching and hand-wringing from the usual cadre of zealots who are flabbergasted, totally flummoxed, that anybody could utter one single criticism of their precious career.

What Kind of Health Care System do You Favor?

I favor a Cuban-style approach. First, we need to abolish political parties and if necessary imprison, exile, or execute politicians who refuse to accept the new order. Then we should severly curtail the traditional civil liberties that we currently enjoy. I’d start with the press and shut down newspapers and television stations that did not support the government. For good measure I’d gradually abolish private ownership of print and broadcast media turning these into propaganda organs of the state. I’m sure we wouldn’t have to execute too many reporters before they fell into line. Maybe establish re-education camps for those who don’t quite get it.

We would also need to get rid of freedom of speech and the right to protest because these kinds of things are messy and make running a modern utopia impossible. Not to mention that it can be embarrassing to the Leader who is, after all, a perfect father to his people. Religion is unessential and unless it can be corrupted to serve the needs of the Party we can ban it too. It’s just an opiate for the people and restricts our ability to condition them for obedience. We can’t put God in a concentration camp so we will need to make the people forget about Him. A good start would be giant portraits of our Glorious Leader along with other heros of the revolution. You know, to give the people somebody to respect. Oh, and marching, lots of marching. Lots of parades.
Poverty is also essential. It’s too hard to keep our hands out of the economy. Besides, we know better than anybody else how to run things. We have college degrees. How hard could it be? At least we can ensure that everybody is at the same low level of poverty. It is a lot more fair that way and the people will not be envious. Envy is bad. Inequality is bad. But party members do deserve some perks. Running a country is hard work, harder than cutting sugar cane, let me tell you!

We also need to keep people from leaving. If we lived on an island it would be a lot easier but maybe we could fortify the boarder and put guard towers every few miles or so. It’s regretable that we don’t have 90 miles of shark-infested ocean to keep people honest but we have to work with what we have.

Oh, and we can have free health care. Nothing elaborate, mind you. Just some low level primary care. What are people going to do, complain?

(To be continued…)

17 thoughts on “More Rambling Conversation With a Lumbering Asian Bear-Mammal

  1. I chose to respond to this post, not so much of its content, but because I had not commented thus far. I really enjoy reading your blog. I am so thankful that through your blog, and others that I read, to be able to get a realistic view of medicine as a profession. I am currently 33 years old, and a minister. For a while now I have been contemplating returning to school and applying to medical school in the somewhat near future. Your blog has shown me what to expect – and darn it all I still want to be a doctor! Keep up the good work and God bless.

  2. “The key point here is that you cannot put your life on hold and say, “I will take my son fishing when I am done with residency.” Those four, five, or six years are precious and once lost are never to be recovered. ”

    Shocking, really, that although this point has been between the lines on your blog for, well, ever, you’ve never actually written it. And it is so true. Those 2 extra hours are indeed stolen from you, and could easily be given back by some common courtesy and common sense from the teaching staff. I’ve said the same thing myself many times. The fact that those 2 hours are -not- given to you is evidence of the abusive nature of the training and the fact that students and residents are, in truth, viewed as worthless pieces of scat that are only there to hold the floor in place and possibly learn by osmosis.

    Maybe I’m being too harsh, but when I know my kids will be sleeping by the time those two extra hours are gone, vs. being able to give them their baths and read them a story or three, harshness is a natural response.

    To those who will say, “Well, you signed up for it!”, screw you. I’m still doing good deeds by becoming a doctor, and I shouldn’t have to sacrifice my family to do it.

  3. Those last two miles are obviously unnecessary. I think our Marine infantrymen should only have to march 18 miles. And maybe cut their 90 pound pack down to a more manageable 60 pounds. And maybe give them all soft fluffy pillows and down comforters too. They would probably turn out to be just as tough and fit examples of Marines, and they would still get the job done. Because they are Marines.

    (But you see, that’s my point.  Extreme physical toughness and endurance are required of a Marine because that’s the nature of our job.  We bitch about it, of course, but I have never heard a grunt turn to his buddy and say, “Man, patrolling through this jungle is so pointless.  It’s not like I’m ever going to have to do this in real life.”    Show me the typical doctor who pulls Q3 or Q4 call for his entire career doing the kind of things that residents do.  Sleep deprivation for the sake of the hospital’s bottom line is pointless

    I also have to add that in Marine Basic Training (boot camp), despite what you think you know, recruits get a full night’s sleep every night except for a few field operations.  The Corps does not think exhausted recruits are effective students and, especially at this stage in their training, need to be sharp.-PB)  

    The difference is that you WERE 20 years younger and you DIDN’T have a family back then. Plus, you took pride in your job.

    Nice post, as always.

  4. One of the few attendings I know that actually does routinely pull 100 hour weeks (and has for around the past two decades), had very little to do with raising his children, and he’s on his second wife. I’ll never understand why someone would do that, and if they decide to do it to themselves, why they would have children and put them through it as well.

  5. I know this is the cliche of all questions: but there still is this issue. How to get the experience and training needed to be out there on your own, if not this way? More specifically, unless there are lots more people in the training program, do some hours go uncovered? If there are more people, to what extent does the experience get diluted? Or would it need to be extended a year or two? I couldn’t agree more that the abuse which is all but institutionalized is inexcusable — the disrespect and derogatory way in which residents are treated. But the hours — I wonder how it’s really possible to lessen them any further.

    (As far as hours going uncovered, that’s the hospital’s problem and one of my points, namely that the hospital uses residents as the medical equivalent of cannon fodder, covering call at night because they are cheaper, much cheaper, than even PAs and other midlevels who they would be forced to hire except that even at 80 hours a week, there is still plenty of cheap resident labor to spread around.  So while I realize that hospitals are 24-hour-per day operations, why does the brunt of making it so fall on the residents other than we are indeed a form of indentured servants who have very little legal protection?

    And I also have to point out that that the availibility of cheap, unprotected labor has made it unnecessary for teaching hospitals to become more efficient.  There is, in other words, no incentive to streamline either training or paperwork.  I don’t doubt that most residents spend a large portion of their training time wrestling paperwork and other bureaucratic tasks of a kind that is only to be found in teaching hospitals and that has very little bearing on their training.

    80 hours a week shoud be enough to train anybody for any speciaty.  That’s six 12-hour days a week and then some which is a lot of training time.  You can still do Q4 call going home at noon post-call from now until the cows come home without going over your eighty.  That’s basically two days of sleep deprivation a week.  Or, like it has been done on some of my rotations, we have a week of night float which is relatively easy and then three weeks of Q3 call, still coming in under the 80 hours averaged over four weeks which is the rule.  But Q3 call, with apologies to those who crawled through broken glass to get to the wards, is pretty brutal.  That’s call, post call day, normal day repeat for those of you who don’t know, or every third night sleep deprivation followed by a half day where all you can do when you go home is sleep until you start over again.

    I think if my readers researched it a little they would be sore amazed at some of the organizations which lobby hard against reforming residency training.  Hint: It’s not out of any concern for patient safety or education.  Like most things, it is only necessary to follow the money. -PB)

  6. I was really looking forward to your “What Kind of Health Care System do You Favor?” answer. I wish you could have seen the disappointment on my face when I had to wade through 5 paragraphs of jackassery.

    Oh well. Maybe one day you can muster up an entry of sincerity. Granted I have not read every single one of your entries. I can only tolerate so much bitching and moaning.

    (You need to learn to deal with your disappointment.  And I repeat, this is not PBS and I am not a public service.  Nobody twisted your arm and the fact that you continue to read my blog even though it causes you such psychic pain is hard to understand.-PB)

  7. The real solution to all of these problems is to make it easier for residents to switch programs. The root of all the evil is the fact that your residency program completely owns your entire future career and can blackmail you into (literally) almost anything, even things detrimental to patient care. If programs knew abusing residents meant they’d just switch over to another program… hoowee, we’d see some changes.

    Actually, the ideal solution would be to allow people to move their PGY spot and medicare funding to another residency program if they can show good reason. Boy would that cause a ruckus.

  8. Your posts point out the obvious fact that you are an experienced adult. When In think back on the CRAP I put up with in residency (in the 80’s) I want to go postal. A key aspect of the hospitals’ (and attendings’) ability to abuse residents is the fact that they are for the most part young and naive. If the entire resident cadre were populated by adults who’d been out in the world and cognizant of the difference between shit and Shinola, there’s be a very different face to medical training.

  9. Panda, I’m a Marine reservist and civilian firefighter/paramedic, and enjoy reading your blog. I recommend it to people all the time, especially as proof that there are lots of young grunts out there smarter than the academy grad officers.
    One thing that makes the Marines different than residency is leadership by example. You could bet that, the more miserable things become, the more likely some grizzled old Gunny or Master Sgt will be out leading the way and slapping backs to keep the team moving. I don’t see any attendings staying 80 hrs/week at our local hospitals to mentor the residents.

  10. responding to the above poster about wanting to go postal while thinking about his residency in the 80’s, how would your experience have been different if you had been 10-20 years older? specifically, what would you not have put up with? and, would you have been able to get away with not putting up with it?

  11. All it would take to up-end the current almost-sex trade in human medical residents is just one measly resident suicide bomber. Why the hell is that person not materializing? Too tired to appreciate all those virgins, I bet.

  12. Great blog, PB, I just found it this morning.

    As the daughter of an ICU Nurse who went back to school and became a Dentist (translation: physically absent but morally present mother) and a father who retired from the army and his business all too early to care for us young’uns, I turned out okay. This is not a testament to my greatness, as my little brothers have shown few errs in judgement despite being teenagers. Ultimately I want to say that I am grateful for what my parents endured. It was only a little odd in elementary school that my parents were not part of the PTA clique or cupcake-making machines. Now I have the advantage of shadowing an internist next summer and assisting dentists in mexico because of my mother’s connections and my father’s eternal willingness to drive me wherever I need to go. The moral of the story is that strong family values can see you through the toughest times.

  13. Thanks for this post. I’ve been thinking about this ever since I started med school, which hasn’t been that long.

    I’ll continue to think about it for a while.

    Neat blog too.

  14. Well put. The Ranger tab on my shoulder reminds me of my old infantry days. I agree with everything you say here. I’d like to see the attending sling load a blackhawk on no sleep.

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